recoveryblog: a blog for recovery advocates!
Our recovery advocacy blog is produced by individuals in recovery! Here you will find commentary and personal discussions on different aspects of addiction recovery and advocacy.
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Faces & Voices of Recovery is seeking a dynamic person to assist in building and managing our advocacy strategy for 2021-2022.
Interns must be available to work 10-14 hours per week. We are open to working with your university or college to establish credit. This is not a paid internship at this time.
Tasks and Responsibilities
Advocacy Interns will assist Faces & Voices of Recovery’s Director of Recovery Innovation and the National Advocacy and Outreach Manager in carrying out the organization’s advocacy priorities and legislative agenda.
Position Duties and Responsibilities
- Assist in policy scans, tracking, analysis, evaluation, and communication of relevant federal and state policy issues, legislation and regulations
- Prepare advocacy effort summary reports for sharing with our grassroots and grasstops advocacy networks
- Assist in developing Action Alert content, social media materials, and sign-on letter drafts
- Support Faces & Voices staff in regard to federal, state, and local policy development, communications, and administrative duties as assigned
- Additional responsibilities as assigned by the Advocacy staff
- Excellent organizational, verbal, written, public speaking and interpersonal skills
- Knowledge in computer programs, including excel
- Ability to work under pressure and think quickly on your feet
- Ability to work independently, as well as part of a team
- Experience/interest in engaging and motivating a large group of volunteers a plus
- Familiarity with and interest in substance use disorders, addiction recovery and healthcare issues a plus
- Excellent writing and editing skills, and a keen attention to detail
- Excellent written and oral communication skills; strong technical writing skills in English (Spanish language proficiency would be highly desirable)
- Excellent computer skills; proficient in Microsoft Powerpoint and Word
- Ability to show creative and flexible thinking
- Strong time management skills
- Strong attention to detail and desire to follow procedures
- People with lived experience who have been involved with grassroots campaigns in the behavioral health, harm reduction, justice reform, multi-pathways of recovery, or LGBTQIA+ communities, are encouraged to apply.
- Comfortable with social media advocacy
- Have an introductory or higher understanding of the U.S. legislative system
- Have worked remotely either as a student, volunteer, or employee for over 12 months
- To apply, send letter of interest, current resume/CV and a writing sample between 500 – 1000 words to email@example.com or apply using the link below.
Equal Opportunity Employer
We believe that diversity in experiences, perspectives, knowledge and ideas fuels creativity, broadens knowledge, and helps drive success. That’s why we’re proud to be an equal opportunity employer and strive to treat all employees with honesty, dignity and sensitivity. We welcome all qualified applicants regardless of recovery status, criminal justice history, race, color, national origin, ethnicity, religion, sex, pregnancy, sexual orientation, gender, gender expression or identity, age, disability, veteran status, marital status or any other legally protected class.
Faces & Voices of Recovery would like to acknowledge that, On January 1, 1863, President Abraham Lincoln issued the Emancipation Proclamation, freeing all enslaved people. Nearly two and a half years later, on June 19, 1865, the enslaved residing in Texas received news of their freedom. Juneteenth marks the day when federal troops arrived in Galveston, Texas, to take control of the state and ensure that all enslaved people be freed. On June 17, 2021 President Joseph Biden signed a law making Juneteenth an official federal holiday. Faces & Voices of Recovery recognizes Juneteenth as a national holiday, and we honor it as the day all slaves in America became free.
On this important day, we are proud to release the following document regarding Race Equity. It is the culmination of a year-long examination and thoughtful reflection on our collective role in the recovery community’s pathway toward race equity. We are grateful to our partners in this endeavor for their painstaking work. We also extend an open invitation to any organization who would like to join us in this work.
We believe there is ample opportunity to heal.
The work continues.
Posts from William White
Since the late 1990s, I have advocated a radical redesign of addiction treatment—one that extends the prevailing acute care model of addiction treatment to one of sustained recovery management (RM) nested within larger recovery oriented systems of care (ROSC). (See HERE for a basic primer on RM & ROSC.). RM moves beyond providing brief episodes of biopsychosocial stabilization to assuring sustained recovery support across six stages of long-term recovery: precovery, recovery initiation, recovery maintenance, enhanced quality of personal and family life in long-term recovery, and efforts to break intergenerational cycles of addiction and related problems. RM models differ across many dimensions, including approaches to treatment attraction, access, assessment, engagement, service components, service relationship, involvement of family and community, and the nature and duration of post-treatment recovery support services.
I am often ask the extent to which addiction treatment in the U.S. reflects this RM and ROSC orientation. Answering this question with current data across all RM and ROSC elements is beyond the scope of a short blog, but a just-published study does inform the present status of one critical RM element.
Traditional acute care models of addiction treatment is based on an expert relational model of service delivery. A professional expert screens, assesses, and diagnoses a substance use disorder and any co-occurring conditions present in the patient/client. The expert then formulates and implements a treatment plan and monitors the progress of treatment using measures defined by the expert. The expert also makes the ultimate decision when and under what conditions the service relationship is terminated—all in an ever-briefer time due to current funding constraints. In short, the individual being treated is considered a recipient of the services and expertise of the professional in a relationship not unlike having a broken arm treated by a physician within a hospital emergency room.
RM relies on a partnership relational model in which the person seeking recovery guides their own recovery process with professionals, family members, and peers in recovery serving as recovery consultants who offer guidance as needed and requested. The client role in co-creating and directing their own recovery processes involves an active role in problem definition and problem resolution with acknowledgement of many pathways and styles of long-term personal and family recovery that differ considerably across clinical populations and cultural contexts. This philosophy of choice is central to the RM approach to treatment and counseling. In mainstream medicine, this personalized model of service delivery is widely advocated as “patient-centered care.”
Park and colleagues have just published an analysis of 2017 data on the degree to which U.S. addiction treatment providers practice patient-centered care. Based on a national sample of 730 addiction treatment programs, only 23% of programs involved clients within clinical decision-making processes. Clinics treating a majority of clients with alcohol or opioid use disorders were most likely to offer a standard, minimally personalized treatment protocol and least likely to involve clients in clinical decision-making.
In a recent blog, Bill Stauffer and I offered a renewed call for the inclusion of people seeking and in recovery into the decision-making venues that affect their lives. Such ideal representation surely includes the active involvement in clinical decision-making of patients undergoing addiction treatment. Based on the Park study, the addiction treatment field has a long way to go in achieving the involvement of its most important constituents. It is long past time for that to change.
Park, S., Grogan, C. M., Mosley, J. E., Humphreys, K., Pollack, H. A., & Friedmann, P. (2020). Correlates of patient-centered care practices at U.S. Substance use disorder clinics. Psychiatric Services, 71(1), January.
White, W. L. (2008b). Recovery management and recovery-oriented systems of care: Scientific rationale and promising practices. Pittsburgh, PA: Northeast Addiction Technology Transfer Center, Chicago, IL: Great Lakes Addiction Technology Transfer Center, Philadelphia, PA: Philadelphia Department of Behavioral Health & Mental Retardation Services.
In 2005, my colleagues Christy Scott, Michael Dennis, Michael Boyle, and I co-authored an article entitled It’s Time to Stop Kicking People out of Addiction Treatment. At that time, 18% (or 288,000) of people admitted to specialized addiction treatment in the U.S. were “administratively discharged” (“kicked out”) prior to treatment completion. Such expulsions most often resulted from alcohol or other drug use, violation of program rules (e.g., missed appointments, refusal to follow staff directives, “fraternization” with other patients, etc.), or failure to pay service fees. We drew the following conclusions in the 2005 review.
- Administratively discharging clients from addiction treatment for AOD use is illogical and unprecedented in the health care system.
- Administratively discharging clients from treatment for AOD use reflects a fundamental misunderstanding of the role of volition in addiction and recovery.
- Administrative discharge casts the role of the treatment agency as one of persecutor, and misjudges the meaning and consequences of administrative discharge (AD) to the client.
- Administratively discharging clients from treatment for rule violations is often the endgame in a process of escalating negative countertransference.
- Administratively discharging clients often involves behaviors that are unrelated to, or have only a weak connection to, the prospects or processes of recovery or safety issues within the treatment milieu.
- Administratively discharging clients from treatment projects casts the blame for treatment failure on the client and prevents treatment programs from evaluating and refining clinical practices.
- Administratively discharging clients from a publicly funded addiction treatment program for failure to pay service fees constitutes clinical abandonment and is a breach of professional ethical principles and (potentially) legal and regulatory standards.
We then outlined 12 policy alternatives to administrative discharge and 6 clinical strategies to reduce such premature treatment discharges.
The 2004 paper contended that expelling a client from addiction treatment for AOD use–a process that often involves thrusting the client back into drug-saturated social environments without provision for alternate care–makes as little sense as suspending adolescents from high school as a punishment for truancy. The strategy, we suggested, should not be to destroy the last connecting tissue between the individual and pro-recovery social networks, but to further disengage the person from the culture of addiction and to work through the physiological, emotional, behavioral, and characterological obstacles to recovery initiation and recovery maintenance.
The 2004 paper was followed by blogs in 2014 and 2015 (See HERE and HERE) that updated AD data and added to these early suggestions. New data at that time suggested that AD decisions inordinately target African Americans and persons of low socioeconomic standing, as well as those persons in greatest need of treatment—those with highest problem severity, complexity, and chronicity, and the lowest recovery capital.
The present blog draws on three additional studies, a study of premature treatment termination in an inpatient addiction treatment unit, a study of discharges for “behavioral transgressions” among patients in methadone treatment, and a paper addressing AD for patient “fraternization.”
A just-published (2020) study by Syan and colleagues explored the characteristics of patients who failed to complete residential addiction treatment. Those failing to complete treatment via AD or leaving against medical advice were distinguished by high severity of illicit drug use and high psychiatric severity (particularly PTSD). This study confirmed anew that those most likely to experience a premature termination of treatment are precisely those in greatest need of such treatment. Syan and colleagues called for assertive efforts to identify and offer specialized support for those at highest risk of premature treatment termination.
A recent (2019) study by David Potik and colleagues explored the prevalence of psychopathy among methadone maintenance patients exhibiting continued drug use and other “behavioral transgressions” (e.g., verbal/physical aggression, selling drugs to other patients, failure to return empty take home medicine bottles, etc.) during the course of their treatment. Both drug use and other behavioral transgressions during treatment were associated with high psychopathy scores.
This study confirmed two important findings. First, as in the Syan study, continued drug use and “behavioral transgressions” in addiction treatment are often indicators of high addiction severity and co-occurring psychiatric disorders (including personality disorders). Second, evidence suggests it is possible to address these issues within the context of treatment over an extended course of treatment without patient drop out or administrative discharge from treatment.
In light of this study, administratively discharging an MMT patient for drug use and behavioral transgressions may involve punishing the patient for exhibiting symptoms of the very disorders for which treatment is indicated. For other chronic health care problems, symptom manifestation during treatment confirms or disconfirms the working diagnosis and provides feedback on the degree of effectiveness of the treatment methods. In marked contrast, symptom manifestation in the addictions field too often results in blaming and expelling the patient. It is contradictory to argue that addiction (with or without co-occurring psychiatric illness) is a primary health care problem involving loss of volitional control over drug use and its consequences while continuing to treat its primary symptoms as bad behavior warranting termination of the service relationship.
A second study by Hafford-Letchfield and Nelson concludes that the addictions treatment field pathologizes and suppresses sexual desire of patients in ways that go far beyond promoting physical/sexual/emotional safety within the treatment milieu and avoiding romantic/sexual acting out as an escape from the treatment experience. Such pathologization is most evident in bans on patient “fraternization” and kicking patients out of treatment for becoming romantically involved during their time in treatment.
Patients entering addiction treatment bring all manner of complex sexual histories—histories that may include sexual victimization or predation, sexual dysfunctions, and self-destructive patterns related to past sexual relationships. It is inevitable that these issues rise within milieu-oriented treatment and require clinical attention. Failing to address such issues can lead to concerns related to patient safety, patients using romantic/sexual attraction as a diversion from treatment, or patients leaving treatment prematurely to pursue their relationship. Such concerns are clinical issues to be addressed within the counseling process. But is the expression of sexual desire or mutually (and voluntarily) acting out that desire grounds alone for discharging patients from addiction treatment? Would treatment of any other medical condition be suddenly and prematurely terminated due to sexual involvement between two patients who met within the treatment milieu? Are there no clinical management strategies that would prove more effective in promoting long-term recovery outcomes? Administrative discharges are often characterized as “therapeutic discharge,” but there is no scientific evidence that kicking a person out of addiction treatment has any positive therapeutic effects.
These new studies point out several shared elements. One, it is the patients who are most in need of treatment and prolonged recovery support that are most likely to be subjected to disciplinary expulsion from addiction treatment. Two, the behaviors most likely to be the justification or expulsion are symptoms of the very problems for which treatment is indicated. In short, too many patients entering addition treatment are arbitrarily discharged for confirming their diagnoses. Third, race, ethnicity, and class interact with problem severity and complexity to predict those patients at greatest risk of expulsion from treatment. Fourth, there are clinical alternatives to management of these behaviors that can enhance long-term recovery outcomes.
We could do much better with these patients and we must.
Hafford-Letchfield, T., & Nelson, A. (2008). Closeness equals pathology: Working with issues of sexual desire and intimacy within the substance misuse field. Diversity in Health and Social Care, 5, 215-24.
Potik, D., Abramsohn, Y., Schreiber, S., Adelson, M., & Peles, E. (2019). Drug abuse and behavioral transgressions during methadone maintenance treatment (MMT) are related to high psychopathy levels. Substance Use & Misuse, https://doiorg/10.1080/10826084.2019.1685546.
Syan, S. K., Minhas, M., Oshri, A, Costello, J., et al., (2020) Predictors of premature treatment termination in a large residential addiction medicine program. Journal of Substance Abuse Treatment, 117, 108077.
White, W., Scott, C., Dennis, M. & Boyle, M. (2005) It’s time to stop kicking people out of addiction treatment. Counselor, 6(2), 12-25.
Introduction (Bill White)
The international recovery advocacy (and peer recovery support) movement is marked by the proliferation of grassroots recovery community organizations that are distinct from traditional addiction treatment organizations and recovery mutual aid societies. As these new organizations emerge across geographical and cultural contexts, one of the critical needs is the creation of a networking process through which such organizations can share their experiences, forge a common vision and shared goals, and exchange new technologies of recovery advocacy and recovery support.
The following brief report from David Best and colleagues offers a quite promising update on such an effort in the UK. I have closely followed the progress of the UK recovery advocacy movement since my visits there in the 2000s. I find these current efforts quite inspiring and suggest their emulation by other countries.
Connecting the connectors: Creating space to develop evidence-based innovation in Lived Experience Recovery Organisations
By David Best, Ed Day, Stuart Green, Dave Higham, Michaela Jones, Tim Leighton, Tim Sampey, Jardine Simpson, Dot Smith, & Stephen Youdell
The UK now possesses a rich and diverse range of Lived Experience Recovery Organisations (LEROs) whose models and methods are driven by mutual support, community engagement and enhancement and a commitment to individual, group and local community wellbeing. This is often driven by a person of lived experience (POLE) who is often championing a gap between specialist treatment on the one hand and the mutual aid fellowships on the other, in order to meet local needs.
Yet the problem for LEROs is one of fragmentation. There are no professional or membership bodies in the UK or in most other countries, no governance or inspection frameworks and not even any annual events or forums that would allow for the sharing and exchange of good practice of innovation. Partly for these reasons, LEROs remain marginalised in the funding and planning of addiction services and systems, and this marginalisation helps to perpetuate our ‘orphan’ status, and are often perceived by treatment organisations and commissioners as bedevilled by in-fighting and lacking in consistent standards.
Early in 2020, in response to the pandemic and the changing face of recovery support services in the UK as elsewhere in the world, a group of recovery leaders and advocates came together with four primary objectives:
1: To identify and champion innovation in LEROs and provide a supporting evidence base
2: To provide connections and support for recovery leadership
3: To champion good practice in LEROs and to develop standards
4: To act as a voice for LEROs and a hub of evidence and knowledge
The catalyst for convening the group was around the emergence of some incredible innovative and flexible practices around both online transitions following lockdown (in response to the COVID crisis) and some continuing and evolving community work to support clients, their families and the broader communities deal with the hardships that the pandemic had generated.
So what does the group do?
The initial aim for the group was to test shared ideas and shared vision but above all to generate a radius of trust where participants felt confident that they would be heard and respected, and where they could be open and honest without concerns about confidentiality and integrity. Much of the first few discussions (which are held weekly by Zoom) were around what we mean by recovery and recovery-oriented approaches leading to agreement that the appropriate language of inclusion was to focus on Lived Experience Recovery Organisations, where Lived Experience referred to marginalisation and adversity rather than necessitating substance use or misuse. The aim here was to promote inclusivity and compassion.
The initial group membership was opportunistic, based on shared working experiences, yet a number of participants did not know each other, and one of the key successes in the early stages has been that there have been no drop-outs and no additions – in other words, the group has been able to develop its own identity and norms.
With that shared vision and understanding in place, the group is now moving to a process of external engagement and will work towards using these solid foundations to build validity in its communication and thoughts with the wider treatment and recovery landscape.
We are now starting a weekly peer supervision component where the final 30 minutes of the session are to be dedicated to addressing key challenges faced by one of the recovery group leaders. The first one of these addressed the question of maintaining personal recovery values while competing in a professional arena that is often inimical to those values. This process has created strong bonds of commitment and empathy within the group.
While we are still very much in our infancy, there is a clear need for members to explore how to deal with complex issues of leadership and management in organisations that have strong ethical and inclusive principles and values. We are still learning and continue to strive to find the most empathic, humane and empowering ways to deal with people with lived experience.
Defining a LERO: principles, values and standards
Our initial definition of a LERO is: “an organisation of lived experience committed to recovery with a focus on autonomy” while we are deliberately being broad and inclusive in our consideration of lived experience as “Lived experience is defined as personal knowledge about the world gained through direct, first-hand involvement in everyday events rather than through representations constructed by other people“.
From this starting point our aim is to promote principles and values of:
- Human rights
- Strengths-based approaches
- Active engagement with lived communities
- Promoting positive human connection
Through these principles our aim is to promote and champion the emerging evidence base for recovery-oriented practice and to ensure that this is effectively and consistently implemented and embedded against a set of standards for LEROs to sign up to. Performance against these standards will be rigorously assessed by those with lived experience.
During the COVID crisis in the UK, there is a general recognition that LEROs and other community organisations have generally been adaptable and effective in responding to threatening and rapidly changing environments. Our aim is to champion this kind of adaptability based on the needs of people in recovery, their families and (crucially) the wider communities. It is often difficult to quantify some of these benefits to service commissioners (whose models are typically designed to address deficits) but they are critical in understanding why LEROs should not be considered as treatment providers nor judged against treatment standards. Our aim is not to be an ‘add on’ to treatment but an equally valued, evidenced and significant component of a balanced recovery-oriented system of care with different (but just as rigorous) standards and values.
Since its inception in the late 1990s, a central goal of the new recovery advocacy movement has been assuring the representation of recovering individuals and families in the decision-making venues that affect their lives. As this movement matured, the complexities of achieving such representation became increasingly apparent. Dynamics within and beyond communities of recovery can threaten authentic recovery representation. Below are six critical dimensions of recovery representation and proposed benchmarks for each.
Authenticity of Representation is the assurance that those representing the recovery experience within decision-making venues are individuals and families with lived experience of recovery who are free from undue conflicts of interest. The problem that sometimes arises is that of double-agentry—persons who present themselves as representing the recovery community who, with or without conscious intent, represent instead personal, ideological, institutional, or financial interests. People with personal knowledge of the recovery process and the historical challenges faced by people seeking and in recovery free of such conflicted interests are the best suited for recovery advocacy leadership.
Guidelines: 1) Members of recovery communities are provided a voice in the selection of persons who represent their experiences and needs. 2) Those representing the recovery experience at public and policy levels possess rich experiential knowledge of personal and/or family recovery from addiction. 3) Persons representing the experiences and needs of people seeking and in recovery are free from ideological, political, or financial conflicts of interest that could unduly influence their advocacy efforts.
Depth of Representation assures a sufficient density of recovery representation within any decision-making group. The challenge is to avoid recovery tokenism, e.g., a single person asked to represent the broad range of recovery experiences and recovery support needs. Too many organizations exploit people in recovery to burnish their organizational image or superficially comply with an external recovery representation requirement, while affording little opportunity to affect policy decisions. Depth of representation also assures that people in recovery are at policy decision-making tables and not just involved in an advisory capacity, e.g., representation on governing boards as well as advisory committees.
Guidelines: 1) Recovery community organizations (RCOs) maintain authentic recovery representation greater than 50% at membership, board, and staff levels. 2) RCO leaders are drawn from individuals and family members in recovery or allies vetted by communities of recovery. 3) The RCO is committed to leadership development of its members. 4) Recovery representation in local organizational decision-making is commensurate with the degree to which recovery is central to the mission of an organization or project. The greater the focus on recovery, the greater the desired level of recovery representation.
Diversity of Representation assures the inclusion of people representing the growing varieties of recovery experiences and the diverse cultural contexts and community spaces in which recovery flourishes or flounders.
Guidelines: 1) The pool of available recovery representatives reflects secular, spiritual, and religious pathways of recovery as well as natural recovery and peer- and/or professionally-assisted recovery (including medication-assisted recovery). 2) Recovery representatives are knowledgeable about diverse communities of recovery and speak publicly not as individuals or representatives of one path of recovery, but on behalf of all people in recovery. (The fact that no one is fully qualified to do that helps us maintain a sense of humility, open-mindedness, and inclusiveness.) 3) Recovery representatives embody a spirit of anonymity—the suppression of self-centeredness—embracing and celebrating the wonderful varieties of recovery experience rather than competing for personal attention or pathway superiority. Falling short of these aspirational values is far too easy in the rarified air of public attention.
Stability of and Support for Recovery Representatives assures that people representing the recovery experience at the public level have sufficient recovery time and stability to offer a positive face and voice of recovery without threat to their continued recovery or their physical and psychological safety.
Guidelines: 1) Recovery representatives exemplify a recovery custodian orientation (rather than a celebrity orientation). 2) The custodian role properly places the focus on recovery messages and off the person or persons serving as messengers. 3) Recovery representatives exemplify servant leadership, affirming their role in serving the community. 4) Recovery representatives are not placed in roles involving physical or psychological risk without supervision and clear safety protocol.
Scope of Representation assures that people in recovery have a voice in shaping the full continuum of care related to alcohol- and other drug-related problems. Recovery representation is critical to effective AOD systems design, program implementation, service delivery, systems performance evaluation, and ongoing systems refinement.
Guidelines: 1) Recovery representation is included in policy and programming decisions related to primary prevention, harm reduction, early intervention, clinical treatment, community-based recovery support services, and the larger arena of alcohol and drug policy decisions. 2) Recovery representation is included in decision-making bodies charged with addressing common recovery challenges and resource needs, e.g., co-occurring health conditions, educational opportunity, employment opportunity, etc.
Public Enfranchisement assures that people in recovery are free from arbitrary restrictions on voting, holding public office, or exercising rights afforded other citizens.
Guidelines: 1) Local recovery community organizations exist and advocate for the full enfranchisement of people in recovery, including encouragement to vote and serve in public service roles. 2) People in recovery disenfranchised due to past addiction-related crimes have their full citizenship rights restored following release from prison or completion of probation or parole. 3) There are no state or local laws or regulations that otherwise suppress the voting, e.g., statutes requiring all fines be paid before voting rights are restored. 4) The addiction treatment and recovery support workforce fully reflects the diversity of the community, is provided a living wage, and is free of administrative burdens that interfere with service provision. 5) The treatment and recovery support system addresses barriers to employment and volunteer participation of people with lived experience of recovery.
Supporting and strengthening long-term recovery across multiple pathways of recovery and diverse cultural contexts must remain a central focus of our efforts. This is “the commons” of our movement for which we need deep, equitable, and inclusive representation in matters that effect our lives.
Nihil de nobis, sine nobis is Latin for NOTHING ABOUT US WITHOUT US and has been a rallying cry for democracy and disenfranchised groups for over 500 years. It means that no policy should be decided without the full and direct participation of those affected by that policy. We must ensure that our voices are included in all systems addressing alcohol- and other drug-related problems.
Harvard-trained historian Ernest Kurtz loved stories. The power of story and the role of storytelling in personal identity and addiction recovery filled his writings on Alcoholics Anonymous (A.A.), and they were central themes in the books he co-authored with Katherine Ketcham: The Spirituality of Imperfection and Experiencing Spirituality.
I apprenticed under Ernie’s guidance for more than two decades in hopes of mastering the art and science of historical research. Sitting across from him in his office, I must have asked Ernie a thousand questions. His most frequent response was to lean forward in his chair, eyes twinkling, arms and hands in motion, to share a story in a voice that would have done Moses justice. Ernie was at heart and above all a spellbinding storyteller.
Ernie was fascinated with how life stories were, by necessity, reconstructed as part of one’s recovery from alcoholism. He often commented on how the A.A. story style helped newcomers construct a new life story from the fragments of their brokenness. The new story helped make sense of experiences that were otherwise inextricable, helped fire hope, salvaged self-esteem, and bolstered the commitment to sobriety.
One of the many themes within Ernie’s historical research was the role of memory in storytelling—writ small (personal identity) and large (collective history). Aware that much of my recounting of the modern history of addiction treatment and recovery flowed from interviews with key players within that history, Ernie cautioned me to think of memory as more construction site than storage drawer. He often discussed the potential loss of objective history due to the filtering of memory through efforts of self-enhancement, institutional interests, and contemporary political and cultural wars. His admonition? Verify everything!
Ernie was equally intrigued by the role of memory as scaffolding for addiction and recovery. He suggested that how we select and attach meaning to events in our life exert a profound effect on our future. The selection and deselection of life events to form a coherent narrative in his view could support either addiction or recovery. An essential feature of the journey between the former to the latter was thus a process of story reconstruction and storytelling. Ernie suggested: change the story, change the life—a process aided by both skilled clinical intervention and participation in a community of recovering people with whom one could identify.
Ernie also explored how recovery stories changed over time, marking a prolonged process of healing and reconstruction of personal character and values. In The Spirituality of Imperfection, he identified six experiences/traits expressed in these evolving stories—all keys to this long-term reconstruction of self: release, gratitude, humility, tolerance, forgiveness, and being-at-home. As is evident, Ernie understood addiction recovery as a process involving far more than the deletion of drugs from an otherwise unchanged life.
During my last visit with Ernie before his passing, he shared with me a number of private documents. Included was 145 pages of raw notes on story and storytelling. This elaborately coded document contained quotations and summaries from all his related readings as well as many of his own reflections, only some of which appeared in his published work. I have cherished these notes for the past five years and have decided, with permission from Ernie’s wife, Linda Ferris Kurtz, to share some excerpts from these notes. Below are just a few of Ernie’s prized discoveries and reflections on story, memory, and storytelling. I share these as a way of continuing to honor what Ernie meant to so many of us. To review selected excerpts from the Kurtz notes on Story, Memory and Storytelling, click HERE.
SAMHSA’s BRSS TACS releases directory of peer recovery coaching training and certification programs
The Substance Abuse and Mental Health Services Administration’s (SAMHSA) Bringing Recovery Supports to Scale Technical Assistance Center Strategy (BRSS TACS) recently released their State-by-State Directory of Peer Recovery Coaching Training and Certification Programs. The directory provides detailed information about certification processes for peer recovery coaches, including training requirements, curricula, exam criteria, fees, and program descriptions. The directory also identifies recovery coach supervisor training requirements and supervisor training courses.
Social anxiety/phobia, often mischaracterized as extreme shyness, constitutes a potential pathway into addiction and a major obstacle to addiction treatment and recovery.
Robert and Kaisha could not be more different at a quick glance, but they shared the curse of what others perceived as extreme shyness. Robert and Kaisha dreaded any social situation filled with strangers, the expectation of conversation, or any undue focus upon themselves. Just the thought of entering such a situation induced a trembling voice, a racing heart, sweaty hands, a blushing face, dizziness, nausea, extreme self-consciousness, and fears of embarrassment and humiliation. In social situations that could not be escaped, they sought invisibility, shunning as much contact as possible, avoiding eye contact, speaking very little or not at all, and spending inordinate time afterwards harshly judging their social performance.
Robert and Kaisha found something of a solution for their social anxiety. They discovered magic elixirs that lessened or dissolved their fears and loosened their tongues. The problems only came when their increasing dependence on ever-increasing dosages and frequencies of these elixirs created all manner of other problems in their lives. When these escalating problems forced them to seek help, imagine their mortification to hear that their “treatment” would involve group therapy and participating in recovery mutual support groups in their local community.
The situation faced by Robert and Kaisha is by no means rare. A study by Book and colleagues found that 37% of people entering addiction treatment also experienced clinically significant social anxiety. The 37% figure would extrapolate to more than 740,000 individuals entering addiction treatment each year. The Book study raises several important questions.
Of 21.7 million Americans in need of help for a substance use disorder in the past year, only 2.3 million received specialized SUD treatment. What portion of those not receiving treatment were dissuaded from seeking help due to social anxiety and the group-orientation of addiction treatment and recovery mutual aid?
Since 1999, more than 770,000 Americans have died from drug overdoses. What portion of those lost lives chose not to seek help due to social anxiety and the group-orientation of addiction treatment and recovery mutual aid?
Since 1999, nearly one million individuals died from alcohol-related causes. What portion of those lost lives chose not to seek help due to social anxiety and the group-orientation of addiction treatment and recovery mutual aid?
There are an estimated 1.4 million suicide attempts and more than 47,000 deaths by suicide in the United States each year. What portion of these people suffer from a substance use disorder and fail to seek help due to social anxiety and the group-orientation of addiction treatment and recovery mutual aid?
The situation faced by people who need help for a substance use disorder but who shun such help due to social anxiety could be improved if:
*Addiction professionals assessed the presence and degree of social anxiety of every person seeking help for a substance-related problem.
*Integrated addiction and mental health services existed that could concurrently treat SUDs and anxiety disorders via potential combinations of psychosocial support and medication.
*Treatment adjuncts/techniques potentially helpful to those with social anxiety (e.g., thought-stopping, reframing, biofeedback, systematic desensitization, situation rehearsal, progressive relaxation, breath training) were routinely available in addiction treatment programs.
*Outpatient individual counseling was universally available as an alternative to the dominant group-oriented intensive outpatient and residential models of addiction treatment.
*Prescriptive bibliotherapy and self-guided manuals were more widely available as adjuncts and alternatives to addiction treatment.
*E-therapy and e-recovery support services, including online recovery support chat rooms and online meetings (e.g., In the Rooms) were assertively promoted to people with social anxiety.
*Each person with social anxiety was assigned a recovery coach as a personal travel guide into the social worlds of addiction recovery.
*People with social anxiety were phased in to recovery-focused social contact, beginning with orientation to program literature and rituals, one-on-one contact, and large speaker meetings where there is no expectation for participation prior to exposure to smaller closed meetings.
Social anxiety constitutes a major obstacle to addiction treatment and recovery. Human connection is a key mechanism of change within addiction recovery, but people with social anxiety may need special support to access such connection. Scientific research, careful clinical observation, and personal lived experience may offer such people improved solutions for the future.
Acknowledgement: Thanks to members of the Recovery Rising Book Club for comments on an early draft of this blog.
Book, S. W., Thomas, S. E., Dempsey, J. P., & Randall, P. K. (2009). Social anxiety impacts willingness to participate in addiction treatment. Addictive Behaviors, 34, 474-476.
Substance Abuse and Mental Health Services Administration, (2019). Treatment Episode Data Set (TEDS): 2017. Rockville, MD: Substance Abuse and Mental Health Services Administration.
White, A. M., Castle, I-J., P., Hingson, R. W. & Powell, P. A. (2020). Using death certificates to explore changes in alcohol-related mortality in the United States, 1999-2017. Alcoholism: Clinical & Experimental Research. 44(1). 178-187.
I believe we live in the greatest era of snake oil salesmen in the history of mankind. —Michael Crichton, Next, 2006
The addictions treatment field has grossly oversold the effectiveness of a single episode of brief clinical intervention. For more than two decades, calls have increased for a radical redesign of addiction treatment and related recovery support services—a shift from acute care models of intervention to models of sustained recovery management (RM) nested within larger recovery-oriented systems of care (ROSC).
Defining Acute Care: Acute care (AC) models of addiction treatment encompass service interventions that intervene at a late stage of problem development via services focused on brief biopsychosocial stabilization that lack sustained support across the stages of long-term personal and family recovery. AC models of intervention that have dominated specialized addiction treatment since its inception in the mid-nineteenth century share distinct characteristics:
*Services are delivered “programmatically” in a uniform series of encapsulated activities (screen, admit, single point-in-time assessment, minimally individualized treatment, discharge, brief “aftercare” as an afterthought, termination of the service relationship).
*Clinical intervention is focused on symptom elimination for a single primary problem.
*Professional experts direct and dominate the assessment, treatment planning, and service delivery decision-making.
*Services transpire over a short (and historically ever-shorter) period of time—usually as a function of a prearranged, time-limited insurance payment designed specifically for addiction disorders and “carved out” from general medical insurance.
*The individual/family/community is given the impression at discharge (“graduation”) that “cure has occurred”: long-term recovery is viewed as personally self-sustainable without ongoing professional assistance.
*The intervention is evaluated at a short-term, single-point-in-time follow-up that compares pretreatment status with discharge status and short-point-in-time post-treatment status.
*Post-treatment symptom recurrence and needed readmission are viewed as failure of the client rather than flaws in the design or execution of the treatment protocol. Treatment in subsequent admissions is essentially the same as that of the first admission.
Why Acute Care? The modern addictions treatment field migrated toward an acute care model in the 1970s and early 1980s. The model reflected a bid for professional credibility of an emerging field, a needed response to the surge in public funding for addiction treatment, and a strategy to acquire private insurance reimbursement for such treatment. The resulting scheme of treatment and related funding policies resembled the acute care hospital, with duration of treatment becoming ever briefer following the advent of aggressive systems of managed behavioral healthcare. Detoxification programs were modeled on the hospital emergency room, inpatient and residential programs were modeled on acute care wards of the general hospital, and outpatient programs were modeled on the outpatient medical clinic. The resulting model prescribed a series of clinical steps all compressed in as little time as possible.
Potential Value of Acute Care: AC models of SUD intervention are very appropriate for people with low to moderate substance use disorders (SUDs) who also possess substantial recovery capital. Millions of people fitting this profile are today in long-term stable recovery who express unending gratitude for the AC treatment they received. For people with more severe SUDs, acute care is one critical stage in what needs to be a multi-staged process of sustained recovery support.
Unintended Consequences of AC Model: Failure to meet SUD severity criteria denies access to care for many people with mild to moderate substance-related problems and substantial recovery capital. People with the most severe, complex, and chronic SUDs are being repeatedly recycled through AC models of care whose low intensity and duration of services offer little hope of sustainable SUD recovery. (58% of people now admitted to addiction treatment in the U.S. have one or more prior treatment episodes, TEDS Data). I have regularly compared AC models of addiction treatment to providing inadequate dosages or duration of antibiotics in the treatment of bacterial infections. In both cases, treatment leads to temporary suppression of the symptoms but inadvertently leads to resurgence of the condition in a more intractable condition.
Cost-ineffectiveness of AC Model
Millions if not billions of dollars allocated to AC treatment is wasted due to the lack of earlier intervention into alcohol and other drug problems and the lack of long-term post-AC recovery support services. Service utilization and related profits within inpatient and residential treatment programs would plummet if improved recovery rates dramatically reduced multiple treatment admissions. Knowledge of that fact is a major obstacle to needed systems transformation within the addiction treatment industry. Ideally, dollars now allocated almost exclusively to AC treatment of addiction in the U.S. would be reapportioned across the stages of long-term personal and family recovery.
Ethics of Acute Care: Acute care models of addiction treatment that lack assertive outreach to shorten addiction careers and recovery support services across the stages of long-term recovery should be called out for what they are: clinical incompetence and financial exploitation, by consequence if not intent. The practice of recycling people with severe, complex and chronic SUDs repeatedly through AC-limited services is more money machine than “treatment “ and should be professionally and publicly exposed as such.
Alternative to AC Models of Care:
The alternative to the AC model that leaders in the addictions field are exploring is a model of recovery management nested within larger recovery-oriented systems of care.
Recovery management (RM) is a philosophical framework for organizing addiction treatment services to provide pre-recovery identification and engagement, recovery initiation and stabilization, long-term recovery maintenance, and quality-of-life enhancement for individuals and families affected by severe substance use disorders.
Recovery-oriented systems of care (ROSC) are networks of formal and informal services developed and mobilized to sustain long-term recovery for individuals and families impacted by severe substance use disorders. The system in ROSC is not a local, state, or federal treatment agency but a macro-level organization of a community, a state, or a nation. ROSC initiatives provide the physical, psychological, cultural, and social space within local communities in which personal and family recovery can flourish.
Distinctive Features of RM and ROSC
The emerging RM & ROSC vision calls for:
*strengthening the infrastructure of addiction treatment to ensure sustained continuity of support and accountability to the individuals, families, and communities served by addiction treatment institutions;
*more proactive systems of identifying, engaging, and ensuring service access for individuals and families at the earliest possible stage of AOD-related problem development;
*individual, family, and community needs-assessment protocols that are comprehensive, strengths-based, and ongoing;
*the utilization of multidisciplinary and multi-agency service models for supporting long-term recovery for those individuals, families, and neighborhoods experiencing severe, complex, and enduring AOD problems;
*the reconstruction of the service relationship from an expert model to a partnership model involving a long-term recovery support alliance;
*expanding the service menu, with an emphasis on evidence-based and recovery-linked service practices;
*ensuring each client and family an adequate dose and duration of pre-treatment, in-treatment, and post-treatment clinical and recovery support services;
*exerting a greater influence on the post-treatment recovery environment by shortening the physical and cultural distance between the treatment institution and the natural environments of those served, and by intervening directly to increase family and community recovery capital;
*assertive linkage of clients and families to recovery mutual aid groups and other indigenous recovery support institutions;
*post-treatment monitoring (recovery check-ups for up to five years following discharge from primary treatment), ongoing stage-appropriate recovery education, sustained recovery coaching, and, when needed, early re-intervention; and
*the systematic and system-wide collection and reporting of long-term post-treatment recovery outcomes for all individuals and families admitted to addiction treatment.
RM and ROSC system redesign would integrate the now isolated siloes of primary prevention, harm reduction, early intervention, treatment, and recovery support services.
People in personal/family recovery and a vanguard of addiction professionals are working diligently across the country to make this vision a reality. If I had another lifetime to devote to the elevation of the quality of addiction treatment in the United States, this is what I would be trying to achieve.
Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS) Discharges, 2015. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2018. Accessed February 13, 2020 at https://wwwdasis.samhsa.gov/dasis2/teds_pubs/TEDS/Discharges/TED_D_2015/teds_d_2015_codebook.pdf
Kelly, J. & White, W. (Eds., 2010). Addiction recovery management: Theory, science and practice. New York: Springer Science
White, W. (2008). Recovery management and recovery-oriented systems of care: Scientific rationale and promising practices. Pittsburgh, PA: Northeast Addiction Technology Transfer Center, Great Lakes Addiction Technology Transfer Center, Philadelphia Department of Behavioral Health & Mental Retardation Services
Until the lion learns how to write, every story will glorify the hunter. –African Proverb
From Lin-Manuel Miranda, Hamilton: “Why do you write like you’re running out of time?”
Me: “Because I am.”
In the late 1990s, I experienced an epiphany of sorts—a sudden awareness that the addiction field had acquired a massive body of scientific and professional knowledge about alcohol and other drug problems and their clinical treatment but possessed little knowledge of the prevalence, pathways, styles, and stages of long-term personal and family recovery. Being over fifty seemed a strange time to plot a new career direction, but that is what I did. My decision was clear: whatever remaining time I had would be devoted to the scientific study of recovery and pushing the addiction field’s organizing center from a focus on pathology and the nuances of clinical intervention to a focus on the lived experience of long-term recovery. Fortunately, I was not alone in either this awareness or that commitment. The subsequent years witnessed the rise of recovery-focused research scientists and a new generation of recovery advocates. Today, recovery journalism–from the scientific journals to the growing legion of recovery blogs–is coming of age.
When I entered the addictions field in the 1960s, there were two distinct classes of workers: “professionals” (doctors, nurses, psychologists, and social workers) and “paraprofessionals” (people with lived experience of addiction and recovery). There was little consideration that one could be both a professional AND a person in long-term recovery: you were one or the other. If you had a foot in each world, your legitimacy could be and often was questioned within each—seen as too broken in the professional world and not broken enough in the recovery world. Over time, people in recovery working in the field were extruded as addiction counseling became more professionalized and as those in recovery, as an act of self-protection, hid their recovery identity behind a smokescreen of increasing credentials.
Now for a present story. A lively discussion recently ensued among a group of people in recovery when the name of a prominent recovery advocate came up. The discussion entailed back and forth arguments over whether the person was a “real addict” [in recovery] or an “academic.” Again, notice the binary choice here—a remaining shadow of the past.
Historically disenfranchised people face the stigmatizing judgement of others in ways that limit the vision of their own potential as individuals and as a people. Black children who excel academically are castigated by some of their peers as “acting White” in oppressed, wounded worlds where Blackness and academic achievement are perceived as incongruent. In a similarly distorted worldview, a person with an advanced degree could not be a “real addict” or a “person in recovery.” In that view, academic achievement and eloquent writing are incompatible with the status of addiction recovery. The good news is that such warped views of self and the world are breaking down.
Under the influence of a vibrant recovery advocacy movement and new recovery support institutions (e.g., recovery high schools, collegiate recovery programs, recovery-focused academic mentoring), legions of people in recovery are pursuing college, university, and graduate training, and they are doing so as visible people in recovery. The result is an explosion in recovery-focused writing that spans memoirs, scientific studies, professional papers, popular journal articles, and social media posts. The perception that academic excellence and exemplary writing are incompatible with recovery status is fading among people in recovery, in the professional world of addiction treatment, and among the public. That is a remarkable achievement of historical significance.
I am part of a community of physicians, nurses, pharmacologists, psychologists, social workers, research scientists, historians, authors, educators, addiction professionals, and community activists. AND we are all people in long-term addiction recovery. If you are a person in recovery, you can be anything you want to be—and still be a person in recovery. Recovery is a launching pad, not a restrictive cage. Don’t let anyone foist you into such a cage.