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In Episode 7 of our ASAM Criteria Unplugged series, we invited David Whitesock to discuss recovery measures and how to set patients up for success and long-term well-being in recovery.
About special guest, David Whitesock
David Whitesock has led innovative and entrepreneurial programs in addiction, recovery, and technology since 2004. While designing new approaches to peer coaching, he developed the Recovery Capital Index® (RCI).
David founded Commonly Well in 2020 to broaden the reach and impact of the Recovery Capital Index and to improve how data is used to enhance the recovery process. Through Commonly Well, David also works with healthcare systems and behavioral health clinics to design and implement improved patient experiences.
Sitting down with The Change Companies Chief Program Officer Valerie Bagley and Train for Change Senior National Director Scott Boyles, David Whitesock shares insights about sustaining successful outcomes in long-term recovery.
Q: What does “Recovery Capital” mean?
David Whitesock: Well, there's two parts to that. There is the thing that we call Recovery Capital. But there is that first word, which is "recovery," and so we kind of have to define both. So, first, recovery is defined [by] SAMHSA [as]: a life that's self-directed towards growth and progress and not necessarily a cessation of a use of drugs or alcohol — but that could be part of it for some people.
Recovery Capital are all of those internal and external resources — either that we have within us or outside of us in the community or in our world — that we can draw upon to help us through that process of change, that recovery process and that process of growth. And so we can get into the weeds of what those specific things of Recovery Capital are.
But just as some quick points: think of your job. That's what we would call personal capital. Your own mental well-being, that's personal capital. Who your friends are, your family. Are they connected? Do they help you? Do you help them? That's social capital. And what's my passion? How do I fit in the broader community? And do I feel belonged? And do I have a purpose? That's our cultural capital. Put all that together and you've got strengths and deficits, and they can either help or hinder your progress.
Q: Why is it important to measure Recovery Capital? And how early should we be thinking about measuring it?
David Whitesock: So measuring [Recovery Capital] gets back to that sort of long-standing success measure around drug and alcohol addiction or substance use disorder. And that is sober/not sober. And for a lot of people, that end-all, be-all kind of determinant of having to self-select sobriety or not using drugs again for the rest of my life is a really hard decision.
It's a really hard goal to reach. And so you have people that kind of cycle through that process. And it is part of the process. However, psychologically, having to have day one happen to me over and over and over again sort of destroys what other progress might be happening around me. So I might have just gotten a job. I might have gotten my kids back. I might have gotten out of jail. I might have rekindled some relationships. I might have started to find a path towards the place in life that I want.
Society and even the treatment system for a long time said, "Nope, you return to use. That relapse hits reset and you’ve got to start over. All the other good stuff be damned." And so Recovery Capital says, "No, no, no. Let's look at the rest of what's happening in your life. Let's bring all that to bear. We can quantify it."
Q: What are the implications for the treatment experience then for that person if we are looking at this whole-person approach?
David Whitesock: I think it means that we get to bring more resources to bear. It also kind of complicates things because for so long, the system has kind of been rooted in this one outcome: "Is David still sober?"
And we kind of let our interventions that have been designed for a long time follow that path. But I think what it means is looking at the holistic nature of a person's life. It opens up a lot of doors of how we might be more of service to that individual, moving to the next stage, getting through that clinical treatment, whatever it is — whether it's residential or outpatient. But moving them to that next stage and finding one or two things, that could be the thing.
If it's a job interview, what do you need? You probably need appropriate clothing. Well, can I as a case manager or can we as a provider, make a connection in the community to serve that? And if that person gets the job, fantastic. Now we've put wind in their sails and the likelihood of treatment success goes up.
Q: How do we measure Recovery Capital?
David Whitesock: I stumbled into this and what I found was that a decade ago, 2012 or so, there are assessments for pretty much everything. Spirituality and well-being and resilience and joy and happiness and life satisfaction, everything. Oh, in the addiction and mental health arena, most of the assessments were specifically tuned to symptoms.
And so when I dove down the rabbit hole, there was an emerging concept of Recovery Capital, but still that was rooted in the engaging in recovery support, specific recovery support — like 12 Steps and peer support and these kinds of things —– still connected to use/non-use. And so when we think about, "How do we measure it?," it's looking at all of these other validated measures that already exist in the world, like the World Health Organization Quality of Life measure and a bunch of other things and sort of bringing them into the context of how I described Recovery Capital before. There's a ton of research that says, "These are the types of indicators. These are the type of determinants that lead to successful cessation of use or reduced relapse."
You mentioned David Gastfriend earlier, he's done a lot of work around contingency management and what works and doesn't work as we motivate people's behavior change. And those things fit too. And so we just took a lot of these items that already existed in the world and put them into a mental kaleidoscope: prioritize them, rank them and say, “Okay, let's give this a try,” and test them. And out came something that we found was pretty valid to demonstrating that recovery experience.
Q: Can you conceptualize how we might use this hand-in-hand with the treatment plan as another way to capture progress and care?
David Whitesock: The treatment plans typically have this kind of end date on them. We look ahead to… it's no longer a “discharge” date, it's a transition date. And I love that now, because this kind of fits with how I want to describe this. We don't think about that end point when we're thinking about measuring Recovery Capital or adding social determinants to the treatment plan. We're looking at a point far [in the] future, like that's the point we want to get to and we're going to skate past that initial line.
So what do we need as we're moving through that transition to help get the person beyond that clinical experience to start to be really successful as they're moving into the next phase of care, whether it's clinical or aftercare or peer support, if you will, non-clinical care? And so I think it informs the next number of steps beyond that clinical experience, which sometimes is very honed in on a handful of things.
Q: How do you continue to measure Recovery Capital after someone leaves your direct care?
David Whitesock: That is the challenge of the industry because we have a lot of research that says… five years is really a gold mark of "Can we get somebody to that five-year point?" But our reimbursement and our fee structure around services isn't past maybe 30 days or nine weeks or something else. And so for a lot of organizations, it just doesn't make financial sense to do it.
My argument is it doesn't make financial sense not to do it because you want to build emotional loyalty with that particular patient or client. Not for an alumni-referral reason, but because your success is rooted in their longitudinal success. First three months when people leave, all the data in the world shows that depressive and anxiety and substance-use symptoms go down. It just does pretty much for 90% of people.
But we start to see this return back to some of those symptoms at six and 12 months... We can start to add and continue measures even though the client or the patient is no longer a client or a patient, but we can continue to engage them and provide some support in very limited ways.
And that's going to allow you to see that change growth over time and get some of that insight to say, "Oh my goodness, our treatment just isn't sticky at 12 months. We've got to do something else because something is dying off here and we've got to re-engage."
Q: Is there anything else you’d like to add related to Recovery Capital?
David Whitesock: All I would say is just keep up that curiosity. We don't have to complicate the process. We shouldn't complicate the process. We have people that are going through really challenging moments in life. And the more we gum that up, the worse our success rates are going to be. So my reminder is always just "Keep it simple."
Yes, there are other measures out there that are shorter and quicker. And I'd say, "Use them, try them. Use them in a context that you think is going to be helpful."
The only thing that I will mention to all of this that we haven't talked about is setting expectations. If you're going to bring a measure into your practice, tell your patients why. "We're going to use this thing. It's new to the process. This is the reason for it. This is kind of what we expect to get out of it. This is what we hope it will help for you in this process." Open up that expectation because expectations set the tone and really can get some positive outcomes.
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