Recovery Oriented Systems of Care (ROSC): It's All About Recovery!
MichaelT. Flaherty, Ph.D.
At the beginning of this century two seismic transformations occurred in our country’s approach to substance use and addiction. Transformations still taking hold today while offering 21st Century modernized practice and support to each person, family and community.
The first transformation came when over 50 leaders and those in recovery gathered and disseminated a consensus paper suggesting the first ever "Unified Vision for the Prevention and Management of Substance Use: Building Resilience, Wellness and Recovery—A Shift from an Acute Care to a Sustained Recovery Management Model " (Flaherty, 2006). Built on paradigmatic changes in the science and practice (e.g. McLellan, et al., 2000; White & McLellan, 2008), this “core group” of 54 change leaders then and subsequently have re-framed what has since been described in medicine (e.g., Barber, 2012) as the 21st Century Medical Model.
Today’s model is one inclusive of a reframed understanding of the illness management that brings shared decision with the person and family and personal recovery as integral to medical practice and ultimate evaluation of success. Since the illness itself was reframed as potentially chronic and life-long, understanding it needed to move beyond the then existing acute care approaches (e.g., broken arm) to a full continuum of care approach, as seen in other chronic illnesses (e.g., HIV, depression, diabetes). A new continuum of medical care was called for and continues to emerge today, calling for enhanced education and prevention, early intervention, and evidence-based practice with continuing care for sustained recovery integrated across specialist and generalist care.
Including people in recovery
...ROSC is more than treatment. It is a set of community values instilled in to the system of indigenous and professional services and relationships of the community that offers access to initial recovery and the sustainment of long-term recovery.
The second seismic shift, and perhaps the most important, was bringing the over 35 million Americans (White, 2012) who had already found recovery back into the transformation process. As one ATTC leader said at the time - with tears in her eyes- “you mean you are finally inviting us back into the tent?”
In this moment today’s Recovery Oriented System of Care (ROSC) may have been born. A potentially chronic illness science was joined by those millions who knew it was so all along...and they could share what worked for them.
and the Addiction Technology Transfer Centers
(ATTCs) played an invaluable foundational role. Examining and participating each step of this evolution, CSAT and the ATTCs provided a vital part in disseminating the new understanding, the reframed model and the then and current emerging science based on this transformation. The ATTCs became the entry for states and providers to knowledge, new approaches and the emerging science—even as they addressed their many other demands (e.g., Northeast ATTC, 2008). Two ATTCs in particular, the Great Lakes ATTC
and Northeast ATTC (Pittsburgh), joined voluntarily to be clearing and publication houses and engines for a recovery model under the tutelage of William White, Ernie Kurtz, Larry Davidson (MH) and many in recovery, now joining scientists, providers and leaders across America.
ROSC: More than treatment
SAMHSA's working definition of recovery from mental disorders or substance use disorders:
"A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential."
Recognizing an immediate need for relevance, field consensus panels quickly emerged and offered first definitions of recovery (Betty Ford Institute, 2007; SAMHSA, 2007), with elaborated shared principles and objectives that could become an early template for building ROSCs locally. Across America some 44 states (and Puerto Rico) sought training as counties, communities, providers and peers set out to define a “process” for recovery in their community (Kelly & White, 2010).
But ROSC is more than treatment. It is a set of community values instilled in to the system of indigenous and professional services and relationships of the community that offers access to initial recovery and the opportunity for the sustainment of long-term recovery. It does this in individuals and families by improving strengths or the “recovery capital” of each and all in the community (Granfield and Cloud, 1999). The “system” here is not a government or any particular agency but a dynamic macro-level local organization representative of the community’s members, values, needs, services, and plans.
Recovery Management is the boiling down of a ROSC and recovery focus into the continuum of care offered and provided so as to then enhance prevention, pre-recovery engagement, recovery initiation, long-term recovery maintenance, i.e., the quality of personal, family and community life. William White (2008) and others have now defined system, agency and recovery measures which have been incorporated into each state’s Federal Block Grant funds for potential implementation by the states. While pathways and phases of recovery become more visible (e.g. White, 2006; Flaherty et al, 2014; ) communities across America are implementing this vision in whole or in part. ROSC is now visible in some form in most states and 8 countries. A Recovery Research Institute under the leadership of John Kelly, Ph.D., is housed at Harvard (https://www.recoveryanswers.org) with a growing library of topics and scholarly citations; the science is also found at www.williamwhitepapers.com or www.samhsa.gov search “recovery,” et al.
ROSC and the opioid epidemic
As America faces the current overdose challenge some would say the ROSC movement is now necessarily overshadowed by the many challenges of this epidemic. Others would say the current epidemic is a symptom of long term absence of ROSC and that by building local community ROSCs we will eventually bring the epidemic under control. Simply, ROSC is a community solving its own problem with its declared values, oversight and resources joined to best science and practice. It focuses on addressing pathology and wellness. A ROSC community includes all that public safety (e.g., law enforcement) and public health (e.g., population health, prevention enhancement) can jointly offer the community. There is no contradiction of ROSC with properly practiced medication-assisted treatment (White, 2010) or many community sought harm reduction strategies, or significant peer workforce development for warm handoffs, or Physician Drug Monitoring Programs (PDMPs), or open access to naloxone, etc. No contradiction at all. None either with recovery housing, Drug Courts, recovery centers or any personal pathway to recovery. Overdose prevention is the extension of the ROSC continuum into one of today’s most challenging areas. In these extremes recognizing the power of addiction and remaining alive can be the potential beginning of recovery. If each individual engaging the “system” is offered hope and an opportunity for recovery, the epidemic will diminish. ROSC is SAMHSA’s Recovery Month message in action. It embeds hope and possibility by strengthening each person, family and community.
Michael Flaherty, Ph.D., is a clinical psychologist with more than 36 years of practice. In 1999, he co-founded the Institute for Research, Education, and Training in the Addictions (IRETA) and became the Principal Investigator for the SAMHSA/CSAT-funded Northeast ATTC. Today he seeks to assist communities seeking to develop and implement Recovery Oriented Systems of Care. Since 2015 he has served as a clinical advisor to U.S. Attorney’s Plan to address the overdose epidemic in western Pennsylvania and nationally. Dr. Flaherty dedicates his work to policy, clinical practice, consultation, research, and the sustainment of a recovery focus in all. In January he received the Pittsburgh Psychological Association 2016 Legacy Award for lifetime contributions to the W. Pa. community.