Defining Recovery-oriented Systems of Care
Federal, state, and local behavioral health authorities have continued to embrace Recovery Management (RM) and Recovery-oriented Systems of Care (ROSC) as new organizing paradigms for addressing substance use and mental health disorders at clinical and community levels. Much of my work over the past two decades has focused on assisting such efforts through my research, writing, training, and consultation activities. A crucial aspect of this work involved collaborations with Dr. Arthur Evans, Jr. and others in what has been depicted as the “recovery revolution in Philadelphia.” The innumerable requests to share the details of the recovery-focused systems transformation process in Philadelphia led to a series of papers and monographs that captured many of the lessons learned from this effort. In those earliest papers, we set forth definitions of RM and ROSC as follows:
Recovery management is a philosophy of organizing addiction treatment and recovery support services to enhance pre-recovery engagement, recovery initiation, long-term recovery maintenance, and the quality of personal/family life in long-term recovery.
The phrase recovery-oriented systems of care refers to the complete network of indigenous and professional services and relationships that can support the long-term recovery of individuals and families and the creation of values and policies in the larger cultural and policy environment that are supportive of these recovery processes.
In 2013, Dr. Evans and I drafted a brief statement on the definition of Recovery-oriented Systems of Care. That statement is reproduced below in response to a recent increase in requests for such clarification.
Since the late 1990s, the authors have been involved in numerous efforts to transform acute and palliative care models of addiction and mental health treatment into models of sustained recovery management (RM) nested within larger recovery-oriented systems of care (ROSC). Through that process, “RM” and “ROSC” have become code for a wide variety of behavioral health system transformation efforts. In this short essay, we would like to share with our readers what we mean when we talk about ROSC as an organizing concept for behavioral health care.
For us, recovery has three potential meanings. The first is the movement from a state of illness and isolation to a state of health and connectedness. In the addictions arena, this end state has been recently defined in terms of sobriety, improvement in global health, and citizenship. In the mental health arena, recovery has been described in terms of medical/clinical recovery (no longer meeting diagnostic criteria of active illness) and functional recovery (a socially connected and meaningful life in the community). Many people who have suffered severe behavioral health disorders achieve such full remission, with “recovery” depicting the process through which hope and health have been initiated and sustained.
A second meaning of recovery is the process through which one actively manages and transcends the symptoms of persistent illness to achieve improved quality of life and functioning. This means that some symptoms of the illness may continue to ebb and flow (e.g., cravings, obsessive thoughts, emotional distress), but they cease being the controlling center of one’s personal, family, and social life.
For historically traumatized and oppressed populations, recovery may also involve drawing upon the historical resilience of a people and the assertion of personal and family health as an act of political resistance or cultural survival.
We see in these patterns of recovery quite different styles of personal relationship to illness: escaping illness, making peace with illness, and doing battle with illness. When recovery advocacy leaders proclaim that “there are multiple pathways of long-term recovery and all are cause for celebration,” they widen the ROSC tent to include all styles of personal recovery management and commit ROSC resources to support these myriad styles of recovery.
“Recovery-oriented” within the context of ROSC means that system resources are strategically allocated toward this vision of recovery and whole health. It means that the principles embedded within the care process are drawn from the lived experience of personal and family recovery and that people in recovery have visibility and voice throughout the system. It means that the core knowledge driving service system design is based on the study of resilience and recovery rather than solely on the study of pathology or clinical interventions. It means that the benchmarks used to measure the performance of roles, organizations, and systems all have a direct or indirect nexus to personal and family recovery. It means that measures of traditional systems health (e.g., number of people served, number of units of service, number of organizational staff, organizational budgets) have virtually no meaning and value unless linked to measurable, sustainable long-term recovery outcomes.
The “system” in ROSC is first and foremost not a treatment provider or even a network of formal treatment providers. Instead, the “system” is a larger mobilization of recovery supports within a neighborhood, community, state, or nation. RM is a philosophical framework for organizing behavioral healthcare services; ROSC is a framework for creating the physical, psychological, and social space in the larger community ecosystem where recovery can flourish. While treatment providers can serve as a catalyst in mobilizing a ROSC, they cannot themselves be a ROSC. The ultimate goal of a ROSC is not an ever-expanding professional services system. While professional services are an important component of any ROSC, such services do not in and of themselves constitute an ROSC. A purported ROSC consisting only of recovery support available within funded agencies would violate the very meaning of a ROSC.
The “care” in ROSC has multiple meanings. First, it reflects but transforms the concepts of “level of care” and “continuum of care.” These latter phrases traditionally refer to the intensities and elements of formal health and human services. Care as services in ROSC shift from a focus on intensity of services to a vision of extensity of services. Recovery-oriented care means that the focus of support spans all stages of long-term recovery and not just the stage of recovery initiation and stabilization. ROSC resources are also directed to support pre-recovery priming, the transition from recovery initiation to recovery maintenance, enhanced quality of personal and family life in long-term recovery, and efforts to break intergenerational cycles of problem transmission. It is in extending its focus across these stages that the ROSC concept theoretically and in practice connects professional treatment and recovery support to indigenous recovery support systems and to the arenas of primary prevention, early intervention, and broader public health initiatives, including harm reduction.
Second, the meaning of care is extended beyond professional services to the creation of a healing community. Professionally directed services that aid the recovery process may be important components of this experience of community, but they are seen as secondary to the long-term importance of connection to community within the recovery experience. ROSC extends the acute care focus on an individual’s thoughts, feelings, and behaviors to create a family and social milieu in which recovery can be ignited and sustained. The caring actor thus shifts from that of a paid professional to the family, extended family, community, and culture.
Third, the “care” in ROSC is a relational construct. “Care” becomes, in addition to a range of services and supports,
1. an expression of empathy and compassion (“We share with you the experience of personal aspirations in the face of limitation and struggle.”),
2. a communication of invitation and acceptance (“Please join us. You are part of our communal family and our fates are inextricably linked.”),
3. a communication of value and affection (“We care about you and your future.”),
4. a communication of commitment (“We are committed to sustaining support to you in the days, months, and years to come.”), and
5. an expectation of responsibility and service (“Join us in this helping process: you now have a responsibility to ‘pass it on’–help others and to help the community.”).
Collectively, these communications serve to break the traditions of contempt, condemnation, and punishment that have so often plagued relationships between communities (and their representatives, e.g., service professionals) and persons with severe behavioral health disorders. A ROSC is as much a change of emotional affect within a community and culture as it is a change in professional service design and delivery.
Creating recovery-oriented systems of care involves a radical re-orientation of approaches to the long-term resolution of mental health and substance use disorders. The ROSC vision is more focused on personal possibilities than pathologies and more focused on continuity of long-term support in natural community relationships than the intensity of short-term professional interventions. Professional interventions can play crucial roles as aids to personal and family recovery, but such services are not a substitute for community relationships that are natural, continually accessible, reciprocal, enduring, and non-commercialized. ROSC is an approach to expanding and integrating these diverse forms of helping. The ultimate measure of ROSC is not the size and scope of professional services but a community’s capacity for compassion, support, and inclusion.
About the Authors: Dr. Arthur C. Evans, Jr., is Commissioner, Philadelphia Department of Behavioral Health and Intellectual disAbility Services. William White is Emeritus Senior Research Consultant, Chestnut Health Systems.