Exploring Recovery-Oriented Systems of Care

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Recovery is change — and it is different for every individual.

People in recovery do not exist in a vacuum. Recovering from mental health and substance use problems is a complex process that requires a coordinated network of community-based services. 

Behavioral health professionals, families, and communities are all part of the infrastructure that helps people in recovery to build resilience and to live full, healthy, and connected lives. 

Many clinicians are involved in recovery-oriented systems of care, which involves a holistic, long-term, coordinated approach to treatment.

What Is Recovery?

The following definition of recovery was agreed upon by leaders in the behavioral health field in 2010, according to the Addiction Technology Transfer Center Network (ATTC)

“A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to meet their full potential.”

How can behavioral health professionals best serve clients in their recovery journeys? 

Recovery-Oriented Systems of Care

New York State’s Office of Addiction Services and Supports (OASS) explains that recovery-oriented systems of care is a long-term strategy to support individuals on their recovery journeys. It requires a paradigm shift from viewing addiction as a crisis to treating it as a chronic condition — like cancer or diabetes. 

  • What are the core values of a recovery-oriented system?
  • Collaboration among agencies and service systems
  • Holistic wellness
  • Cultural diversity
  • Spirituality
  • Data-informed decision making
  • Avoiding stigmatizing language
  • Empowerment for people in recovery, their families, and advocates

Person-Centered Care

Recovery is a long-term process of transformation that begins when the person becomes aware that positive change is possible. The elements of person-centered care systems, according to OSAS, include:

  • Acknowledging multiple paths to recovery
  • Welcoming entry at any point, regardless of earlier experiences
  • Providing a rapid response to people who have experienced relapse
  • Focusing on prevention and early intervention for children
  • Using a chronic care model for individuals, children, and families
  • Being inclusive
  • Relying on global assessment instead of focusing on problems
  • Respecting individual choice
  • Promoting partnerships with professionals and peer supporters
  • Valuing person-centered goals
  • Recognizing that spirituality and faith can play an important role in recovery
  • Building on the strengths of the individual, family, and community

Standards of Care

For behavioral health professionals, it is important to learn the protocols for documenting when providing person-centered, recovery-oriented services. In this video of an April 2022 Connecticut Women’s presentation, David M. Howe, LCSW, shares the importance of a person-centered, strengths-based approach to documentation and treatment. 


Howe provides the following standards, which apply to high- and low-intensity clinical services.

  • Application of recovery skills
    • Preventing relapse
    • Improving emotional functioning
    • Assuming personal responsibility
    • Reintegrating the person into work and education
    • Demonstrating the need and justification for services
    • Recognizing co-occurring mental health disorders

Individualized Treatment Plans

Because every person’s recovery journey is different, clinicians need to develop individualized treatment plans that take into account strengths, needs, abilities, preferences, and desired goals. That means listening to each person’s story with humility and understanding that we are all experts on our own lives. 

People in recovery are learning to take charge over their own illnesses, and as they do that, they are gaining control over their lives. When clinicians communicate treatment goals in understandable language, the people served are involved and empowered in their own recovery plans.

Surviving and Thriving

In order to thrive, people must first find the internal motivation to survive. What motivates people to survive? In a recovery situation, it can be immensely useful for clinicians to help people identify their genuine life goals and dreams. These don’t have to be elaborate. For example, some people want a home of their own, a car, a job, or to find a partner. Some dream of living with a pet. 

Helping people to identify goals is a key part of helping them to take charge of their lives.

There may be more specific goals related to recovery and survival. These might include any of the following:

  • Finding and keeping friends
  • Finding ways to help deal with loneliness
  • Learning to manage symptoms that interfere with living
  • Finding ways to stay out of the hospital
  • Finding ways to avoid having drugs and alcohol cause personal problems
  • Learning ways to manage depression
  • Reducing disturbing thoughts
  • Finding medications that work

Sharing the Journey, and Sharing Our Stories

It takes a village to help someone in their recovery. And when people experience individual or community trauma, they experience more barriers to health and wellness. That is why trauma-informed care and recovery-oriented systems of care work to treat the full individual and help them reach their full potential.

Clinicians can help people by approaching each person’s story with humility and helping them tap into their inner strengths, goals, and reason to want to survive.

When individuals, systems, families, and communities are engaged and empowered, more people will find their way through addiction and mental illness and move toward long-term wellness.

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