Variability of Recovery Support Outcomes
In past communications, I have energetically objected to the marketing slogan “Treatment Works!” Professionally-directed addiction treatment of complex disorders generates highly variable outcomes that defy such simplistic claims. So what can be said of such outcomes? Whether we are talking about widely varying approaches to addiction treatment; participation in a secular, spiritual, or religious recovery mutual aid group; or participation in any of the newer recovery support institutions or services, individual responses span at least six possible outcomes.
First, there may be no sustained measurable effect. This means that the frequency, intensity, and consequences of substance use and one’s global health status are not measurably different following the helping effort than they were before such help was provided. This category includes interventions that produce brief improvements that quickly erode to the pre-service baseline.
Second, there may be a minimal effect. Here, there is a slight measurable decline in substance use indicators and/or a slight improvement in global health indicators, but substance use and related problems continue to exert profoundly negative effects on the individual and his or her family and social network. The effects are measurable, but not substantial enough to effect long-term trajectory of the disorder or its effects on quality of life.
Third, there may be a moderate effect. In this scenario, there are clear changes in substance use severity (frequency, intensity, and consequences), with some substance use and related problems continuing. There may also be a change in one dimension of the disorder (such as achievement of sustained remission of the substance use disorder) but no change in broader indicators of global (physical, cognitive, emotional, relational, spiritual) health or social functioning. Moderate change is medically referred to as partial recovery.
Fourth, there may be an optimal effect, sometimes referred to as full recovery. In this case, the problem resolution effort has resulted in complete resolution of the substance use disorder and measurable improvements in global health and functioning. Optimal effects occur when there is a near-perfect match between the person, the intervention, and the timing of the helping effort.
Fifth, there may be an exemplary or exceptional effect, sometimes referred to as amplified recovery. In this scenario, the intervention is both curative and transformative. This means that the substance use disorder is in complete remission and that the individual has experienced dramatic elevations in global health and service to the community. Sometimes referred to as “getting better than well,” this style can be a product of “quantum change” or “transformational change”–a process of change that is unplanned, positive in its personal and social effects, and permanent—a sudden cleaving of one’s life into the categories of “before” and “after.”
Sixth, there may be a harmful effect, sometimes referred to as iatrogenic illness (injury caused by the helping effort). This means that the individual seeking help is in worse condition (a process of clinical deterioration or other accompanying injury) following, and as a direct result of, the intervention that was purported to be helpful. There is a long history of harm in the name of help within the alcohol and drug problems arena (See here and here).
Here are some further principles/observations related to these potential outcomes.
- Effects of interventions into complex disorders (those with multiple etiological influences, diverse and remitting/recurring symptom manifestations, and frequent co-occurring disorders) can vary dramatically from person to person. What is transformative to one may have no, minimal, or even harmful effects on another.
- Effects of interventions can vary in the same person at different points in time, suggesting that person-treatment matches must be tailored to evolving stages of addiction and recovery.
- No effects and minimal effects can result from interventions that lack any potent ingredients, a mismatch between person/intervention, or the delivery of inadequate or excessive doses of the intervention. The latter effects are comparable to inadequate dose/duration of antibiotic therapy or the harmful side effects of excessive dosages of effective medications.
- When one compares the effects of different interventions (e.g., a professionally-directed treatment protocol, participation in a recovery mutual aid organization, participation in a recovery residence or collegiate recovery program, or recovery coaching), there are common factors related to measured effects (shared active ingredients) and intervention-specific factors (active ingredients found only within a particular intervention). The isolation of common and specific factors is as important to potential replication and clinical and cultural adaptations as are measuring general intervention effects.
- Combining and sequencing interventions with potent ingredients may generate amplified/synergistic effects greater than could be expected by adding the effects of the separate ingredients. The future of enhancing long-term recovery outcomes may well rest on such combinations and selective sequencing. For example, with some individuals, combining medication with psychosocial support in the treatment of a substance use disorder may generate outcomes superior to either medication or psychosocial support used in isolation.
- The presence, degree of potency, and duration of support may have greater influence on recovery outcomes than who (what role) delivers the intervention.
- The greater the physical, psychological, and cultural distance between the location of service delivery and a person’s natural environment, the greater the difficulty in sustaining institutional learning within one’s natural environment. Treatment (recovery initiation) may be able to be provided in a remote location, but long-term recovery (maintenance of change) must be anchored within one’s own physical and cultural landscape.
For those interested in average recovery outcomes with and without professionally-directed treatment, see my 2012 monograph summarizing the findings of more than 400 community and clinical studies.