Supporting Long term Recovery and the Tragedy of the Commons

August 9, 2020
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Strengthening and supporting long term recovery for diverse communities across multiple pathways of recovery is a goal that would reap huge benefits for our entire society. As I have written about before, the single most important focus of substance use treatment and recovery policy in the United States should be on getting as many people as possible into long term, stable recovery.  As I noted in a Statnews piece in January, few Americans get anywhere near 90 days of care, which is the minimum effective dose for the average person. Within the confines of existing insurance networks, short-term treatment of 28 days or less is all that most Americans are offered — if they can get any help at all. It is an inadequate care system designed to deliver less than what people need because we still moralize addiction and do not value people who have substance use disorders. These dynamics has created fragmented care with large gaps. We are not properly focused on the ultimate goal, achieving and sustaining long term recovery for all persons who are addicted. One way to look at how this has unfolded is to view it in terms of a tragedy of the commons.

The tragedy of the commons originally focused on environmental concerns and the dilemma created by the pitting of short term self-interest against long term whole community interests. In more recent years the concept of tragedy of the commons has been applied to decision making processes and social policy. They are problems that generally transcend solutions using the tools at hand using the systems in place. Long term recovery is well within the tragedy of the commons as achieving it benefits all institutions but individual, short term interests prevent us from focusing on these needs. A related concept is the free rider problem, in which individual interests are to take advantage of work done to strengthen community resources but to not be contributive towards those ends. An example of a free rider problem in respect to substance use treatment is the tendency for private insurance entities to provide minimal care and shift costs to the public system as the person loses their job because their drug use begins to interfere with job performance. As noted by Griffiths and Kickul “there are two practical ways to try to overcome any Free Rider problem: compulsory participation (taxation) – a form of regulation, and secondly, linking the public good to a desirable private good (getting people to pay voluntarily).” We may well need to develop policy that strengthens addiction recovery and support that benefits the commons of long-term recovery that assist us in navigating around the tragedy of the commons.

We have an existing support fellowship model historically set up intentionally to avoid these dynamics. Mutual aid support groups such as AA focus on the needs of the commons by design. They are decentralized, autonomous and focused on the common goals of the community through group consensus. In reflection, the development of these mutual aid societies, while now ubiquitous were nothing short of miraculous to have occurred here in America considering our highly individualistic culture. As noted by Ernie Kurtz in his interview with Bill White on the history of AA. “AA, I think could have only come out of the American 1930s—after the crash of 1929 and the Great Depression taking effect. For the first time, this “go get ‘em” optimistic American culture hit bottom. Some people who had been titans of business and were doing very well—suddenly they were rummaging through garbage pails outside of restaurants….People who had been used to controlling things learned that they were powerless, and I think that it was in this clash that some first discovered AA . . . that level of business-people who had to confront their powerlessness…AA could have only come out of the American 1930s.” Mutual aid rose out of an era in which the tools of self interest were not working that well even for the most privileged and as a result there was a heightened sense of communal need.

What is “in the commons” in respect to long term recovery?

  • Long term, whole person recovery focused research that examines recovery over the long term in order to understand what works for whom and under what conditions.
  • Focused effort to reorienting our entire addiction care system to fully create and sustain the five year recovery care model as the research is showing us is that this is the point at which 85% of persons will remain in recovery for life.
  • Full inclusion of persons in recovery in the design, implementation, delivery and evaluation of services in order to ensure that care meets the needs across the full spectrum of diverse persons seeking help.
  • Tools to hold our care systems accountable when disparate, short term care is provided to ensure that applicable laws around access and duration of services are consistent with applicable laws.

Developing the commons of long-term recovery services has not as successful as we had hoped. We have made progress in some areas, but even the gains made tend to degrade back to baseline over time. Non-Government Organizations who have attempted to focus on developing the infrastructure to support long term recovery quite often end up suffering from mission creep away from holistic strategies focused on long term recovery into more narrowly focused goals. This occurs because grant funding and foundation money tends to have more narrowly focused goals and focus skips from funding source to funding source in ways that reduce the development of a cohesive system. They can also get trapped in fee for service models that make it difficult to achieve the goals that were originally envisioned. Over time, pursuit of these resources moves organizations away from their holistic focus on long term recovery.

So how do we move forward with the work of long-term recovery in ways that stay true to the vision of developing an infrastructure to support long term recovery in America?  Government has traditionally been a resource for developing and sustaining the commons. For it to work, there needs to be the vision and inclusiveness over the long term to develop it. Fundamental to achieving that end, it is necessary for governmental institutions to possess deep understanding about recovery and a commitment for inclusion of communities of recovery. History also shows us that private interests and politics can interfere with these dynamics as they have more narrow interests.

Despite all of the challenges, the vision of a long-term care and support system is well worth the effort. It would have dramatic benefits for our entire society. Benefits to pursing a long-term recovery care and support model include reducing social costs like incarceration, reducing healthcare expenses and slashing social service demands. This could happen if, our era is in some ways parallel to the dynamics of 1930s in which there is recognition that our traditional models of responses are not working and more community wide solutions are needed. As we collectively work to build out long term care and support infrastructure, we need to pay attention to building out and protecting the commons. We will need to consider how are actions and efforts are contributive to the larger goal and work with each other to build out a cohesive, multiple pathway care system that supports recovery for all communities across the nation.  Lets do this and support a recovery commons that ensures that recovery is the probable outcome for the next generation!

“What I try to tell young people is that if you come together with a mission, and its grounded with love and a sense of community, you can make the impossible possible.” – John Lewis

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