Increase Support for Individuals in Recovery

Introductory paragraph

This article focuses on the role of the individual in the socio-ecological model's continuum of individual-family-peer-community. It addresses clinical or therapeutical topics, such as progress tracking and motivational interviewing. Likewise, it introduces concerns around quality of life, as experienced at a personal scale.

Key Information

Recovery Science is a relatively new field. The application of its principles at the individual scale can be seen as mirroring the history of prevention science. In its early development, the prevention community placed the burden of responsibility of SUD on the individual, with a simplistic “Just say no” approach. As it matured as a field, prevention science began to balance individual roles with more environmental strategies, such as access, social norms, and media advertising. Recovery science has its flagship success at the interpersonal scale, as reflected in peer support, and it is beginning to become more effective in addressing environmental concerns, such as stigma reduction and social determinants of health, as well as in providing more effective support at the individual scale.

Both disciplines have a challenge in balancing the role of quantitive measures with the qualitative components of their fields — people. This struggle can be seen in prevention science which has a two-pronged approach to both reduce risk factors and increase protective factors, but which leans to the more readily measured component of risk factor reduction. In recovery science, the single most widely used metrics are the binary score based upon abstinence and the duration of an abstinence-based sobriety. However, the advent of harm reduction and the growing acceptance of multiple pathways makes quantification of outcomes more problematic. Even more challenging is the qualitative side of the equation in recovery science which can be seen as a parallel to protective factors in prevention science. How does one measure self-esteem or resilience?

The complexity of working on both the quantifiable aspects of risk factor reduction and the intangible, but essential qualities of recovery can be seen in the need to concurrently deploy all three of the complementary approaches detailed below.

• Progress tracking aligns to the quantitive risk factor domain.
• Quality-of-life tools address the more subjective elements in the implementation of recovery science.
• Motivational interviewing can be seen as a blending of the two approaches.

Progress Tracking

Tracking progress in behavioral health recovery is essential because it allows us to gauge how far we’ve come, what we’ve become stronger in, what we’ve learned so far, what we can and should zero in on next, and how we can help others with the tools that we’ve learned. Progress tracking is a tool that has been used by mental health practitioners that, “measures, monitors, and provides feedback,” to allow for real-time treatment responses and adjustments to be made. The success of progress monitoring in mental health, especially when a specific illness is targeted, is well-documented and shown to be a beneficial tool that allows efficient, treatment-paced monitoring and evaluation of the treatment efficacy. While there isn’t a significant amount of literature on its use in substance-use treatment, the few studies done on its use with SUDs have shown similar rates of positive patient outcomes. It allows both the therapist and the client to monitor and adjust treatment in the interim, rather than waiting to view results at the end, ensuring that treatment is patient-focused and individualized. Documented results in mental health treatment and promising outcomes for substance use indicate that recovery tracking should be a key component of treatment in a population with relapse risk as high as 85% within the first year.

Much of SUD progress tracking has revolved solely around treatment attendance and urine testing. Since metrics are compared to group data, this often fails to address individual progress outcomes beyond the scope of continued drug use. Goodman, McKay, and DePhilippis (2013) report in their study that, while progress monitoring should be standard practice, only about 37% of therapists use any form of tracking. Further, they report that there is evidence of frequent inaccuracies in tracking and unrecognized deterioration of treatment. The importance of effective progress tracking for patients with SUDs lies in the ability to recognize ineffective aspects of the treatment and to adjust accordingly during active treatment. This ensures that the patient is receiving care that is matched to their situation. The use of scales in progress tracking allows the practitioner to maintain focus on both the individual and the symptoms. This aligns with the NASW ethical principles of commitment to the client, their autonomy, and treatment competency. Substance Use Disorder is a recognized mental health disorder and has a high rate of comorbidity with other mental illnesses, especially with anxiety, PTSD, depression, panic disorder, and bipolar disorder For successful progress monitoring to occur, clinicians must recognize and address comorbidity.

Quality of Life.

The term “quality of life” within recovery science parallels protective factors within prevention science. Any tools which enhance quality of life (QoL), either at the individual or inter-personal level (family and peers), actively build recovery capital. Aspects within the umbrella of QoL include physical and material well-being, such as health and employment and housing. Likewise mental well-being includes educational opportunities. However, most of the emphasis in QoL is in the emotional and relational realms. For example, fostering self-determination includes autonomy, personal control, choice, goals, and values. Enhancing interpersonal relations and social inclusion involves increasing interaction and community participation, finding new relationships and support, and creating new roles within community.

Motivational Interviewing (MI).

MI is a method for implementing behavioral change that has been used for over 40 years. As a person-centered approach, it has proven success in meeting individuals "where they are at" and helping them to advance to their chosen goals. This progress is quantifiable, but remains highly personalized. For more information on MI, its network of trainers, and various tools, such as the MI app, see the SAFE Solutions article on MI

Relevant Research

• The Canadian Psychological Association published a report titled “Outcomes and Progress Monitoring in Psychotherapy.” This report provides a framework for progress modeling that includes relevant research on its success and background, an evaluation of gaps between research and implementation, and recommendations for clinical implementation, maintenance, and training.

• Vista Research Group provides a website with links to a variety of current research findings. Gaps: They conclude that there is very little clinical research, especially randomized control trials in regard to progress monitoring for use with SUD, despite promising results and documented success with use in other mental illness treatments. Clinicians struggle to find inexpensive, user-friendly, real-time feedback tools, making progress monitoring a challenge.

• A meta-analysis. This article provides a review of findings associated with progress tracking in SUD. It compares several studies addressing traditional urine/attendance tracking against adaptive intervention including therapy treatments along with urine/attendance requirements. It is a comprehensive review showing the significance of including treatment and progress monitoring outside traditional parameters in relation to positive patient outcomes.

• A Preliminary Study of the Effects of Individual Patient-Level Feedback in Outpatient Substance Abuse Treatment Programs. This is a unique study done on the effectiveness of patient-level feedback on treatment outcomes for SUD. It showed that patients who were “off track” in their progress and given the adapted Outcome Questionnaire (OQ-45) fared better than those who did not participate in the OQ-45. There was a marked decrease in drug use and promising improvement in mental health outcomes. A review of the OQ-45 allowed practitioners information to tailor treatment to the individual and provide any additional, unique support.

Impactful Federal, State, and Local Policies

SAMHSA has a comprehensive list of acts regarding mandated federal treatment guidelines that address evidence-based treatment and monitoring, disparities, and protected individuals.

Laws addressing progress tracking typically pertain to individuals who have a criminal history related to substance use. The U.S. Department of Justice notes that while drug testing can be mandated as a condition of bail, probation, and parole, its implementation and duration vary by jurisdiction. While treatment may also be a condition of probation and parole, its requirements also vary by jurisdiction.

Promotion/Implementation of Progress Tracking. Current research and recommendations can be used by clinicians to lobby for available progress monitoring tools, conduction of further studies, and encouragement for the use of innovative tools that are cost-effective and user-friendly. Practices, whether private or public, should advocate for the use of (and ongoing training in) progress monitoring tools as an active component of treatment programs.

Available Tools & Resources

Partners for Change Outcomes Monitoring System (PCOMS) combines the Outcome Rating Scale (ORS) and Session Rating Scale (SRS) in a collaborative effort on the part of the therapist and patient. The therapist and patient work together to create goals that are reviewed by the SRS and encourage a positive partnership. SAMHSA recognizes PCOMS as a significant tool for progress monitoring, and the Canadian Psychological Association notes that such union of the ORS and SRS has shown significant promise in tracking and treating SUD. It facilitates discussions of progress and relationship issues in the treatment, as well as the ability to alert the therapist to issues by “identifying off-track progress and alliance measures.”

Modern handheld technologies support an autonomous form of tracking one’s progress in recovery. There are dozens of apps dedicated to assisting people in their recovery journey. They range in modality, from providing resources, motivation, peer connection, use and recovery tracking, and much more. Dual Diagnosis provides a list of top-rated apps that clinicians can review and suggest to their clients. GoodRx has a comparable list. A small sample of these types of apps is provided below:

• Sobriety Clocks. These apps track the number of days in sobriety. They provide the ability to share clock data with people in a recovery support network. They also provide the capacity for an individual to message an accountability partner if they are feeling triggered to use.

• REC-CAP is shorthand for recovery capital which is conceptually linked to natural recovery, solution-focused recovery therapy, strengths-based case management, recovery management, resilience and protective factors, and the ideas of hardiness, wellness, and global health. The REC-CAP tool is appropriate for implementation in both clinical and peer settings, bridging the gap between a client’s exiting addiction treatment and assuming responsibility for self-directed recovery. The tool:
  • Assesses an individual’s recovery strengths, barriers and unmet service needs
  • Supports trained navigators to guide individuals in the execution of concrete recovery goals
  • Delivers longitudinal measurement of recovery capital gains over quarterly intervals

• Cost Benefit Analysis (CBA). This app is distributed by SMART Recovery. The CBA strategy helps many people recover from addiction and addictive behaviors, ranging from substance use to sexual addiction. The app makes performing a CBA convenient and easy. SMART Recovery recommends uncensored journaling about daily activities, thoughts, and ideas. This serves to identify recurring thought/behavioral patterns when reviewing entries dating back weeks, months, even years. This also fosters communication with people in an individual's recovery network, who may more rapidly recognize changes. The CBA tool serves to bring awareness to the consequences of potential actions by assessing four questions:
  • What are the advantages of using/doing?
  • What are the disadvantages of using/doing?
  • What are the advantages of NOT using/doing?
  • What are the disadvantages of NOT using/doing?

Promising Practices

• Progress Assessment. The PA is a tool created and tested by clinicians. It includes 5 items that assess the risk of relapse and 5 items that assess protective factors. Study results showed that cocaine use participants with high risk and low protective scores at baseline and the 3-month mark were at greater risk of relapse. The PA tool is short and easy to administer and allows for flexible and adaptive intervention to take place, addressing the ongoing and changing needs of the client.

• Treatment Progress Assessment-8 (TPA-8). This instrument aims to monitor SUD symptoms and treatment progress. Items that measure symptoms use DSM-V criteria, while items addressing treatment progress focus on self-efficacy, therapeutic alliance, emotion regulation, and hopefulness. TPA-8 fosters a collaborative partnership between the clinician and patient to create a treatment plan based on goals, autonomy, and hope, allowing for assessment and adjustment monthly. It shows promising results in retention and preventing relapse.