Revisiting recovery-oriented harm reduction (part 2)

April 9, 2021
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I’ve been watching a really interesting twitter discussion about the conceptual boundaries of recovery. One branch of the discussion got into recovery as a process and as an outcome. It reminded me of this post from 2019.

Yesterday, we began to revisit the concept of recovery-oriented harm reduction. Why recovery-oriented harm reduction and not just recovery? 13 years ago, recovery-oriented harm reduction was thought of as a bridge between harm reduction and treatment or recovery. Today, in some circles, it might invite questions about why one would want to maintain a distinction between harm reduction and recovery.

Defining harm reduction

Harm Reduction International defines harm reduction this way:

Harm reduction refers to policies, programmes and practices that aim to minimise negative health, social and legal impacts associated with drug use, drug policies and drug laws. Harm reduction is grounded in justice and human rights – it focuses on positive change and on working with people without judgement, coercion, discrimination, or requiring that they stop using drugs as a precondition of support. Harm reduction encompasses a range of health and social services and practices that apply to illicit and licit drugs. These include, but are not limited to, drug consumption rooms, needle and syringe programmes, non-abstinence-based housing and employment initiatives, drug checking, overdose prevention and reversal, psychosocial support, and the provision of information on safer drug use. Approaches such as these are cost-effective, evidence-based and have a positive impact on individual and community health.

Harm reduction emerged in response to the failures of medical, public health, and addiction treatment systems to meet the needs of people currently using alcohol and other drugs. Harm reduction saves lives and has challenged other systems (like my own) to face their shortcomings and biases and improve our services. Harm reduction is an essential part of the service continuum and its existence has created pressure to improve the care delivered by other systems.

Defining recovery

There have been several proposed definitions of recovery by academics, professional associations, panels, federal agencies, and state agencies. The trend among these definitions is toward more porous conceptual boundaries and greater inclusion. The first wave of attempts to define recovery seemed to originate from a sentiment like the following, “There are people out there who are doing what you call recovery. They just are not doing it in 12 step groups or they are using medication to assist their recovery. They are just using another pathway to get to the same destination (i.e. outcome). To exclude this people from the boundaries of recovery is inaccurate and wrong. And, by the way, you might want to wrestle with whether there are ways in which your thresholds are too low (e.g. tobacco use and other unhealthy behaviors). Recovery is less about the pathway and more about the destination/outcome.” The best example of a definition arising from this wave is from the Betty Ford Consensus Panel:

Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.

The next wave of definitions seemed to arise from something like, “What you’ve thought of as recovery is way too narrow. It shouldn’t be confined to addiction. There’s a whole spectrum of problems and changes within the context of those problems that constitute recovery. It’s not a outcome at all. It’s a process, and anyone engaged in a process to improve their wellness is in recovery. Recovery is the pathway not the destination/outcome.” SAMHSA’s definition is an example of this is type:

A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

Another, more recent, example is from the Recovery Science Research Collaborative:

Recovery is an individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness.

Process, direction, outcome?

Long before researchers and scholars took an interest in recovery, recovering people have described recovery as a process. What’s interesting here, is that I think recovering people have thought of recovery as a process and a destination/outcome. Some might think of it as a process that leads to an outcome, while others might think of it as an outcome maintained by a process. Whatever the case, both elements are considered essential. The Betty Ford Consensus Panel definition integrates a lifestyle (destination) that is voluntarily maintained (process). This more recent wave of definitions emphasize a process and a direction (“improvement . . . striving . . . full potential” and “sustained efforts to improve wellness”) rather than an outcome or destination.

Does it matter?

In is paper on the conceptual boundaries of recovery Bill White observed:

Defining recovery also has consequences of great import for those competing institutions and professional roles claiming ownership of AOD problems. Choosing one word over another can shift billions of dollars from one cultural institution to another, e.g., from hospitals to prisons. Medicalized terms such as recover, recovery, convalescence, remission, and relapse convey ownership of severe AOD problems by health care institutions and professionals, just as words such as redeemed and reborn, rehabilitate or reform, and stop and quit shift problem ownership elsewhere. It is important to recognize that rational arguments for particular definitions of recovery may mask issues of professional prestige, professional careers, institutional profit, and the fate of community economies. The answer of who has authority to define recovery will vary depending on the question, “define for what purpose?” Given that defining recovery could generate unforeseen and harmful consequences, efforts to define recovery should include broad representation from: 1) individuals and family members in recovery, 2) diverse recovery pathways and styles, 3) diverse ethnic communities, and 4) policy, scientific, and treatment bodies, including leaders of the major institutions that pay for behavioral health care services.

So . . . yes, it matters. A lot. To a lot of people and a lot of interests. I don’t presume any nefarious motives. I imagine everyone believes their definition will ensure more people recover or will protect recovery from a harmful erosion of its boundaries. In some cases, they wish to extend it to include mental illness and other problems. In other cases, they wish to include people who are taking steps toward change, but have not yet crossed the threshold into traditional notions of recovery. Others want to secure the status of MAT patients within the boundaries of recovery. Others see opportunities for stigma reduction and political action by enlarging the number of people in recovery. Others see opportunities to address the needs of people with lower severity problems. Others may see progress on stigma reduction benefiting people in recovery but neglecting people who still use alcohol and other drugs. Others see the concept of recovery as imbued with moral panic and wish to challenge that. There have been attempts to address some of these issues and bridge the divide between harm reduction and recovery. Scott Kellogg has proposed a model he calls gradualism. He describes it as follows:

[Gradualism] seeks to create a continuum between the world of harm reduction interventions and the abstinence-oriented treatment field. Again, this approach differs from other calls for integration (Denning, 2001; Marlatt et al., 2001) because there is a much greater emphasis on making abstinence the eventual endpoint of most harm-reduction enterprises. This paradigm would combine the harm reduction emphases on outreach to the addicted, incremental change, and gradual healing with the abstinence-oriented therapeutic perspective that the use of substances in an addictive or abusive manner is antithetical to the growth and wellbeing of humans.

Bill White has proposed the concept of precovery, which he described this way:

Precovery is a recovery incubation period arising during active drug use that moves one from the center of addiction to the edge of addiction. Experiences within this stage prepare us for the potential break-up of the person-drug relationship and move us close enough to the recovery territory to feel its contagious pull. Brief sobriety experiments within this boundary region do not constitute sustainable recovery, but they have the potential to incrementally move us to the center of the recovery experience and the physical and cultural world in which that experience is nested. The center of recovery is a region of stability and safety within the recovery process.

These models embrace harm reduction, but not as recovery. They embrace harm reduction as a path to recovery.

Why does it matter?

Why does it matter if harm reduction is placed inside the definition of recovery? There are a few concerns:

  • It defines recovery in a way that is contrary to the lived experience of cultures and communities that have identified with the concept.
  • This tension between professionally developed definitions and organic, indigenous definitions is likely to alienate communities of recovery rather than engage them. Bill White suggested that the job of professionals “is to do what the community at any given moment cannot do.” It is our role to fill gaps, address unmet needs, support the community, or even try to facilitate the creation of new communities, rather than try to bend the community to our vision of a better community.
  • These definitions fail to consider who “recovery” is important to and what its redefinition might mean to them. For example, consider the founding of AA. The date of Dr. Bob’s achievement of sobriety (or, recovery) is considered to be founding date of AA. By some of the proposed definitions, Dr. Bob was in recovery for some time prior to this. One could argue that he was in a “individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness.” Was this period of time recovery to him? His wife? His children? His coworkers? His patients? If that period is characterized as recovery, what does that do to the relationship between all of these people and the concept?
  • “Recovery” is an attractive label for a reason. It’s become associated with wellness, citizenship, and other positive attributes. It’s clear that these attributes do not accurately described many people traditionally considered to be “in recovery” and may exclude others who do live up to those attributes. However, extending the label too far risks eroding the positive associations that make “recovery” attractive in the first place.

Tomorrow’s post will revisit the parameters of recovery-oriented harm reduction.

UPDATE: One more relevant thought from a recent post. I believe, if these new definitions take root, recovering people will feel a need to establish typologies of recovery or select a new word to convey the identity they share. Productive discussion around typologies is likely to become very challenging. The need for typologies stems from the desire to distinguish one type from another, and use them. How might they be used? They would likely be used to organize research and programming around each type. This means these typologies would be used in inclusion/exclusion criteria for everything from research to treatment to recovery housing to collegiate recovery programs to physician health programs to state or unstated hiring practices. And, if there was success in establishing typologies, wouldn’t that bring us back to our starting point?

Previous posts in this series

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