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Measuring an individual`s recovery barriers and strengths
In 2008, Granfield and Cloud defined recovery capital as “the sum total of one's resources that can be brought to bear on the initiation and maintenance of substance use cessation.” These authors discussed the four component parts of recovery capital as social, human, physical and cultural. They also introduced the idea of “negative recovery capital” to indicate that certain circumstances (a significant history of mental health problems, a history of engagement with the criminal justice system, older age and female gender) constitute barriers to recovery.1
The concept of recovery capital has since been cited in a number of locations, including the U.K., Australia and the U.S., and is recognized in official policy documents ranging from the U.K. Drug Strategy2 to the Victorian drug treatment system reform in Australia.3 In the U.S., recovery capital is also included in SAMHSA's white paper on recovery-oriented systems of care.4 However, while widely discussed, recovery capital remains a poorly operationalized term that has offered little to practitioners or policy leaders in developing metrics for recovery progress.
In 2012, Groshkova, Best and White published the psychometrics for the Assessment of Recovery Capital (ARC), showing positive reliability, internal consistency and concurrent validity for a scale developed in partnership with community recovery services in Scotland and England.5 The ARC consists of 50 items: 25 relating to personal recovery capital and 25 relating to social recovery capital. The questions cluster into 10 subscales providing greater detail into the areas of strength and support that an individual in recovery possesses. The measure was designed to sit alongside a previous measure developed by the same team that evaluates recovery group engagement: the Recovery Group Participation Scale (RGPS).6 This 14-item questionnaire assesses involvement not only in Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) but a range of other community recovery groups. These 64 items in total provide the basis for measuring what resources and support a person has at that stage in his/her recovery journey.
While these scales have been used in both research and clinical practice in several countries, they have never previously been embedded into a measure that tracks recovery progress. This approach utilizes a strengths-based perspective that can be implemented before, during and after specialty treatment. We have embedded both recovery strength measures into a single scale that can be administered by clinicians, peer mentors or people in recovery to create a simple visualization of recovery stage and needs. This new method of assessing recovery capital is a measurement tool called the REC-CAP.
We offer here an overview of initial results from the initial phase of the first U.S. pilot project assessing REC-CAP implementation. This project has been undertaken as a partnership between Sheffield Hallam University, the Florida Association of Recovery Residences (FARR) and eight FARR members. William White is the external partner and adviser to the project.
We present the findings from 100 of the first cases successfully completed at three of our participating sites to showcase what the REC-CAP is capable of, and to illustrate the initial profile of resources, barriers and needs of a cohort living in recovery residences.
Overview of study method
Eight recovery residences throughout Florida signed on to pilot the REC-CAP with their residents. The survey took an average of 20 minutes for each resident to complete.
After basic demographic data, the next section of the REC-CAP assesses quality of life and satisfaction using a “ruler” to measure five areas of well-being: psychological health, physical health, quality of life, accommodation and social support. Barriers to recovery are then assessed in five areas: accommodation, substance use, risk taking (injecting), offending and employment. The aim is to see whether there are problem areas that would block progress in the recovery journey. Also, to assess barriers, questions are asked about specialist help needs across a broad spectrum of services, evaluating whether the participant has ongoing or unmet service needs in areas including housing, mental health and family support, as well as alcohol and drug specialty treatment.
The REC-CAP then turns from barriers to strengths. The core of the strengths measure is the ARC. Following the ARC is the Recovery Group Participation Scale (RGPS). Next is a four-scale measure, the Social Support Scale7, which evaluates the second aspect of social support: support satisfaction that is not related to the level of involvement in recovery groups. The battery of quantitative tools concludes with the Commitment to Sobriety Scale (CSS).8 This measures commitment to or motivation for sobriety and is a six-point Likert-like scale consisting of five statements.
Finally, because recovery is a very personal journey, the final section provides a space for residents to fill in their own thoughts about where they are in the process, what needs they have, and what their individual goals are. The basic REC-CAP process is illustrated in Figure 1.
Findings on barriers and strengths
The sample consisted of 100 cases: 31% of residents from Safe Haven, 28% from Trinity by Traditions, and 41% from Good Works Recovery. The mean time in residence was 180.8 days. The sample consisted of 84 men and 16 women, with an average age of 28.5 years (range: 19 to 62).
Findings on barriers to recovery were as follows:
- Housing: The predominant patterns for accommodation were very low risk of eviction (6%) or housing problems (12%), while 29% of residents reported historical debt issues.
- Substance use: 63% of respondents reported not having used legal or illegal substances in the past 90 days. Among the 34 residents who did, the most problematic substance was tobacco, with 23 residents reporting its use, closely followed by cannabis (16 residents). Substance use was associated with lower quality of life and satisfaction.
- Risk taking: 12% of residents reported injecting drugs in the past three months.
- Offending: Ongoing criminal justice involvement was low, with 25% on probation and 6% on parole. Similarly, only 13% reported recent offending and 11% reported police involvement in the past three months.
- Lack of meaningful activities: 57% reported working full- or part-time, and 16% were involved in volunteering. 27% reported no engagement in meaningful activities.
In total, 49 people reported no barriers to recovery in the last three months, with 21 people reporting one barrier, 16 reporting two barriers, and 14 reporting four or more barriers. It is critical to know and address current barriers (ideally utilizing the strengths identified below), as they will actively block recovery capital growth if not addressed.
Six participants reported ongoing additional needs (needs that were not being met at the time of the survey, irrespective of whether they were engaged with services) around drug treatment, five around alcohol treatment, 10 around mental health services, 11 around housing, nine around employment, 14 around primary care, and 12 around family relationships. Shorter time in treatment was associated with greater unmet needs reported for drug treatment, alcohol treatment, mental health and housing, suggesting that some of these problems may apply more to individuals new to the recovery residences. Thirty-two participants reported additional support needs: 12 in a single domain, nine in two domains, eight in three domains, two in four domains and one in five domains. More barriers to treatment and more ongoing support needs both were associated with shorter time in the residence.
Having identified current recovery barriers and unmet support needs, the focus then switched to strengths:
- Well-being: The mean scores out of 20 on the five well-being indicators are shown in Figure 2, with all scores exceeding 15 and particularly high scores for quality of accommodation and quality of relationships.
- Recovery capital: The mean raw score for personal recovery capital was 20.5 out of 25, and for social recovery capital was 21.2. There was a strong positive correlation between personal recovery capital and social recovery capital, indicating a positive and dynamic relationship between the two.
- Recovery group participation: This was mirrored in recovery group participation, where the mean score was 10.8 out of 14.
- Social support: This was strongly endorsed, with a mean score of 24.3 out of 28.
- Commitment to sobriety: There was almost complete commitment to sobriety, with a mean score of 28.8 out of 30.
There is support for our assumption that ongoing support needs and barriers reduce the person's ability to build recovery capital. Those with more ongoing needs reported worse psychological and physical health, lower quality of life, and less satisfaction with the accommodation. Ongoing support needs were also associated with much lower personal and social recovery capital, less involvement in recovery groups and poorer perceived social support. Actual barriers to recovery were associated with lower quality of life; less social support, personal recovery capital, social recovery capital and involvement in groups; and lower motivation. In contrast, those who reported higher personal and social recovery capital indicated strong associations to the other core measures used in the REC-CAP.
The ARC remains the core of the new measure, but the REC-CAP broadens this to create a wider platform of strengths, including motivation, group support, mutual-aid group involvement and a range of well-being markers measuring factors that are linked but conceptually and practically distinct.
Implications for services
The data presented here illustrate the range of measures collected using the REC-CAP to provide an initial overview of barriers to recovery and needs for ongoing professional involvement, then moves to a more in-depth analysis of the strengths the individual has for addressing recovery needs and overcoming any barriers. This is fundamentally a positive and strengths-based approach, with the solutions to recovery problems believed to lie in the personal, social and community capital that the individual can draw upon, and the therapeutic resources he/she has.
It is important to say that, having set a target of 300 completed forms from our eight participating sites, 630 actually were completed, although we present data here for only 100 of that total. This is not only testament to the commitment of the recovery residences but also a reflection of how easy, accessible and intuitive the instrument is. We specifically requested that half of the surveys be done as resident self-complete and half with worker support, and this did not make a difference in the response we received. This was coupled with the fact there were almost no unanswered questions within the instrument.
However, our goal is not to be restricted to a “paper and pencil” measure. Our next iteration will translate this into an online version that will facilitate follow-up, increase opportunities for anonymous completion and user accessibility, and allow results to be computed and reported back instantly to the client and/or mentor. This is critical in utilizing the REC-CAP as a recovery planning measure that will track change over time and can be used within the recovery alliance. This will help to build a positive and strengths-based relationship to building stable recovery and a positive quality of life.
Finally, the online version will also prompt a series of visualization maps around building strengths and overcoming obstacles. This means the REC-CAP is not only a record of recovery progress but also a method of reviewing and planning the stages of a recovery journey that will take place outside treatment.
The project team is working on the science and will continue to write about the REC-CAP and its properties. We will look to establish norms and profiles associated with the strongest recovery outcomes. But the primary aim is to provide a systematic way of measuring recovery capital. The scale will allow recovery growth to be tracked over time as the person transitions to stable and lasting recovery, and will address any obstacles on that journey using a model predicated on furthering hope and growth, not on managing pathology or illness.
David Best is Professor of Criminology and Head of Research for the Department of Law and Criminology at Sheffield Hallam University. He is the author of more than 160 peer-reviewed research papers, 60 technical reports and papers, and four books on addiction recovery. His key research interests are around pathways to recovery and the relationship between recovery and desistance. Michael Edwards, Adam Mama-Rudd and Ivan Cano also are with the Department of Law and Criminology. John Lehman is President of the Florida Association of Recovery Residences.
References
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2. UK Home Office. Drug Strategy 2010 Reducing Demand, Restricting Supply, Building Recovery: Supporting People to Live a Drug Free Life. London: HM Government; 2010.
3. Victorian Department of Health. New Directions for Alcohol and Drug Treatment Services: A Framework for Reform. Melbourne: Victorian Government; 2013.
4. Kaplan L. The Role of Recovery Support Services in Recovery-Oriented Systems of Care. Rockville, Md.: Substance Abuse and Mental Health Services Administration; 2008.
5. Groshkova T, Best D, White W. The Assessment of Recovery Capital: Properties and psychometrics of a measure of addiction recovery strengths. Drug Alcohol Rev 2013;32:187-94.
6. Groshkova T, Best D, White W. Recovery Group Participation Scale (RGPS): factor structure in alcohol and heroin recovery populations. J Groups Addiction Recovery 2011;6:76-92.
7. Haslam S, O'Brien A, Jetten J, et al. Taking the strain: social identity, social support, and the experience of stress. Br J Soc Psychol 2005;44:355-70.
8. Kelly J, Greene M. Beyond motivation: Initial validation of the Commitment to Sobriety Scale. J Subst Abuse Treat 2014;46:257-63.
