Breaking the Cycle by Jun Li

breakingthecycle How might we use design to support individuals in early recovery from substance abuse, with the particular goal of long-term recovery? By Jun Li

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Cover design by Jun Li Book Design by Jun Li

Master of Design for Social Impact at The University of the Arts 320 South Broad Street Philadelphia, PA 19102

First Printing May 2017

A Thesis Submitted in Partial Fulfillment of the Requirements for

the Degree Master of Design for Social Impact in the College of Art, Media and Design The University of the Arts

Philadelphia, Pennsylvania

May, 2016

Approved by:

Acknowledgments My sincere thankfulness to Fred Martin, John Carlson and Jody Newell, my thesis committee, who gave me indispensable opportunities for

my collaboration and enlightening recommendation to enhance this

project. As well as my sincere thankfulness to staff, volunteers and other members in PRO-ACT, who trusted me, included me and helped me to learn so deeply about the recovery community.

I want to thank Liana Dragoman and Sharon Lefevre, my thesis advisors, who gave me enormous support to structure my thoughts, manage my decisions and navigate the project. I want to thank Anthony Guido, my great mentor, my source of courage and motivation to continue this

project. Without any of your support I could not have progressed this far. Great appreciation to whom had assisted me in this project: Jonas Milder, my professor, who provided insightful suggestion to my design strategy;

Tito William and Wanting Lin, my friends, who gave me great knowledge about poverty and addiction and how to communicate appropriately with individuals experiencing specific difficulties; Mike Begley, my friend,

who gave me great recommendation and encouragement at the most important turning point of this project.

Abstract Collaborating with front-line staff in a recovery support service, we

develop a tool kit to support individuals who are in early recovery of

substance abuse. Our research indicated that our focus should be on

helping individuals sustain the behavior changes that keep them from substance abuse. Initiating changes is easier than maintaining.

This project is an example of using design to address social problems. It diverges from consumer based design in both its end and its methodological focus on user input.

Table of Contents Introduction Behavior Change and Substance Abuse....................................... 12 Project Background and Project Goal........................................... 14 Thesis Organizations and Thesis Committee................................ 16

Behavior Change Relationship between Behavioral Science and this Project........... 20 The Transtheoretical Model: Stages of Change............................ 21 Self-Efficacy and Confidence........................................................ 22 Decisional Balance and Motivation............................................... 23 Processes that are Helpful for Confidence and Motivation............ 24

Substance Abuse Extreme Users and Mainstream Users......................................... 28 Substance Abuse in the U.S., Pennsylvania and Philadelphia...... 29 Impact of Substance Abuse.......................................................... 34 Relapse of Substance Abuse........................................................ 38

Stakeholder Analysis The Field of Substance Abuse, Treatment and Recovery.............. 42 The Council of Southeast Pennsylvania....................................... 46 PRO-ACTâ&#x20AC;&#x2122;s PRTC and PRCC...................................................... 48 Journeys of Individuals Experiencing Services in PRO-ACT......... 50 Peer to Peer Support Program..................................................... 52 Stakeholder Profiles..................................................................... 53

Research Methods and Tools Field Research Methods............................................................... 58 Visual Research Tools.................................................................. 62

Intervention Opportunities How do Those in Recovery Make Progress on Their Goals?........ 66 Whatâ&#x20AC;&#x2122;s Good about being Aware of Progress?.............................. 68 Whatâ&#x20AC;&#x2122;s Good about Taking Incremental Steps?............................ 70 Why is Inspirations for Incremental Steps Helpful?....................... 72 Intervention Goals........................................................................ 73

Design and Deliverable Design Strategy: Collaborative Design......................................... 76 Design Strategy: Rapid Prototyping and User Testing................... 78 Design Deliverable: Story Sharing and Inspiring........................... 80 Deliverable Tools.......................................................................... 84 Story Sharing Tool, Prototype #1.................................................. 85 Story Sharing Tool, Prototype #2.................................................. 88 Story Sharing Tool, Prototype #3.................................................. 92 Handbook of Inspiration, Prototype #1.......................................... 94 Handbook of Inspiration, Prototype #2.......................................... 97 Handbook of Inspiration, Prototype #3......................................... 100 Future Consideration................................................................... 102

Appendix Postscript.................................................................................... 106 Glossary of Terms....................................................................... 107 Bibliography................................................................................ 108

Introduction

Behavior Change and Substance Abuse Behavior Change In all domains of life, there are challenges with behavior change. Some people struggle with initiating a healthy behavior, while others struggle with maintaining the behavior they initiated for good.

Many of us can start a behavior change easily. However, we get bored,

tired, frustrated or even satisfied in our way to maintain it, which tempts us to fall back to the unhealthy behavior we were getting rid of.

This project involves one of the most critically destructive forms of

behavior â&#x20AC;&#x201C;â&#x20AC;&#x201C; substance abuse and applies a prevailing theory of behavior

change to help understand the mechanisms of it and to orient the project.

Work harder,

consume less

$0.35

$35.00

Out of money

Have more money Stop working,

consume more

Substance Abuse To discover the unarticulated challenges in behavior

individuals who are struggling to maintain sobriety are

experience extreme positions. In the large group

become relapse temptation.

change, this project focuses on individuals who

of individuals experiencing challenges of behavior

change, drug and alcohol addiction is one of the most extreme situations.

Substance abuse has a negative impact on not only

the individuals who experience substance abuse but also many other related individuals. Nevertheless,

also faced with many related issues, any of which can There are organizations utilizing science of behavior change to help individuals faced with challenges of

and associated with substance abuse. In this project, I collaborated with a recovery community to learn about the context of addiction and recovery and to address integrated issues behind the challenge of relapse.

Photo credit: Roman Legoshyn

Project Background and Project Goal Project Background

As an individual in early recovery, Jake was at high

Shown in the graphic is Jakeâ&#x20AC;&#x2122;s journey of recovery from drug addiction.

When Jake was addicted to drugs, he was assisted

by a treatment service to become independent from drug. Jake then graduated from treatment, which means he was in early recovery.

risk of relapse. A recovery support service supported Jake to prevent relapse and to maintain recovery.

Recovery support services nowadays have become very sophisticated about relapse prevention. Many front-line staff are contributing to strengthen their

support for the community of individuals like Jake.

Treatment Services

Recovery Support Services

Treatment

Recovery

Specialists

Recovery Support

Jake is addicted to drugs.

Relapse

Maintain Jake is in

early recovery.

Jake is in longterm recovery

Project Goal As shown in the graphic, the goal of this project

was to develop a toolkit that enables the recovery

specialists to provide stronger support to individuals

like Jake, reduces possibilities to relapse, and makes it easier to maintain recovery.

Breaking the Cycle

Recovery

Specialists

Stronger

Jake is addicted to drugs.

Less possible

Easier Jake is in

early recovery.

Jake is in longterm recovery

Thesis Organizations and Thesis Committee Thesis Organizations The recovery support service I worked with is PRO-ACTâ&#x20AC;&#x2122;s Philadelphia

Recovery Training Center (PRTC) and Philadelphia Recovery Community

Center (PRCC). PRTC receives and trains volunteers who are passionate about supporting people in recovery. It coordinates the volunteers to

the front-line of recovery community, PRCC, which provides services to

support individuals who are in early recovery and their family members.

Thesis Committee from PRO-ACT To develop the project, I communicated closely and deeply with staff in

PRO-ACT. As coordinators, they provided great research opportunities to my thesis project and contributed important advice to the research that oriented the project.

Fred Martin

John Carlson

Jody Newell

Philadelphia Project

Volunteer Coordinator in

Coordinator at PRO-ACT, Thesis Advisor

PRO-ACTâ&#x20AC;&#x2122;s PRTC

PRO-ACTâ&#x20AC;&#x2122;s PRCC

Behavior Change

Relationship between Behavioral Science and this Project The study of behavior change and behavior maintenance is often now

applied in many different fields such as stress management, depression

prevention, adherence to antihypertensive medication, adherence to lipid-

lowering drugs, weight management, and smoking cessation. In more and more areas, researches want to determine what factors can contribute to motivation over the short-term and long-term behavior change.

This project is specifically about substance abuse and unemployment,

which relates very closely to behavior change. Thus, I included behavior change and maintenance in the literature research. This research

provided rich knowledge about different factors that influence behavior. This section presents my understanding of the most structured theory

about behavior change and maintenance, which is The Transtheoretical Model. It will explain two of the core constructs of the model: decisional

balance and self-efficacy. The section ends by introducing how motivation and confidence may react differently in the same circumstances.

The study of the behavioral model provided very important resources to guide my strategy in developing my thesis project.

The Transtheoretical Model: Stages of Change The Transtheoretical Model, also known as Stages of Change, was developed in 1977 by James O.

Prochaska and Carlo Di Clemente of the University of Rhode Island. By integrating various theories of

behavior and psychology, the Model breaks down the stages of behavioral change. It explains important

processes needed in each stage, and enumerates factors that impact behavioral change.

Stages of Change illustrates a behavior change in

five main stages: precontemplation, contemplation, preparation, action and maintenance.

In this part of the model, relapse is discussed as a

step of falling back from maintenance stage to any stages backward. Self-Efficacy

The Four Core Constructs The Transtheoretical Model is constructed with four

cores: stages of change, self-efficacy and decisional balance and processes of change. Maintenance

Stages of Change

This core construct discusses the degree of feeling

tempted to relapse to an unhealthy behavior and the confidence of maintaining the healthy one. Decisional Balance

Termination

Decisional balance is the balance between the pros and the cons: the pros are the potential benefits of

initiating and maintaining the behavior change, while the cons are the potential costs. Processes of Change This core construct introduces the processes needed

Action Preparation

to initiate a behavior change and to maintain it. Each Relapse

Falling back to

previous stages

Contemplation

Precontemplation

processes impacts on self-efficacy and decisional balance in different ways.

Self-Efficacy and Confidence Self-Efficacy in The Transtheoretical Model

keeps working out and controlling diet (seriously

According to The Transtheoretical Model, self-efficacy

the mirror, or the reading on the scale. The way to see

is the confidence to maintain behavior change

in situations that often trigger relapse. It is also

measured by the degree of feeling tempted to return to the old behavior in high risk situations.

The less the individuals feel tempted to relapse, the higher self-efficacy they have.

and properly) for a month, and still can’t see any

recognizable changes on either his/her reflection in

how confident he/she is to see how much frustration he/she can suffer before telling himself/herself that losing weight is impossible for him/her.

Fortunately, confidence can be reinforced by realizing the positive sides of the reality. Support for the

positive can be given by either an example of a

Confidence

person who has successfully overcome the same

In a behavior change, confidence is the capability

member (or a close friend) who is able to strongly

to believe that a particular goal can be achieved by

maintaining the beneficial behavior one has initiated, especially when the effect of this behavior does not seem to take place immediately.

For instance, in a weight losing case, a person might

seem to be very encouraged to start working out and going on a diet. However, since losing weight is a

surprisingly slow process, it’s possible that this person

challenge and accomplished the same goal, a family believe that his/her goal can be accomplished, or the baby steps he/she has taken towards his/her goal.

How does confidence influence behavior change and behavior maintenance? Well, there’s a song which

illustrates the answer very clearly: “If I just believe it, there’s nothing to it.”

Decisional Balance and Motivation Decisional Balance in The Transtheoretical Model

habit will be much more challenging for him/her

According to The Transtheoretical Model, decisional

realizing how much benefit he/she can potentially

balance is the balance between the pros and the cons.

Motivation and Barrier If we illustrate confidence as “I believe I can fly, I

believe I can touch the sky”, then motivation will be

“I want to fly, because I need to touch the sky.” From my perspective, motivation is the fact that a person

wants to accomplish his/her goal, the degree of how

much he/she wants to accomplish it, and the essential reason why he/she wants to accomplish it.

The growth of motivation depends on a person’s

current situation (dissatisfaction) and the potential benefits of the new behavior: either because the

because the motivation is lower. However, even in a comfort zone, he/she can still be motivated by obtain from a healthy way of managing money.

Motivation plays a significantly impactful role in one’s decision making. Each process of self-asking “to do or not to do” is a battle between motivation (crucial situation + potential benefit of a healthy decision)

and obstacles (comfort zone + potential cost of this

decision). Sometimes a motivation that is just a little

stronger than the obstacle will be enough for a person to take action.

Pros 1. Potential benefits of behavior change

current situation a person is in couldn’t be worse, or

2. Motivation to initiate

initiating or maintaining the new behavior.

maintain it

there is a clear vision of what benefits will arrive by A person experiencing challenges of shopping

addiction for instance, when he/she is experiencing serious financial crisis, it’s more likely for he/she to try hard to reduce unnecessary expenses as much as possible. In this crucial situation, this person is

highly motivated to initiate a healthy and progressive

financial habit. When the same person is in a comfort zone, maintaining a healthy/progressive financial

the change and to

Cons 1. Potential costs of behavior change

2. Barrier to initiate the

change or to maintain it

Processes that are Helpful for Confidence and Motivation Reverse Relationship between Motivation and Confidence

Relapse prevention is a balance between confidence

Most of the failures of maintaining behavior changes

what the growths of confidence and motivation are

are the failures of understanding the reverse

relationship between confidence and motivation: a

and motivation. To help a person with his/her relapse prevention, we need a structured understanding of base on.

likely to impact on motivation in reverse.

Processes that are Helpful for Confidence and Motivation

In other words, when a crucial situation (in which

The Transtheoretical Model concluded these

circumstance that impacts confidence in one way is

one has a strong motivation) starts improving and

becomes a more comfortable one, a person will be

less doubtful that he/she is capable to overcome the

challenge. This has a healthy and positive impact on his/her confidence. However, if he/she isnâ&#x20AC;&#x2122;t aware

that he/she still has a long way to go (to completely overcome the challenge), his/her motivation will be reduced, which will possibly cause relapse.

In this case, relapse is caused by satisfaction. This doesnâ&#x20AC;&#x2122;t mean that one should always see his/her situation as critical as possible. It is true that a crucial environment can keep oneâ&#x20AC;&#x2122;s motivation high, but if

he/she is always overseeing how much progress he/

she has made (mostly in order to stay motivated and prevent relapse), it is likely for him/her to undertake too much pressure and frustration.

In this case, relapse can still take place, not because of satisfaction, but frustration.

processes that help grow confidence and motivation in a behavior change:

1. Social liberation, counter conditioning and stimulus control are the processes of gaining support and

removing temptation of relapse, which in turn helps grow confidence;

2. Consciousness raising, environmental reevaluation, reinforcement management and self reevaluation are the processes of being aware of the situation of the

pass and the potential success in the future, which in turn strengthens motivation;

3. Dramatic relief and helping relationship are the processes of getting support from one another

who had been through similar challenges, seeing

an example of success and being inspired by that example, which in turn develops both confidence and motivation.

Transtheoretical Model Stages

of Change

Self

Decisional

Efficacy

Balance

Processes of Change

Confidence

Motivation

Confidence + Motivation

Counter Conditioning

Consciousness Raising

Dramatic Relief

Replace old behaviors with

Be aware of the causes and

Be inspired by othersâ&#x20AC;&#x2122; healthy

Stimulus Control

Environmental Reevaluation

Helping Relationship

Remove temptations to engage in

Realize negative impact on others

Seek and use social support to

Social Liberation

Reinforcement Management

Self Reevaluation

Realize that social norms are

Increase the rewards for healthy

Create a successful image of

behavior.

rewards for old behaviors.

healthy behaviors.

the old behavior.

changing to support the healthy

consequences of the old behavior.

and positive impact of change.

behaviors and decrease the

changes.

make and sustain changes.

oneself in the future.

Substance Abuse

Extreme Users and Mainstream Users There are many different types of behavior change which have different levels of impact and difficulties. After exploring and observing different groups of individuals who have the challenge of maintaining healthy behaviors, I decided to focus on individuals in extreme positions.

According to IDEO, mainstream users share the challenge that the

extreme users have, while the extreme users are influenced by the challenge more than the mainstream users are. As a result, if the designers work with the extreme users, itâ&#x20AC;&#x2122;s easier to identify the

challenge. If a service or a product is well designed enough that it can

support the extreme users effectively, it can potentially be modified for the mainstream users.

Extremes

Designed for

extreme users

Mainstreams

Extremes

Modify and apply to extreme and mainstream users

My research on different subjects related to behavior change addressed

substance abuse as one of the extreme challenges, due to its high rates of relapse and the consequences it causes to individuals

Substance Abuse in the United States, Pennsylvania and Philadelphia In the United States, large groups of researchers

contribute significant amounts of time and energy to study substance abuse. Researchers from different fields study the issue from various perspectives,

which provides abundant information and findings that construct comprehensive understanding of substance abuse and related issues.

Substance Abuse in the United States Research from 2013 gives us a frightening sense of the enormous number of Americans who are either

illicit drug use or substance dependent, more than 9 percent of the population respectively.

“In 2013, an estimated 24.6 million Americans aged 12 or older were current (past month) illicit drug

users, meaning they had used an illicit drug during

the month prior to the survey interview. This estimate represents 9.4 percent of the population aged 12 or

older. Illicit drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics (pain relievers, tranquilizers, stimulants, and sedatives) used nonmedically.

In 2013, an estimated 21.6 million persons aged 12

or older (8.2 percent) were classified with substance dependence or abuse in the past year based on

criteria specified in the Diagnostic and Statistical

Manual of Mental Disorders, 4th edition (DSM-IV). Of

these, 2.6 million were classified with dependence or

abuse of both alcohol and illicit drugs, 4.3 million had dependence or abuse of illicit drugs but not alcohol,

and 14.7 million had dependence or abuse of alcohol but not illicit drugs.” Photo credit: Evdokimov Maxim

–––– U.S. Department of Health And Human Services “Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings”

Substance Abuse in Pennsylvania Research from The National Drug Intelligence Center shows that substance abuse is influencing large population in Pennsylvania.

The National Drug Intelligence Center also found that substance abuse is influencing population in young

age (under the age of 25). This research shows that not only the population of youth is growing, but also the ages of first-time users are becoming younger. This is a serious concern in Pennsylvania.

“In Pennsylvania, users over the age of 25 constitute the largest proportion of addicts seeking medical

and treatment assistance; younger users (under age 25) are the fastest-growing user group. In 2000, 32 percent of heroin treatment admissions in the state

were under age 25, up from 16 percent in 1996. The average age of first heroin use was 20. According

to the 1999 Youth Risk Behavior Survey, 2.4 percent of Philadelphia high school students reported using heroin during their lifetimes, matching the national

figure. New heroin users are increasingly younger, and some young people take heroin to offset the

effects of club drug stimulants such as MDMA. The

Shaler Township (near Pittsburgh) Police Department reports that heroin is considered the greatest

threat in its jurisdiction, partly because the low cost increasingly attracts users as young as 15.”

–––– National Drug Intelligence Center

“Pennsylvania Drug Threat Assessment June 2001”

Substance Abuse in Philadelphia In the research “Drug Use in Philadelphia,

Pennsylvania: 2013” by National Institute on Drug

Abuse, Treatment admissions data for residents of

Philadelphia County (provided by Behavioral Health

National Institute on Drug Abuse shows the amount

of drug overdose among the drug-abusing population in Philadelphia, using data collected from the

Philadelphia Fire Department’s Emergency Medical Services (EMS).

Special Initiative) reported that 9,130 individuals were

“EMS reported 341,745 medical runs in 2013, of

Office, Philadelphia Department of Public Health

accidental poisonings.”

admitted to treatment in 2013. Medical Examiner’s reported 679 deaths with the presence of drugs.

“In Philadelphia, heroin-related DAWN ED mentions

which 11,028 were runs in response to overdoses or –––– National Institute on Drug Abuse

“Drug Abuse in Philadelphia, Pennsylvania: 2013”

increased 15.8 percent from 1998 (3,586) to 1999 (4,152), after increasing 51.7 percent from 1992 (2,364) to 1998.

National Institute on drug abuse collected information from treatment admissions in Philadelphia. It

According to ADAM data for Philadelphia, 14.8

shows what constitutes drug abuse in Philadelphia,

arrestees who were tested for drug use tested

the four most abused drug in Philadelphia.

percent of male arrestees and 14.2 percent of female

indicating alcohol, heroin, marijuana and cocaine as

positive for opiates in 1999.

“Data for 2013 showed mixed indicators for drug

The Philadelphia Medical Examiner Office reported

use and abuse. The four drugs of most concern

according to 1999 preliminary data. DAWN ME data

marijuana, and cocaine. Together, these drugs

Philadelphia region have fluctuated from 385 in 1996,

admissions in 2013 with known drug of abuse”

210 mortality cases with the presence of heroin,

in Philadelphia continued to be alcohol, heroin,

indicate that heroin/morphine-related deaths in the

constituted 92.6 percent of the primary treatment

to 571 in 1997, to 413 in 1998, to 417 in 1999.”

–––– National Drug Intelligence Center

–––– National Institute on Drug Abuse

“Drug Abuse in Philadelphia, Pennsylvania: 2013”

“Pennsylvania Drug Threat Assessment June 2001” The Philadelphia APPD analyzed urine specimens from people placed on probation or parole status.

The proportions of probationers/parolees who tested positive for any drug is 44.9 percent in 2013.

In Philadelphia:

9,130 11,028

individuals admitted to treatment in 2013.

medical runs in 2013 were in response

to overdoses or accidental poisonings.

2,028

adults in probation or parole status were

tested positive in Drug-Positive Urinalysis (44.9 percent among the total of 4,515 adults).

679

of the deaths in 2013 were detected with the

presence of drugs.

victims of homicide resulted from drug-related motives

(15.7 percent of the 284 victims of homicide in 2014).

Impact of Substance Abuse Substance abuse is one of the most concerning

issues of our society. Its negative effects cannot

be seen as independent of many other aspects of

community life such as public health, public security and crime, poverty, education, employment and

Impact on Individuals Research shows serious damage to physical health and mental health of the individuals who have substance abuse.

unemployment, social services and taxation, etc.

“People who suffer from addiction often have one

society, not only causing physical and mental health

include lung or cardiovascular disease, stroke,

insecure situations to their families, coworkers, and

Drug abuse may trigger or exacerbate those mental

Substance abuse has widespread impact on the

or more accompanying medical issues, which may

issues to the individuals themselves, but also causing

cancer, and mental disorders.

many others with whom they have contact.

“Alcohol and drug abuse has become a very serious social, medical and economic problem in America pervading every area of life. More specifically,

substance abuse can have an adverse effect on work performance, the quality and quantity of services

provided to the citizens of the City of Philadelphia,

disorders, particularly in people with specific vulnerabilities.”

–––– National Institute on Drug Abuse “Addiction and Health”

Drug use through injection also brought blood

infective diseases such as AIDS by shared needles.

and the health and welfare of employees. Further,

“Injection of drugs such as heroin, cocaine, and

of medical benefits.”

percent of new AIDS cases. 21 Injection drug use

substance abuse contributes to increasing the cost –––– City of Philadelphia

“Drug and Alcohol Policy”

methamphetamine currently accounts for about 12 is also a major factor in the spread of hepatitis C, a

serious, potentially fatal liver disease. Injection drug

use is not the only way that drug abuse contributes to

Homelessness Welfare Spending on Unemployment

Social Services

Physical Health Issues

Substance Abuse

Public Security and Crime

Mental Health Issues

Incarceration

Domestic Violence

the spread of infectious diseases. All drugs of abuse

cause some form of intoxication, which interferes with judgment and increases the likelihood of risky sexual behaviors. This, in turn, contributes to the spread

of HIV/AIDS, hepatitis B and C, and other sexually transmitted diseases.”

Unnatural Death

Caused by Drug

Overdoses, HIV and other issues

jobs are very likely to lose the jobs; those who don’t have jobs yet are very unlikely to be employed.

“An individual who enters a residential drug treatment program or is admitted to a hospital for drug

treatment becomes incapacitated and is removed from the labor force.”

–––– National Institute on Drug Abuse “Addiction and Health”

Individuals with substance abuse or history of

substance abuse are at high risk of unemployment. When labeled a substance abuser those who have

–––– U.S. Department of Justice,

National Drug Intelligence Center and

National Drug Threat Assessment 2010

“Impact of Drugs on Society”

Impact on Families, Co-workers, Friends and other Related Individuals

Impact on Society Through its impact on individuals and families,

Substance abuse can bring significant damage to

substance abuse has a critical impact on society. This

alcohol can cause domestic violence, accidents and

financial costs.

families. By influencing mental status, drug and

impact spreads to areas of public security and

other traumatic experiences to individuals and their

National Institute on Drug Abuse concluded from its

families. By reducing financial income, unemployment can cause poverty and homelessness.

research, “The Economic Impact of Illicit Drug Use on

American Society”, research from Centers for Disease

For families with children, these issues caused by

Control and Prevention, “Smoking-Attributable

the children.

Losses”, and from Rehm Jurgen, Mathers Colin,

substance abuse also bring harmful experiences to “A mother’s abuse of heroin or prescription opioids

during pregnancy can cause a withdrawal syndrome (called neonatal abstinence syndrome, or NAS) in

her infant. It is also likely that some drug-exposed children will need educational support in the

classroom to help them overcome what may be subtle deficits in developmental areas such as behavior, attention, and thinking.”

–––– National Institute on Drug Abuse “Addiction and Health”

“Some users are parents, whose deaths leave their children in the care of relatives or in foster care.”

–––– U.S. Department of Justice,

National Drug Intelligence Center and

National Drug Threat Assessment 2010

“Impact of Drugs on Society”

Mortality, Years of Potential Life Lost, and Productivity Svetlana Popova, Montarat Thavorncharoensap,

Teerawattananon Y. and Patra, J., “Global burden of disease and injury and economic cost attributable

to alcohol use and alcohol-use disorders”, showing

astonishing costs of substance abuse in the United States.

“Estimates of the total overall costs of substance

abuse in the United States, including productivity and health- and crime-related costs, exceed $600 billion annually. This includes approximately $193 billion

for illicit drugs,1 $193 billion for tobacco,2 and $235 billion for alcohol.”

–––– National Institute on Drug Abuse

“Understanding Drug Abuse and Addiction”

The National Drug Intelligence Center referred to DEA

children who can’t play safely outside, to business

one of the East Coast’s biggest markets for high-

elderly who can’t leave their homes for fear of drug-

“In Philadelphia, heroin-related homicides increased

Center showed in its research that 90 percent of the

Philadelphia.”

admitted heroin users, and that the percentage in the

Administrator, Donnie Marshall, that Philadelphia “is

people whose livelihoods are threatened, to the

purity, inexpensive heroin”.

related violence.” The National Drug Intelligence

20 percent from 1995 to 1999, according to DEA

–––– National Drug Intelligence Center

“Pennsylvania Drug Threat Assessment June 2001” In the same report, it’s also indicated that drug abuse, trafficking of drug and other drug-related violence

has threatened the safety of many communities in

Pennsylvania, and has tragically impacted the daily

burglaries in the Shaler Township are committed by state is increasing.

“The number of property crimes, including thefts, burglaries, and shoplifting, committed by heroin

users continues to increase in the state, according to the Pennsylvania State Police.”

–––– National Drug Intelligence Center

“Pennsylvania Drug Threat Assessment June 2001”

life of almost everyone in the communities: “from the

Photo credit: Brad Larrison

Relapse of Substance Abuse Not only does substance abuse have a significantly

negative impact on the society on a large scale, but

also individuals recovering from substance abuse are at high risk to relapse. This makes substance abuse an extremely important case for behavior change.

Relapse Rates of Substance Abuse

Causes of Relapse For individuals in early recovery, depending on the neighborhood they live, environment they work,

community they’re engaging with, they face many

different types of temptations, which causes relapse. In the research “Clinical Report Series: Relapse

The National Institute of Drug Addiction showed the

Prevention”, the National Institute on Drug Abuse

different types of drugs after admission to treatments

many situations or experiences are considered as

(DATOS) Relapse as a Function of Spirituality/

Stress

percentages of total respondents who report using

pointed out that for individuals in early recovery,

in its report “Addiction Treatment Outcome Study

significant causes temptations to relapse:

Religiosity”.

34 47

Marijuana or Hashish: Alcohol Intoxication:

23 61 38

Heroin: Crack:

Whether due to discrete negative life events percent

percent

Benzodiazepines:

Negative Emotions A wide range of emotions, including anger, anxiety,

depression, and frustration, can precipitate relapse. stronger determinant of relapse than the desire to feel good.

Positive Emotions Good feelings that come from socializing can

percent

vulnerability to relapse.

The need to blot out these emotions is a much

percent

Cocaine:

or everyday hassles, stress greatly increases

sometimes trigger relapse. In other cases, drug use percent

For individuals who graduated from treatments, it is very difficult to maintain recovery,

might be used as a reward or a means of celebration.

Interpersonal Conflict Relapse is often associated with conflict with family members and other

individuals brought on by poor communication, unresolved conflicts, and other factors.

Social Pressure Sometimes social pressure is overt, as when someone offers the addict

a drug. Often it is not. Being enmeshed in a social network in which other people abuse substances is especially risky. Use of Other Substances Use of another substance can trigger cravings for the primary drug of abuse, undermine self-control, or impair a personâ&#x20AC;&#x2122;s ability to respond

effectively to a relapse crisis. Taking prescribed medications can also be problematic.

Presence of Drug-Related Cues Environmental cues (e.g., drug paraphernalia, or people or places

associated with substance use) elicit strong cravings in some people.

Stakeholder Analysis

The Field of Substance Abuse, Treatment and Recovery Organizations In this stakeholder map, the field of recovery is shown as organizations contributing to it and their relationship to different types of individuals.

This stakeholder map shows the main organizations that are related to the field of addiction recovery. Governmental Departments Collecting data, statistic analysis, research, making (designing) policies, providing fundings to social services (welfare spendings) Treatment Services Such as rehabs, 12-step programs, clinics, halfway houses providing treatments to help overcome addictions or behavioral illness. Recovery Support Services Mostly funded by government, run by communities of people who are

in recovery. They provide relapse prevention support, information and resources sharing and other related supports.

Family Supports Services and Educational Programs Consulting and intervention for related families, preventative supports for children and teenagers who are at risk of drug abuse or mental challenges.

Other Social Services Providing housing resources, personal care, healthcare, life skill training and job searching, etc.

Training Departments and Programs in Colleges Training, educating and evaluating human resources with specialized skills for other departments and services

Family Support

1. Policy

Services

2. Analysis

Governmental Departments

3. Funding

Treatment Services

Recovery Support

Training Programs

Services

Other Social Services

Workforce Preventative Programs

Colleges

Individuals

Addiction and Mental Health Challenges Individuals with drug and alcohol addictions or

behavioral health challenges will go to treatment

services. When they graduate from treatment, they become individuals in early recovery.

Addiction

Families

Family Support Services

Long-term Recovery

Mental Health

Treatment

Early Recovery

Services

Recovery Support

Unemployed

Services

1. Continuing

Other Social

Homeless

recovery support

Services

2. Resource and Preventative LGBTQ

Programs

At Risk

information

Early Recovery

Long-Term Recovery

Individuals in early recovery from addictions or

Being supported by recovery support services,

prevent that, some of them seek help from recovery

Individuals in long-term recovery may volunteer in the

behavioral health challenges are at risk of relapse. To support services to maintain recovery.

individuals can achieve long-term recovery.

recovery support services to help other individuals in

early recovery. They may also receive training in other programs to become certified specialists. Families Including women, children and teenagers of

individuals with addictions or behavioral health challenges: family support services.

Individuals at Risks of Use and Mental Illness In some communities, women, children and teenagers are at risk of substance abuse or mental illness

because of different issues. They are received by Governmental Departments

educational programs and preventative supports.

Homeless, Unemployed Individuals, LGBT, etc Individuals and their families may experience

associated issues such as poverty, unemployment

and discrimination. There are other services providing support for them to overcome these challenges. Certified Specialists Training

Programs

Individuals who received training and certifications

from the training and education departments will work as specialists in different organizations. Students Graduating students from related programs in

Workforce

colleges will become interns, social workers and Colleges

volunteers in the departments and services.

The Council of Southeast Pennsylvania “To provide resources and opportunities to reduce the impact of addiction, trauma and other related health issues for the entire community. We

accomplish this through prevention, consultation,

education, advocacy, assessment, intervention and recovery support services.”

–––– Mission Statement of

The Council of Southeast Pennsylvania

History A study group was founded in 1974 as Bucks County Council on Alcoholism (The Council). It received grants from Commonwealth of Penn and Bucks

County Drug and Alcohol Commission Inc in 1975, the same year it applied for affiliation to NCADD (National Council on Alcoholism and Drug Dependence).

The Council of Southeast Pennsylvania

Commonwealth of

Pennsylvania, United Way, SAMHSA, etc.

Governmental Departments

PRO-ACT’s

PRTC and PRCC

Family Support Services

MHASP, Penn State

Abington’s, DBHIDS and Pennsylvania

Treatment

Certification Board

Services

Programs

Recovery Support Services

Other Social Services

Training

U Penn, Drexel U, Preventative Programs

Temple U, Philly

U, UArts and other universities

Colleges

Nowadays, The Council has grants from and

partnership with SAMHSA (Substance Abuse and

Mental Health Services Administration) and CSAP

(Center for Substance Abuse Prevention) and other Governmental Departments.

Roles in the Field of Recovery The Council (name updated to The Council of

Southeast Pennsylvania) nowadays provides wide

rage of services (including prevention, intervention,

recovery support, advocacy, training and information

dissemination, etc.,) to varying groups of people who

are struggling with different issues related to drug and alcohol addiction and behavioral health challenges (individuals, families, schools, businesses and the community).

Services Provided in The Council The Council has 16 different programs, which

includes Central Intakes, Children and Youth Social

Services, Criminal Justice Services, Family Education Program, School Services, and PRO-ACT.

Locations The Council serves in the counties of Bucks,

Chester, Delaware, Montgomery and Philadelphia. Its programs are distributed in 5 locations: Doylestown Office (where The Council is headquartered), Case Management Service Unit, Women's Recovery Community Center, Southern Bucks Recovery Community Center, Philadelphia Recovery

Community Center and Philadelphia Recovery Training Center.

Certified Peer Specialist An individual with documented experiences of

addiction or mental health challenges and complete GED can receive training in MHASP (Mental Health

Association of Southeast Pennsylvania) and receive

certification from DBHIDS (Department of Behavioral Health and Intellectual Disability Services) to

become a CPS (Certified Peer Specialist). Instead of volunteering as a peer mentor, a CPS can work as a peer mentor with pay.

Certified Recovery Specialist An individual who is interested in working in this

field can receive training in Penn State Abingtonâ&#x20AC;&#x2122;s

Professional and Corporate Education Healthcare Certifications Program and receive certification

from Pennsylvania Certification Board to become a CRS (Certified Recovery Specialist). Different from

CPS, CRS doesnâ&#x20AC;&#x2122;t require a documented history of addiction or mental health challenges.

PRO-ACTâ&#x20AC;&#x2122;s PRTC and PRCC PRO-ACT was founded under the umbrella of The Council in 1998 as one of the first generation of recovery support services in the United States. PRO-ACT was created to support the recovery

community by reducing the stigma of addiction,

ensuring the availability of treatment and recovery

support services, and by influencing public opinion and policy regarding the value of recovery.

PRO-ACT has two locations in Philadelphia: the Philadelphia Recovery Training Center and the Philadelphia Recovery Community Center.

Philadelphia Recovery Training Center Philadelphia Recovery Training Center (PRTC)

provided opportunities for individuals to receive volunteer training to become peer mentors and group facilitators.

Essential training provided in this location includes: volunteer orientation, volunteer roles, group

leadership and facilitation, peer mentors, Philadelphia Peer Leadership Academy and GED Tutoring.

Philadelphia Recovery Community Center

Individuals who finished training will volunteer in the Recovery

Community Centers (the one I

go to is Philadelphia Recovery Community Center). Some

of them volunteer as group

facilitators, some of them peer up with individuals who need mentoring.

peer recipient by a volunteer

resume building and interview

PRCC includes: Recovery Group

responsible to support a peer to

with challenges of unemployment

Gateway to Work.

plan in the first meeting (with a

Essential Services provided in

coordinator. A peer mentor is

Discussions, Peer Mentoring and

set goals and create an action

Recovery Group Discussions Recovery Group Discussions

are walk-in discussions in which individuals share their stories of

recovery depending on what the

topic is commitment to recovery, managing relationship, anger management, recovery in my

community, etc. Sometimes there

are open topic discussions. In the discussions, there are usually a

facilitator and a co-facilitator who are both volunteers in PRO-ACT. Peer to Peer Mentoring Peer Mentors trained in PROACT will be matched with a

Wellness and Recovery Action

Plan worksheet). A peer mentor is

also responsible for relating a peer to other resources depending on what they need. A peer recipient is usually an individual in early

recovery from drug and alcohol addiction, who is experiencing

challenges of relapse prevention, and very likely, issues with

housing, health, unemployment,

education, families, relationships and neighborhoods. Gateway to Work This is a program in PRCC

created in 2008 by Jack Land. It provides services including

training especially for individuals caused by documented history of addiction, mental health

issues and incarceration. Mr.

Land helps individuals develop

career plans depending on their

situation, including relating them to resources for education and

training. He also helps individuals recognize their potentials and skills to be documented on resumes and presented in

interviews, and to convince

potential employers by actions that they have changed and

become good (functional and

trustworthy) persons who are ready to work.

Journeys of Individuals Experiencing Services in PRO-ACT 1. Individuals in addiction coming to PRO-ACT

4. Unemployed individuals will be introduced to

addiction. After overcoming addiction (graduated from

building, interview training, job searching and relating

will be related to a treatment service to overcome

treatment, in early recovery) they will come back to PRO-ACT and receive services.

2. Individuals in early recovery will be introduced to

recovery group discussions and matched up with peer mentors. They will be supported in the community center to maintain recovery.

Gateway to Work. They will be supported by resume to resources for education and work skill training. 5. Unemployed individuals with incomplete GED

will be introduced to GED tutoring to continue and

to complete GED. A complete GED is necessary for

applying for not only jobs, but also higher education and training such as CPS and CRS.

3. Individuals in recovery (who may have been helped in PRO-ACT) can sign up to volunteer in PRO-ACT.

Theyâ&#x20AC;&#x2122;ll receive volunteer training in the training center and become mentors or facilitators.

Volunteer orientation and

Group leadership and

volunteer roles training

I want to

volunteer!

facilitation training

PRO-ACTâ&#x20AC;&#x2122;s Philadelphia Recovery Training Center

GED tutoring and Tom

other training

Peer mentor training

6. For unemployed individuals in recovery,

volunteering in PRO-ACT (or any other recovery

support services) can be documented as proof for becoming ready to work.

7. Volunteers with complete GED can sign up for CPS or CRS training. Once they become CPS or CRS, they can work in this field and get paid.

8. Individuals who are not in recovery can also

volunteer in PRO-ACT, receive training and become facilitators and mentors.

9. Individuals who become CRS before coming to

PRO-ACT has potential of getting hired in PRO-ACT. 10. Graduating Students from colleges (Temple,

Drexel, Philly U, Community U, U Penn, UArts) can

work as interns in PRO-ACT can has the potential to get hired after graduate.

Volunteering peer mentor Volunteering facilitator

Recovery Group Discussion

Tom

Peer to Peer

PRO-ACTâ&#x20AC;&#x2122;s Philadelphia Recovery Community Center

Support Program

Long-term recovery

Iâ&#x20AC;&#x2122;m in early

recovery and I need help!

Gateway to Work Program

Jake

Peer to Peer Support Program When volunteers accomplish peer mentoring training

if the peers are making progress. The mentors also

connect them to The Peer to Peer Support Program in

resources depending on what other challenges they

in PRTC, a volunteer coordinator in PRTC will

PRCC, in which each of them will be matched with a

peer (an individual in early recovery who needs help). At the first time the peer mentors meet with their

peers, the mentors will guide them to go through the “Wellness and Recovery Action Plan”, in which the peers will set goals. In the following meetings, the

mentors and their peers will review the goals and see

I’m in early

provide information that connects the peers to other are experiencing.

The Wellness and Recovery Action Plan (WRAP) is

a structure for individuals in recovery to review their situation and to set goals. The WRAP covers ten

domains in life that are associated with recovery,

which guide the individuals to manage daily life and reduce risks of relapse in as many effective ways as possible.

Peer to Peer Support Program

recovery and I need help!

Wellness

Recovery Action

Jake

Peer

Mentor

Training

Tom

Plan

Project Tom

Home

1. Mentoring 2. Relapse prevention 3. Information and

GED

resources

Family

Support

Services

tutoring

Treatment Services

Gateway to Work

Stakeholder Profiles

Staff, Volunteers and Recipients The stakeholder profiles are built based on information collected in interviews. During the interviews, staff, volunteers and recipients in PRO-ACT were invited as individuals to share their stories. These interviews

provided comprehensive materials of how each person’s past experiences connect them to the community of

recovery. My goal of building and presenting these profiles is to share a granular visual of the characters, their

background, their expectations and their challenges. These profiles also help us understand the shared desires and shared challenges of the community.

Fred Martin Philadelphia Project Coordinator at PRO-ACT Fred knew that being in recovery was similar to living a dream. He was

living life on life terms and wanted a way to share it to all. In 1998 Fred was introduced to PRO-ACT and began as a volunteer. He was one of

the original volunteers and now is one of the leaders within the PRO-ACT organization. Today Fred’s passion is to create an opportunity for people with similar experiences and challenges to share not only obstacles but also solutions and being that successful example.

John Carlson Volunteer Coordinator in Philadelphia Recovery Training Center, Certified Recovery Specialist

Two traffic accidents caused by his own drug abuse brought John from a seemingly normal and successful life to unemployment, the edge of

homelessness and serious family issues. After a seven-month treatment, he was assisted by PRO-ACT to overcome multiple life challenges and

to maintain recovery. Eventually, John decided to help other people who

are struggling for recovery and wellness. John’s goal is to strengthen the administration of PRO-ACT.

Jody Newell Volunteer Coordinator in Philadelphia Recovery Community Center Jody witnessed consequences of alcohol abuse while she was a child. She also learned while she worked in the field for HIV prevention that a lot of people are infected because of drug abuse (sharing needles) instead of sexual intercourse. Jody is currently working as volunteer

coordinator in PRCC and is contributing by training volunteering group

facilitators, coordinating recovery group discussions and scheduling other events in the Recovery Community Center.

Jack Land Director of Gateway to Work Program, Certified Recovery Specialist Jack studied law before becoming a part of the community. While

working in PRO-ACT, Jack recognized that most individuals in recovery also struggle with unemployment, as the result of incomplete general education, criminal background or documented history of substance abuse. He established the Gateway to Work program, in which he

assists individuals with career planing, job searching, resume building

and interview training. Jackâ&#x20AC;&#x2122;s goal is to help people present the healthy change they have initiate to potential employers.

Ira Maxfield Volunteering Peer Mentor Ira became addicted to drugs when he was a teenager, under a growing

depression caused by racial discrimination and serious family tragedies. Rescued from his twentieth attempted suicide, Ira was introduced to a

treatment center and started his recovery. Ira is in twelve-year recovery and has been volunteering in PRO-ACT as a peer mentor for eight

months. Ira is passionate about helping individuals in recovery to initiate healthy changes in multiple aspects of life to overcome challenges.

Melody Scofield Certified Recovery Specialist Melody is working in PRCC as a recovery specialist. She has been

helping individuals in early recovery to review their situations in life, setting goals and managing daily lives.

Anthony Maddox Volunteer Peer Group Facilitator, Certified Peer Specialist Anthony had been introduced to recreational use of marijuana and

alcohol under peer pressure when he was 9. After 13 years of tortuous experiences with addiction, illegal habits, imprisonment, treatment

and family issues, he started his recovery. Anthony is now in 30 years

recovery. He is currently a certified peer specialist and is volunteering as a group facilitator in PRO-ACT. He is also a successful example for his peers in recovery who are experiencing temptations to relapse.

Joe Volunteer Joe was a treatment specialist. He started abusing alcohol after a family

trauma, which caused his unemployment. During his struggle with alcohol Picture Not Found

addiction, he went through several treatments in different rehabs because of the difficulty to maintain recovery after graduating from each treatment. Joe was then introduced by a friend to PRO-ACT, which assisted him to maintain recovery. After his third month of recovery, Joe started

volunteering in PRO-ACT and is looking for an opportunity to work as a specialist again to help other people in addiction and early recovery.

Research Methods and Tools

Field Research Methods As a human-centered designer, my field research involved a lot of

observation and user engagement. I applied user experience research, visual thinking and visual communication in my field research. These methods helped me build empathy and understand the context more

comprehensively, which in turn helped me discover unarticulated desires and challenges.

Volunteering as an Observation Opportunity

experiencing it on my own. I also attended as many

When I introduced this project to Fred and John,

but also the organization.

expressing my need to communicate with other staff and volunteers and PRO-ACT, John said: â&#x20AC;&#x153;What is a

better way for you to research something than being a part of it?â&#x20AC;?

Recommended by Fred and John, I started

volunteering in PRO-ACT. By receiving volunteer training, attending, co-facilitating and facilitating

group discussions, I gained the opportunities not

only to interact with a lot of the other volunteers, but also to observe and understand the environment by

staff meetings as possible, which empowered me to

understand the challenges of not only the individuals Observing the Organization I volunteered in PRO-ACT for the opportunity to

observe the structure of the organization, services provided in the organization, the context of the

community and character of deferent individuals.

By staying in the organization, I was able to dive deep into details about the situation around the individuals and the organization.

Experiences and Empathy Being a volunteer also empowered me to experience being in the community as a member. It allowed

me to feel how the other members feel and to learn

how they communicate, which in turn allowed me to research more effectively.

Building Trust and Relationship My constant attendance in the training and discussions built reliable trust between my

stakeholders and me. This provided me chances

to invite my stakeholders to describe their specific

real-life stories, which helped discover shared values among the community and shared challenges. Objectivity I was aware during my research that becoming part of the subject of my research may influence objectivity. This awareness enabled me to maintain objectivity.

Additionally, being an individual without the history of addiction made it easier for me to stay objective.

Co-Design Research Tools and Prompts Co-Design Collaborative design is a design

strategy that includes users in the

design team. In a co-design team, users rapidly evaluate the design and actively provide opinions.

Co-design is widely applied by

human-centered designers. In this project, this strategy is not only

used to develop the design, but

also used to improve my research. Involving Staff in Prompts Design

Prompts designed for the interviews are brought to the staff for suggestions.

We communicate about the

expectation of the interviews and how we expect the

interviewees to tell their

stories. The staff have deeper

understanding of how to speak appropriately and effectively

to recovery community. As a

result, they provide powerful

suggestions for the prompts.

Individual Interview In this project, many of my

research findings and insights

are learned by interviewing my

stakeholders individually. I learned from my observation that in this

particular community, an individual discussion is more likely to avoid

interruption, focus on a particular topic and learn about one person comprehensively.

In each interview, I invited the

interviewee to describe his or her

story before and after becoming a part of the recovery community. I

ensured adequate time length for

the interviewees to tell the stories deep enough. In this way, I was

able to uncover not only facts, but

also values, opinions, desires and challenges.

Visual Research Tools Journey Map As a design research tool, A journey map is a visual

these information, I was able to understand what

experiences and associated thoughts and emotions

the recovery community, what challenge does each

prompt that encourage users to describe their

through a timeline. In the project, journey maps

are used in my individual interviews to stimulate

the conversation about the past experiences and goals of the interviewees. By diving deep into

happened to each person and brought him or her to person have and what he or she is trying to achieve.

As the number of my interviewees grew, I was able to understand the context of the community, the shared desire and the shared challenges.

Experience Evaluation This is a research tool I created to work in conjunction with the journey maps in the individual interviews. It also became a prototype to collect stories from recovery group discussions. In this exercise,

interviewees were asked to describe an experience

they had that influenced their emotions and thoughts.

the self-efficacy, decisional balance and processes of change described in the Transtheoretical Model.

Using this tool, I wanted to collect real-life examples that demonstrate how each type of experiences

impact on ones confidence and motivation. This

helped to discover the experiences we can encourage individuals in early recovery to pay attention to.

Then they were asked to rate how much more (or

The experience evaluation tool did not only get

more (or less) they believe they can achieve it after

conversation in which interviewees and participants

less) they want to achieve their goal, and how much

answers of what I asked, but also stimulate the

the experience.

shared their own tools to maintain their confidence

This tool was develop under the inspiration from

and motivation to maintain recovery.

Intervention Opportunities

How do Those in Recovery Make Progress on Their Goals?

Findings from interviewing Jody Individuals in early recovery who lost jobs because of substance

abuse have difficulty finding employment again. Becoming a Certified

Peer Specialist is an opportunity for individuals in recovery: it requires

documented history of substance abuse or behavioral health challenges. However, it also requires a completed GED when they sign up for the training.

Many of the other job opportunities also require a completed GED. Thus many need to receive GED tutoring until they pass the exam.

After passing the GED exam, they can sign up for training, take the

classes, take the tests and get certification to become a CPS, which

usually takes several months. They will then search and apply for jobs.

Findings from interviewing Jack No matter if they are applying for an ideal job or a temporary one, they all need to search for jobs, update their resumes, receive training if

necessary, send out applications and prepare for interviews. In some

cases, individuals became addicts or went to jail before they completed their education, and they donâ&#x20AC;&#x2122;t know what a resume is, how to use

computers, and how to send applications.

Insights:

Individuals go through long processes and have difficult challenges to

Individuals in early recovery

convince potential employers that they are ready to work. The most

effective way to overcome that challenge is to take action. For instance, a good volunteering record (long-term, consistent, responsible) will be

a good proof that a person has changed from a substance abuser or a criminal to a healthy, progressive and trust-worthy person.

are faced with complicated

challenges, which make their

goals difficult to set, and their progress difficult to measure.

Healthy Progressive

Employed

Trustable Addiction History

CPS

Need income for food

Search for other job opportunities

Need income to pay bills

Need income to pay treatments

Need income to support family

Search for part-time jobs

12 months Consistence Responsible

By action: volunteer

How to convince potential employer

Send application Update resume Prepare for interview

What is resume

How to use computers Learn

How to send applications

What’s Good about being Aware of Progress? Confidence and Motivation

Finding from talking with Anthony

Findings from interviewing John

A lot of people in early recovery look at their current

Recovery (or any other healthy change) is not a

they relapse, because they don’t see their progress.

go to get the next. Recovery is a change of a whole

situation and say “I ain’t getting nowhere”. That’s how

mission to finish. It’s not a thing that we get, and then person, and something we commit to in the rest of our lives.

However, it takes a long time for a person to figure that out, and a long time to commit. But a tool that encourages and motivates them (individuals in

Findings from interviewing Fred Individuals who come into PRO-ACT need to see the

early recovery) can keep them clean, sober and progressive long enough to realize that.

progress they have made.

They may have spent years in recovery but still have not reached the goals (get a house and get a job, for example) they come in with. It’s likely for them to be frustrated by this fact.

However, if they realize that they are actually making progress towards those goals (being able to rent an apartment, volunteering and having some part-time

jobs), they become more confident and motivated to move on.

Homeless Unemployed 2 days clean

Insights When individuals in early recovery are aware of progress they have made, they are more confident and motivated to maintain recovery.

Confident and motivated to keep going

Apartment Part-time job 2 months clean

I am making progress!

Recovery is not a goal or a mission. Itâ&#x20AC;&#x2122;s a change of a person and a life-long commitment.

I ainâ&#x20AC;&#x2122;t getting nowhere!

A House A dream job Long-term recovery

Progress

Goals

What’s Good about Taking Incremental Steps?

Tangibility of Goals and Visibility of Progress Findings from a recovery group

Another participant said in response to that situation:

In a recovery group discussion, a participant reflected

“If you take baby steps, you move forward slowly.

giant progress made him want to speed things up,

up, it only makes you fall back to where you were,

that setting only giant goals and only expecting to see

But if you take giant steps, and you wanna speed

which brought him into a certain level of stress and

sometimes even further.”

anxiety that he cannot handle. This situation caused

relapse many times, associated with illegal actions to get drugs.

Findings from talking with Anthony: Progress in recovery is not measurable on a scale. Recovery is a behavior and a practice, and it’s not

Giant goals

tangible. It’s easier for people to see and to peruse the tangible progress, such as being wealthy and

Treatment and Incarceration

No progress

Relapse and crime

Anxious and stressed Speed up

improving appearances, than to see the intangible

ones like living with healthy behaviors and learning new skills.

Findings from talking with Melody: Setting a smaller goal, which is easier to achieve,

is more likely to build confidence and motivation to move on.

Difficult

Be wealthy Buy a house

Be healthy

Buy a car Get a job

Maintain recovery

Clothing Learn to use computer

Hairstyles Nails

Invisible and intangible

Exercise regularly

Visible and tangible

Read a book Find a gym Go to a meeting Send an email

Insights When individuals in early recovery take baby steps:

1. Goals become more tangible to achieve;

2. Progress becomes more visible to review; This will strengthen confidence and motivation.

Easy

Watch a movie

Why is Inspirations for Incremental Steps Helpful?

Findings from talking with Melody After the recovery group, I talked with Melody about how would an

individual take baby steps as goals and progress. The conversation

revealed that it’s not easy for individuals to come up with baby steps. Individuals setting goals to pursue fulfillment trough recovery, for

instance, after a long period in jail or treatment services, many are

disconnected from what they like. It makes it hard for individuals to remember what they can do to fulfill a day other than using drugs.

“

It happens many times that they can’t maintain recovery just because it’s so boring.

Insights

”

Many individuals in early recovery have difficulty coming up with incremental steps. They need inspirations.

Intervention Goals

1. Collect examples of incremental steps from recovery groups. 2. Create inspiration for incremental steps for mentees. 3. Make goals and progress more tangible. 4. Strengthen confidence and motivation.

Design and Deliverable

Design Strategy: Collaborative Design What is collaborative design? Collaborative design is a design strategy that increases usersâ&#x20AC;&#x2122;

participation in a design process. In other words, it includes users as a

part of the design team, instead of an object for the designers to study.

Why did I apply collaborative design? Collaborative design is applied by many human-centered designers to utilize the creativity of the users.

Staff and volunteers are also more familiar with the shared desires and challenges of the community, the work flow in the organization, and

resources it has to support the new design. Thus, including them in the design team makes it easier to uncover design opportunities.

Design Team

Design for Social Impact

Designer

Co-Designers

Collaborative design reinforces evidence based design. By involving

users in my design process, I gain feedback from the community more

rapidly and learn from them about their needs more effectively. I base my design on what my users expressed.

How did I apply collaborative design? In this project, I invited staff and volunteers in PRO-ACT to collaborate

as co-designers in the design team. We had deep conversations about how to utilize the features and resources of the organization to orient

the project properly. We also frequently had conversations that helped develop and improve the deliverable of the project.

Staff and

volunteers in PRO-ACT

Tools

Individuals in

early recovery

Design Strategy: Rapid Prototyping and User Testing What is rapid prototyping and user testing? Rapid prototyping and user testing is a design strategy that increases

the frequency of prototyping and user testing by decreasing the amount of time to refine each iteration. It allows the designers to see if a design

works well or not before spending a great amount of time and resources to improve the artifact.

Why did I apply rapid prototyping and testing? In this project, there are many uncertain and unforeseen factors in the

communities for the designer. Chances are high that an idea generated

by the designer does not work as itâ&#x20AC;&#x2122;s expected to. Itâ&#x20AC;&#x2122;s more effective for

efi

Research

Problem

Statement

the design process to prototype fast and cheaply, bring it to the users and observe how they interact with the design, discuss with the users on how to improve it, and do it all over again in a short period.

How did I apply rapid prototyping and user testing? In this project, I shorten the loop of prototyping, testing and evaluation

into a week. In each week I develop the prototype, invited co-designers to try using the prototype. I observed the process and collect their feedback about what worked well, what did not work well, and what the potential improvement is for the next iterations.

e yp ot ot Pr

yp ot ot

es rT

Design

t Prototype

Evaluation

Prototype

Evaluation

Prototype

Evaluation

Design Deliverable: Story Sharing and Inspiring In a recovery group discussion The group facilitators will use a prompt that invites

Itâ&#x20AC;&#x2122;s also helpful for the participants to be aware that

steps are toward a particular goal. Their incremental

other peers in the community. It strengthened the

provided to help the others.

are productive members in the society, which in turn

the participants to discuss what their incremental

what they share during the discussions will also help

steps will then be noted and become examples they

awareness of community engagement and that they

encourages and motivates them to maintain recovery.

1/4 In A Recovery Group

BABY STEPS I have made towards Long-term recovery

Facilitator Co-facilitator

Participants

In a staff meeting The staff, group facilitators and peer mentors will

The structure of WRAP is currently applied in the

in the peer to peer support program. They will select

goals and measure progress in different domains

prepare inspirations for individuals who gain support and refined the examples collected from the recovery groups, and categorize them with the structure of the Wellness Recovery Action Plan (WRAP).

community, which guided many individuals to set

of life. Categorizing the examples by following the

structure makes it easier for the individuals to use them in conjunction with their recovery plans.

2/4 In A Staff Meeting Categorized

Sel Examples

g ctin

Discussing...

inspirations

Ref i nin

g..

collected from recovery groups

Staff, facilitators, peer mentors, etc.

Production After the staff meeting, the categorized inspirations will be sent to

one person to input to a document. There will be a framework of the

document for the person to build the document. Then the document will be printed and binded into handbooks, and will be delivered to the peer mentors in PRO-ACT.

3/4 Production

Input...

Bind

Peer Mentoring When the peer mentors meet with their mentees, if the peers have

difficulty coming up with smaller steps to set as goals or to review as progress, the mentors can show them the Handbook of Inspiration.

Opening the handbook, the mentees can be inspired by how simple and

specific a goal or a progress can be, and can be inspired to come up with the incremental steps toward their own goals.

4/4 When A Peer Mentor Meet with A Mentee

Oh! Now I know what my baby steps to my goals are!

I just wanna get a job. I can’t think of a smaller step to it

Well, try this.

Peer

Mentee

Mentor “I started Handbook of Inspirations

building my resume!“

today“

my self evaluation

“I sign up for a training

“I show Jack

“I went to a GED tutoring today“

yesterday!“ “I made a phone call to that company“

Deliverable Tools

Story Sharing Tool and Handbook of Inspiration The deliverable of this project is a process that needs to be supported by a set of tools. Thus, I selected two of the most important tools to develop: the

story sharing tool and the handbook of inspiration. I develop them with my co-designers by rapidly prototyping new iterations and testing them.

Story Sharing Tool

Handbook of Inspiration

Story Sharing Tool, Prototype #1: Confidence and Motivation Axis I WANT TO DO IT AND

I BELIEVE I CAN DO IT

I WANT TO DO IT BUT

I DON’T BELIEVE I CAN DO IT

I BELIEVE I CAN DO IT BUT I DON’T WANT TO DO IT

I DON’T WANT TO DO IT AND

I DON’T BELIEVE I CAN DO IT Please tell me something you did that changed your confidence and/or your motivation.

After you did it, how do you feel? Did you become more confident? Did you become more motivated?

Design This iteration of the story sharing tool contains cards to share stories and an axis of confidence and motivation.

By using this iteration, users are prompt to write down one of their action

that influenced their confidence and motivation. Users are then prompt to situate their story in the axis depending on whether that action increase or reduce their confidence or motivation.

User Tests I brought this story sharing tool to 3 potential users. They tested the prototypes and reflected potential improvement for the next iteration.

What worked or did not work in the user tests? The card for story sharing successfully prompted users to write down information. However, the

information tended to be statements or a thoughts rather than an action as expected.

Users also wrote down information on the axis

instead of situating the card they had already filled out onto the axis. Some users saw the exercise as

two separate exercises. Moreover, the process and questions worked confusingly.

What did the test result inform for the next iteration?

The result of the user tests also informed the

necessity of reducing the complexity of the process. The result also reflected a need of developing a

facilitation process that prompt the users to provide information more expectedly.

Story Sharing Tool, Prototype #2: Confidence and Motivation Evaluation Describe a time you experienced something that changed your confidence and/or your motivation

Before the experience

After the experience

How much did I feel motivated to stay committed? 1

How much did I feel confident to stay committed? 1

How much did I feel motivated to stay committed? 1

How much did I feel confident to stay committed? 1

Design This iteration of the story sharing tool contains only

cards to share stories. I invited Jody and other staff to reframe the question so that itâ&#x20AC;&#x2122;s clearer to the users. To reduce the complexity of the process, I removed

the axis of confidence and motivation. However, the

axis remained on the card in a different format, which visually prompted the users to rate their confidence and motivation before and after the experience.

User Tests To test this prototype with an effective facilitation, I

co-facilitated a recovery group discussion, which also gave me the chance to interact with more potential

users. I also brought them to the individual interviews and asked the interviewees to describe their

experiences and rate their confidence and motivation before and after those experiences.

What worked well or did not work well? The presence of a clearer question, a reduced complexity of process, a visual prompt and proper facilitation, the users are more able to

provide specific events they had experienced (instead of statements and thoughts).

However, some suggested that not all users will comprehend the

differences between confidence and motivation in the same way, and

that itâ&#x20AC;&#x2122;s also helpful to collect experiences that increase confidence and motivation at the same time. In fact, stories collected indeed increased both confidence and motivation.

How did the result inform the next iteration? Based on new opportunities of facilitating recovery groups, I decided to develop a process and a story sharing tool that fit in the group

discussions, which will stimulate more conversation and more stories.

Story Sharing Tool, Prototype #3: Baby Steps Prompts

Design To develop a tool to collect stories

from recovery groups, I built it into a surface on which participants

can share stories and see what others shared.

In this iteration, the prompt is clearer, simpler and easier to communicate.

The design of this iteration of the

story sharing tool utilizes available resources in PRO-ACT and can

reduce cost. It reduced the need

for printing. The tool can simply be built using large post-its and postit stickers: materials that PROACT is already using.

User Tests Assisted by Anthony, a volunteering facilitator, I facilitated another recovery group to test this

prototype. The topic of the group was â&#x20AC;&#x153;fulfillment

through recoveryâ&#x20AC;?. We asked the participants to share the small things they did to fulfill their daily lives. What worked well or did not work well? Putting side the discussion about confidence and motivation, the conversation became much more

natural and humanized. Participants came up with

very authentic experiences in daily lives. The post-it notes allowed participants to write down what came up in their mind when one another was speaking. Some times participants were inspired by shared stories pasted on the board.

This was the most recent prototype so far. New prototypes will keep coming.

Handbook of Inspiration, Prototype #1

Every Little Step Matters A Handbook of Inspirations for Your Baby Steps

Design This iteration of the Handbook of Inspiration was designed to be an

8 x 8 book. It categorized and displayed some examples collected from the recovery groups. It followed the structure of WRAP (a currently

applied tool for individuals in recovery to build action plans) so that the

users can search for inspirations depending which part of their recovery plan or what type of goal they are working on.

Feedback As I presented the first prototype to the staff in PROACT, I received very positive reaction. A recovery

specialist reflected that this is something they can actually use in their work.

There are also considerations about using different

sizes of paper and different ways of binding so as to save paper. It is also suggested to add blank pages

or blank spaces so that instead of only presenting

inspirations from the recovery groups, it also allow the owners of the book to write down their own

inspirations. For instance, a peer mentor who realizes that he or she just did something very inspiring to

the other, he or she can write it down. Then, when

meeting with his or her mentee, that inspiration from the peer mentor is also presented.

Handbook of Inspiration, Prototype #2 Design As recommended in the discussion about the first

prototype, I created this iteration with blank spaces for the owner to write down their own experiences. In consideration for production, I designed it in

8.5 x 11 inches so that less time is needed for cutting.

Feedback This iteration also received very positive responses from the potential users. The day I showed this

prototype to the community, two volunteers asked if

they could take them and use them. However, there

were still potential improvement to be made in terms of the size of the book and stories presented in it.

As a quick prototype, its content wasnâ&#x20AC;&#x2122;t complete, which indicated that more recovery groups are

needed to collect stories. I also invited more peer mentors and recovery specialists to contribute examples they heard from who they helped.

My observation also showed that the size of the book made it inconvenient to carry around. Thus I decided to shrink it.

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Handbook of Inspiration, Prototype #3

Every Little Step Matters

A Handbook of Inspirations for Your Baby Steps

Here are baby steps collected from other peers in recovery. Check it out, create goals or review progress of your own.

Design Based on feedback collected for the second prototype and my

observation, I developed the third prototype with an introduction of itself and more information collected from the community.

The size of the handbook is reduced to 5x7 inches, which reduces costs of material and time for production and increases mobility.

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Feedback The community reflected positively on the functionality of this iteration.

Some potential users found that they were able to keep the handbooks with them and write notes.

According to Fred, project coordinator of PRO-ACT, the mentees wonâ&#x20AC;&#x2122;t be able to meet with the mentors everyday. Sometimes the mentees

need to work on their recovery plan on their own and their mentors will be supporting them through other forms of communication (calling, texting or emailing). Fred suggested that not only the mentors, but also the

mentees have their own handbook as their instruction of working on their recovery plans.

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Future Consideration â&#x20AC;&#x153;Design is never finishedâ&#x20AC;?

My observation on other human-centered design projects taught me that designers have the

responsibility to stay with their users to ensure that

their designs work well. This responsibility requires many more cycles of prototyping and user testing.

To ensure the feasibility of my deliverable, this project will continue to improve the process of story sharing, synthesizing and producing the handbook. This

project will also continue to refine the handbook.

Develop Synthesizing Process This project has not created a process that bring the staff and volunteers together to synthesize

the examples collected from the groups. Thereâ&#x20AC;&#x2122;s a necessity to create such process which allows the

community to refine and categorize these examples.

Handbook of Inspiration By inviting peer mentors to use the handbook for their

Potential Improvement of the Story Sharing Tool

mentees, more specific feedback can be collected

The story sharing tool is currently used in a scenario

improvements for other parts of the project.

for further improvement. It is likely that feedback collected via the handbook could also inform

in which facilitation is needed. I see a necessity to

Digital Version Development

effective way to communicate and collect examples. It

This project is currently based on analog prototypes

develop a facilitation process framework that is an can be adopted by the volunteering facilitators.

I also see the necessity to improve the sustainability of the process and the physical tool. The process should be able to be maintained so that the

community has a sustainable resource of stories and inspirations. The design of the physical tool should

allow it to effectively support the activities and cost less material.

for time and cost efficiencies. However, the project can potentially uncover certain needs that analog

version could not satisfy. In this case, when analog version are well developed, digital versions will be created to further support the community.

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Photo credit: Wanting Lin

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Appendix

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Postscript Feedback from Thesis Presentation After presenting Breaking the Cycle project, it was reflected that the

environment of the recovery community was successfully captured and that the design deliverable is well-developed and practical. However, I also received suggestions for potential improvements for the project.

First, one of my thesis advisor, Sharon, questioned if the phrase “baby steps” I used in my design deliverable was appropriate. She pointed

out that the word “baby” creates a infantilized feeling and that people

may have patronizing reaction to it. I’m recommended to discover more options of other terms, test them and make sure that the terms used in the design have a healthier impact to the users.

Secondly, it was suggested that this project was presented abstractly because most of the content as illustrated by infographics. I was

encouraged, as a designer under the circumstances when taking photos

may not be appropriate, to develop tools to document and present actual people and their stories in a more authentic manner.

Last but not least, my audience also reflected that it wasn’t clearly

presented how the behavioral theories informed my research and design. As a result, the theories seemed irrelevant to the project. I’m suggested to focus on the most inspiring part of the theories and explain how it

contributed to my decisions. This will be helpful for not only presenting the project clearly, but also orienting the project.

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Glossary of Terms Behavior change

Recovery Support Service

A transformation or modification of behavior.

A service that provides relapse prevention and other

Collaborative Design (Co-Design)

substance abuse or other mental health challenges.

A design strategy that includes users as a part of the design team and increases usersâ&#x20AC;&#x2122; participation in a design process.

Certified Peer Specialist (CPS)

related supports for individuals in early recovery from

Relapse A process of falling back from a healthy behavior change to the old and unhealthy behavior.

A person who is willing to self-identify as a person

Stakeholder

support others to overcome the same challenges.

affected by a proposed action.

with experiences of behavioral health challenges to

An individual or a group that are likely to affect or be

Certified Recovery Specialist (CRS)

Substance abuse

A person who serves as a mentor to recovering

A patterned use of a drug in which the user consumes

promote long-term recovery.

harmful to themselves or others.

individuals in order to help prevent relapse and

the substance in amounts or with methods which are

Rapid Prototyping

Treatment Service

A design strategy that increases the frequency of

A service that provides treatment to help overcome

prototyping and user testing by decreasing the amount of time to refine each iteration.

Recovery The process of becoming clean, sober and healthy

after an addiction and the process of returning to a normal state after a period of difficulty.

addictions or behavioral illness.

Wellness Recovery Action Plan (WRAP) A currently applied recovery model for individuals in recovery from substance abuse and mental health challenges to build action plans.

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About the Author

Jun Li Design Researcher and Industrial Designer In 2016, I graduated from the Master of Design for Social Impact (DSI)

program at University of the Arts. By integrating multiple design skills, I

collaborate with communities to tackle complex challenges and innovate human-centered solutions to overcome these challenges.

I began my design education in the Industrial Design program at

Guangdong University of Technology in China. During my design

practice, I recognized that to develop a truly beneficial solution to a problem, designers need a holistic understanding of its context.

In the DSI program, I learned the context of how the world of design

evolves and how designers develop solutions to complex challenges

nowadays. I practiced design research methods that uncover important factors hidden in the blind spots of other research methods (market

research and scientific research) and design strategies that ensure a

healthier impact on the stakeholders. This stage of my education enable Photo credit: Rachelle Schneider

me to properly navigate an evidence-base design process.