After the initial introduction (Chapter 1) of SAMHSA’s working definition of recovery provided by Neil Russell (SAMHSA), Steven Fry (SAMHSA) and Donna Hillman (SAMHSA) discussed the agency’s definition in more detail. Fry began by noting that SAMHSA’s Center for Mental Health Services began working on a definition of recovery in 2004, focusing at that time on mental health. In 2009, the agency commissioned an environmental scan of measures and instruments to gain an understanding of what the scientific community was using as definitions of recovery. SAMHSA’s definition was developed in collaboration with a large group of stakeholders who were brought together in 2010. After a working definition was developed, the agency solicited public feedback.
Fry said that the current working definition (see Box 1-1 in Chapter 1) reflects that recovery is a process of change, not a static event. An individual’s work to improve health and well-being, live a self-directed life, and strive to achieve full potential are all important aspects of recovery. He pointed out that living a self-directed life is particularly important for the mental health recovery community because opportunities for these individuals have often been limited. Fry recalled that when he was hospitalized as an adolescent with schizophrenia, he was told that he would never be able to work or have a family. To him, that was astonishing and lacking in hope. However, he went on to have a 30-year career in the mental health system, become a homeowner, and become a father.
Fry described the four dimensions that SAMHSA delineated as supporting life in recovery, shown in Figure 3-1. Home is a stable and safe
place to live. Community is relationships and social networks that provide support, friendship, love, and hope. Purpose is meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income, and resources to participate in society. Finally, health is overcoming or managing one’s condition and symptoms.
Fry said that the four dimensions he described, along with a set of principles that will be described by Hillman (see below) are what guide decisions at SAMHSA about the design of programs and about how resources should be considered in their implementation. He argued that when these guidelines are applied to how resources are used, there are reductions in emergency room visits, reductions in incarceration or contacts with the correctional system, and increases in employment and in the rates of returning to school. He added that the people affected by these resource decisions are also found to enjoy life to a much greater degree.
Hillman began by saying that she is a person in long-term recovery and for her that means that for almost half of her life she has been free of alcohol and substance use. She agreed with previous speakers about
the role of behavior in addiction and recovery. In her case, she said that there were specific linked behaviors that kept her in her addiction, and throughout her recovery there are behaviors that support that recovery. She also added that she does not associate recovery only with 12-step programs. She has not participated in a 12-step program; rather, there have been multiple pathways and multiple interventions that have assisted with her recovery. There have also been many markers in her life of being successful and moving forward.
Hillman pointed out that the four dimensions of recovery discussed by Fry are not only dimensions of recovery, but also of universal desires. People in recovery aspire to the same goals as everyone else, but they may have had a harder time achieving them. She noted that there is a general expectation across society that anyone can recover, although there are risks associated with the exacerbation of symptoms and there is the risk of relapse.
Box 3-1 summarizes the guiding principles of recovery developed by SAMHSA. Hillman said that the most important principle is hope, because without hope there is no recovery. Self-determination and self-direction are also important foundations for recovery, as individuals define their own life goals. As Hillman’s own experience illustrates, there are many pathways to recovery, and everyone’s experience is different.
Many of the principles reflect characteristics and systems that need to
be in place to support recovery. Recovery is holistic, and Hillman stressed a great need for integration between primary health care and behavioral health care. Peer support and the support of other allies are also important, as are relationships and social networks. From a measurement perspective, Hillman highlighted the fact that there are strong recovery community organizations that can be a great resource to researchers who are developing survey questions and want to reach out to potential study participants who are in recovery to test the questions.
Another guiding principle discussed by Hillman is that recovery is culturally based and influenced. Cultural background shapes a person’s unique pathway to recovery, and services and programs need to be culturally grounded and adapted to the given context.
A less frequently discussed aspect of recovery on the list of SAMHSA’s guiding principles is the need to address trauma. Hillman pointed out that in addition to considering exposure to traumatic events, such as sexual abuse or child abuse, it is important to also consider historical trauma that may affect particular racial or cultural groups. Fry’s example of being told as a child that he will never be able to have a job or a family is also a type of trauma from which one needs to recover.
A final guiding principle on SAMHSA’s list is that recovery involves individual, family, and community strengths and responsibility. These resources and social determinants serve as foundations of recovery. Hillman noted that being treated with respect is also essential for people to begin the process of recovery and stay in recovery.
In conclusion, Hillman said that she does not think that recovery can be measured as one point in time. In treatment programs, recovery is often measured as people’s improvement from admission to discharge, and it is expected that there will have been some progress toward improvement in that context. However, she argued that the focus of measuring recovery should be on impact. In other words, what is important is the impact of recovery on the person’s life. Input from people in recovery can shed light on what factors contributed most to that impact and what were the markers of improvement. Hillman argued that a longitudinal perspective seems to be essential because even those who have been in recovery for many years continue to improve over time. She said that she describes herself as a person in long-term recovery because recovery is a process.
In terms of the population of interest for measuring recovery, Hillman said that SAMHSA has a good grasp on how many people are in treatment, but there is a large number of people in recovery who have not been counted. Reaching out to peer support recovery communities would be one avenue for reaching out to a broader population, beyond those individuals who are in treatment.