Is it possible to recover from recovery?

Since 2008, the UK has based its overall drug treatment policy and allocation of resources on “recovery”, the overall goal being abstinence and patients becoming “chemical free” (Home Office, 2012). The policy change came after criticism of the orthodoxy of harm-reduction measures, which the UK is traditionally known for. The policy change implied major consequences for patients in substitution treatment: the treatment goals shifted from retention to tapering and exiting treatment. This shift in treatment policy is thought by some to be the lead cause for the recent surge in overdose deaths and treatment dropout in the UK (Middleton, McGrail, & Stringer, 2016). In his article in this issue, David Best presents some of the advantages and problems associated with the shift to a recovery-based treatment system, and argues for a broad concept of recovery that includes harm reduction and medical substitution treatment (Best, 2017).

But is it likely or even possible to reach a consensual definition of a concept laden with specific historical, scientific and cultural pre-connotations? A. B. Laudet writes: “Determining what authors mean by ‘recovery’ in scientific articles often does not become clear until the methods section. There, ‘recovery’ typically vanishes, to be replaced without explanation by ‘abstinence’” (Laudet, 2008, p. 2002). Another question is whether the term “recovery” which is applied in Scandinavian treatment policy would contribute to the positive development described by Best.

Between rehabilitation, recovery and user involvement

The Scandinavian countries (here Denmark and Norway) do not have a native term corresponding to the meaning of “recovery” either in the mental-health field or in drug treatment. Mental-health professionals and policy makers have therefore imported the untranslated term “recovery”, indicating that this approach represents something totally new in the Nordic context. Only in the Nordic 12-step rhetoric has the word “recovery” been translated as bedring or tilfriskning (“getting better”).

Traditionally in Denmark and Norway, rehabilitation has been a key term in the treatment and care of psychiatric patients, drug addicts and socially marginalised citizens. Rehabilitation describes the process that needs to be organised regarding the (re)integration of the individual into a broader social context, and is frequently addressed in legal texts and guidelines. For instance, medically assisted drug treatment in Norway is labelled as LAR (legemiddel assistert rehabilitering) – medically assisted rehabilitation. In both Denmark and Norway, rehabilitation of drug addicts has traditionally been highly prioritised, and the state and the municipalities are obligated to offer services in relation to family members, housing, employment and health.

In Denmark, the goal of psychiatric rehabilitation is the inclusion of the patient into broader society through structured treatment efforts. “Rehabilitation is based on the citizen’s whole life situation, and consists of coordinated, consistent and knowledge-based activities” (Marselisborgcenteret, 2007, p. 16, translated by the author). Recovery, on the other hand, is described by Eplov (2010) as a unique personal journey, impossible to structure and organise. Following these definitions, the treatment process must include a great deal of cooperation between professionals and clients. Considering the many guidelines and large amount of legislation on user involvement in health and social services in both Norway and Denmark, the exact contribution of the concept of recovery remains unclear. However, the concept of recovery in mental health remains a disputed and internationally discussed subject.

The US recovery concept

Historically, the concept of recovery in addiction treatment originates from the American 12-step movement, and embeds its own original perspectives in relation to addiction, treatment, mental health and personal outlook. In 2015 Michael Botticelli was appointed “drug czar” in the United States, his own recovery being the sole qualification. On 13 December 2015, Botticelli was guest on the popular TV show 60 Minutes, where he gave a short presentation of the American road to recovery. A self-defined “sober recovering alcoholic”, who has remained abstinent for 26 years, he still attends AA meetings and intends to do so for the rest of his life. He will never be able to take mind-altering drugs, not even as pain medication, as it will trigger his alcoholism. Also, he still identifies as an “addict” suffering from a chronic and life-long disease that requires life-long abstinence. Botticelli’s recovery narrative is not unique. It is shared by millions of Americans who have traditionally turned to self-help and religion in the absence of public health and social services.

Redefining recovery for local utilisation?

This concept of 12-step recovery has permeated American culture regarding identity and outlook, as illustrated by historian Trysh Travis in her 2010 book about the traditions of recovery and American self-help. And as shown by numerous researchers, the 12-step-based concepts of addiction and recovery have largely monopolised the American treatment system, underscoring the need for abstinence-based services and excluding harm-reduction approaches (Fletcher, 2013; Peele, 1995). Adding the notion mentioned by Laudet, that scientific literature tends to define recovery as abstinence, and given the large production of scientific research and publications by American scholars, it remains an open question whether a local redefinition of the recovery concept in accordance with the broader meanings suggested by David Best is feasible.

As the Scandinavian welfare states traditionally focus on rehabilitation and politically prioritise user involvement at all levels of treatment and care, the usefulness of introducing “recovery” in the planning and practice of treatment in Scandinavia seems dubious. The positive potentials described by Best are already integrated into the Danish and Norwegian legislation and covered by the concept of rehabilitation.

Should we nevertheless choose to import the concept of recovery into the Danish and Norwegian drug-treatment policies, then the challenges portrayed by Best will pose real problems, and as Scandinavians tend to import Anglo-American treatment technologies while failing to consider the problems associated with their application to a different context, this could very well happen.

Would we risk kindling the old unproductive battle between harm-reductionists and abstainers? The American and British experiences demonstrate this as a possible and likely consequence. And Best presents another possible outcome, that professional treatment will be downgraded for the benefit of a naïve (but economically and bureaucratically tempting) notion of “inclusion in the community supported by family and peers”. In Denmark, the long-term, damaging effects of the closing of psychiatric hospitals for the benefit of “social inclusion” of psychiatric patients has been evident. A similar process was seen in Norway, when institutions for the mentally disabled were closed following the same line of reasoning. Such reorganisation, however well intended, led to major problems and failures for some of the most vulnerable citizens.