How Addiction Care Learned to Think in Episodes
In the 12-Step community we talk about "what it was like, what happened and what it is like now."
What I have been talking about at a treatment conference this week with other attendees is the fundamental split in philosophy that makes it tough to holistically fill the Missing Middle. We currently have a clinical treatment system in CA that is largely built and funded around one or more episodes of care, and then we have long-term recovery solutions like recovery housing, which is what somebody has to be able to sustain after those episodes end. They are both important. They are not the same thing.
What it was like, for much of our modern history, was that substance addiction was largely thought of as a moral weakness, a crime and/or a purely mental health issue, even though the medical and disease models did exist before the 1980s. The 12-Step community was there before our modern treatment system and has remained since, focused much more on long-term recovery processes. But because it was anonymous, peer driven and not easy to monetize, it did not fit neatly into what insurance would cover or what researchers could easily fund and follow over time. Insurance focused on clinical treatment modalities, therapy and psychiatry, medication and medical treatment, while also heavily influencing the duration of coverage via the utilization review system. That helped shape the buildout of clinical detox, residential treatment and outpatient services systems.
The history of the initial 28-day residential treatment model is more complicated than insurance simply deciding that was the right number. The Minnesota model developed in the 1950s included professional treatment, recovering staff, connection with the 12-Step community, family involvement and planned aftercare. Then insurance coverage and provider practice started reinforcing each other. In 1981 the National Association of Insurance Commissioners endorsed a model benefit of 30 inpatient days and 30 outpatient visits a year, and a 1986 survey of 230 chemical-dependency programs found the average inpatient stay was 28 days. This National Academies history helps explain how it happened. Twenty-eight days became a familiar episode of care. It did not become familiar because anyone proved that was the most efficacious amount of time to achieve long-term recovery.
This reimbursement focus was coupled in time with reducing long-term psychiatric institutions without fully building the community infrastructure that was supposed to replace them, the increase in incarceration through a punitive turn in drug policy and longer sentencing, and modern mass homelessness emerging through several different forces that did not cause one another in one simple line, but often landed on many of the same people.
That is what happened: episodes became easier for the system to fund than long-term recovery.
So what is also at play is the idea of the disease model of SUD. If you believe as I do that someone can have a mind, body and spirit disease, and has experienced it for any considerable time, continued substance use is much more likely to get worse over time, not better. The controversial question is when does somebody cross over to the point where that is the most likely outcome. I don't think there is one research-based line that applies to everybody. But in my experience the other options are typically not longitudinally successful in terms of eventual return to SUD-type use progressively getting worse over time, not better, especially for those with chronic and severe SUD histories. I would not build a recovery home or long-term recovery process around moderation for that group. The same is true for harm reduction: it can keep somebody alive, which matters a lot, but for most people with chronic and severe SUD histories it is not the long-term destination.
The distinction that Dr. Harry Tiebout made between surrender and compliance is usually not fully considered. A person can sincerely comply and still believe they can manage the disease. One patient said to him, "I know all the reasons but I don't know how to be reasonable." Surrender did not mean submission to somebody else; it meant internal acceptance. Completing one or more treatment episodes is often not enough time to tell whether that internal acceptance has happened.
A 2020 Cochrane review found that Twelve-Step Facilitation designed to connect people with the 12-Step community improved continuous abstinence and probably reduced healthcare costs. The research does not turn the 12-Step community into treatment; it supports the value of a clinical bridge to that continuing peer connection and community.
It is why I have always believed long-term recovery solutions should be the dog and clinical services should be an important part of the tail. Too often, clinical is wagging the recovery dog—both in funding and in society's broader value system.
What it is like now is that long-term recovery housing is often the glue and thru-line alongside clinical services while staying within the scope of lived-experience peer mentoring and support.
At Awakening Recovery, we provide gender-specific, abstinence-based recovery housing to those without financial resources as a part of our nonprofit mission through a dynamic, year+ process focused on the 12-Step community and peer mentoring, toward graduation. We do not provide clinical treatment or make medication decisions. Residents work with appropriately licensed outside providers, with staff providing warm referrals and care coordination when appropriate. As our residents typically don't have insurance our care coordinated and referral local clinical partners are mostly fellow nonprofit organizations who take Medi-Cal.
Spending a year+ in the same healing place, within the same dynamic recovery home process and community, gives residents time to learn how to stay sober, keep a job, begin healing relationships, take responsibility, commence making restitution, and reduce repeated returns to incarceration, hospitals and emergency rooms.
Recovery housing can be the glue, bridge and safe container that helps residents build self-esteem and self-care while reconnecting with outside mental-health, psychiatric, medical and dental services, including for those most vulnerable in our community Medi-Cal providers. Many have either never been able to focus on those needs or have gone years without doing so because of active substance use and everything that comes with it.
From where I sit, insurance and public funding remain overwhelmingly focused on short-term episodes of clinical services. When that is what the system primarily pays for and measures, we should not be surprised when it produces mostly short-term outcomes.
Recovery housing also operates with limited regulatory control. DHCS does not license or certify recovery housing or sober living environments, and California still lacks a single statewide enforceable operating standard specific to recovery housing. Concerns about quality and integrity in some organizations are legitimate, and I wholeheartedly advocate for better systems that ensure high standards, transparency and accountability.
However, long-term recovery supports like recovery housing should not take a back seat to treatment services in the priorities of our major funding systems. They can be at least as important to whether recovery is sustained over time. Treatment can help somebody get sober; long-term recovery infrastructure gives them time, accountability, connection and community to learn how to stay sober.
It takes a village to build the connection and community that sustained recovery requires. I have hope and faith that we can all work together to improve our current fragmented system.
