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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On July 20, The Senate Caucus on International Narcotics Control held a hearing on the state of treatment and recovery in the United States, entitled “The Federal Response to the Drug Overdose Epidemic.” Witnesses included federal officials Regina LaBelle (Acting Director of the Office of National Drug Control Policy) and Tom Coderre (Acting Director of the Substance Abuse Mental Health Services Administration.) The role of recovery support services was a central theme of the testimony.
Tom Coderre shared his personal story of recovery and urged lawmakers to see the positive results it has yielded. “True success with substance use disorder also involves enduring efforts, many of which are through recovery supports,” he stated.
Coderre cited that Recovery Support efforts have been part of SAMHSA’s portfolio since the late 1990s. SAMHSA first launched the Recovery Community Support Program, later the Recovery Community Services Program (RCSP) in 1998. This grant helped launch and supported the development and strengthening of recovery community organizations (RCOs). Their focus has been emphasizing the critical importance of as a bi-directional bridge between communities and formal systems, including SUD treatment, and the criminal justice and child welfare systems. Coderre praised RCOs for being peer-led and managed.
Also receiving attention in the hearing were two newer grant initiatives, the RCSP 5-year grant program and the Treatment, Recovery and Workforce Support Grants (Workforce Support). The 5-year RCSP grants build peer recovery support services capacity through recovery community centers, and the Workforce Support grants enhance employment opportunities for individuals in recovery from SUDs by addressing gaps in services and providing opportunities for veterans, homeless individuals, and those reentering the community after incarceration. Coderre mentioned that also of note, SAMHSA developed the targeted capacity expansion-peer to peer (TCE-PTP) grant portfolio forging the path for the extensive ongoing training of peers towards certification and expanding the workforce. This portfolio has provided state recognition for peer support service providers in the workplace and, in some states where allowable, Medicaid reimbursement for their services.
Since 2017, SAMHSA allocated over 60 million dollars to recovery support initiatives, but Coderre urged the Senate to do more to build out the continuum. Following the lead of President Biden’s FY 2022 Budget, he reiterated his call for a 10 percent set aside for recovery support services in the Substance Abuse Prevention and Treatment Block Grant which would provide states with funding to further invest in building out recovery support services.
Acting Director LaBelle reiterated the priorities of the Biden Administration, including a need to expand access to recovery support services, as well as the advancement of recovery-ready workplaces. She recognized that recovery support services are offered in various institutional and community-based settings and include peer support services and engagement, recovery housing, recovery community centers, and recovery programs in high schools and colleges, and increased capacity and infrastructure of these programs will create strong resource networks to equip communities to support recovery for everyone. The required infrastructure includes a safe, reliable, and affordable means of transportation to access recovery support services. She pledged that ONDCP will work with Federal partners, State, local, and Tribal governments, and recovery housing stakeholders to begin developing sustainability protocols for recovery housing, including certification, payment models, evidence-based practices, and technical assistance.
A Historical Summit
by: Bill White
In 2001, more than 130 recovery advocates from more than 30 states gathered in Saint Paul, Minnesota at the invitation of the Johnson Institute’s Alliance Project and with support of the Center for Substance Abuse Treatment’s (CSAT) Recovery Community Support Program (RCSP). That gathering marked the formal launch of a new recovery advocacy movement in the United States. The vision of culturally and politically mobilizing people in recovery and their families and allies was not a new vison, but those of us in St. Paul during those momentous days had an unmistakable feeling that we were participating in something that could reshape the future of addiction recovery. Now, with 20 years of hindsight, we can acknowledge what was so significant about this event.
The 2001 Recovery Summit marked a clarion call to shift the center of the alcohol and other drug problems arena to a focus on the lived solution for individuals, families, and communities. The shift from pathology/clinical paradigms to a “recovery paradigm” exerted pressure for urgent changes in policy, research, treatment, recovery support practice, and service system evaluation. The emergence or elevation of such concepts as recovery management, recovery-oriented systems of care, recovery coaching, recovery support services, recovery capital, recovery cascade (contagion), culture of recovery, community recovery, etc. would be missing from our current landscape without this paradigm shift, as would many recovery-focused research studies.
The 2001 Recovery Summit marked the passing of the recovery advocacy leadership torch from an earlier generation of advocacy organizations, most notably the National Committee for Education on Alcoholism (1944, later the National Council on Alcoholism and Drug Dependence) and the Society of Americans for Recovery (1991). The founding of Faces and Voices of Recovery as an outcome of the Summit set the stage for subsequent efforts, including Young People in Recovery, Facing Addiction, Shatterproof, the Recovery Advocacy Project, Latino Recovery Advocacy, Black Faces Black Voices, the African American Federation of Recovery Organizations, and other national recovery advocacy efforts. Faces and Voices provided the connecting tissue for RCO leaders to gather, communicate, share resources, and speak with a collective voice. The 2001 Recovery Summit set the foundation for the landmark accomplishments of Faces and Voices of Recovery and other recovery advocacy organizations.
The 2001 Recovery Summit marked the coming of age of a new organizational entity—the grassroots recovery community organization (RCO). The emerging RCO was not a recovery mutual aid fellowship, an alcohol/drug problems council, or a prevention or treatment organization, but rather an organization focused exclusively on recovery community mobilization, recovery advocacy, and recovery-focused community development. Subsequently linked through the Association of Recovery Community Organizations, RCOs have been instrumental in supporting further recovery community institution building, e.g., recovery community centers; recovery residences; occupational/workplace recovery programs; recovery high schools and collegiate recovery programs; recovery ministries; recovery-focused health, sports, and adventure programs; and recovery-focused projects in music, theatre, art, and community service.
The 2001 Recovery Summit marked a milestone in multicultural and multiple pathway recovery advocacy. The 2001 Summit was diverse in its representation of women, communities of color, and the LGBTQ community as well as its representation of diverse pathways of addiction recovery. The Summit was historically noteworthy in bringing affected family members into the advocacy movement on an equal footing with those with lived experience of addiction recovery. The Summit marked a milestone: people representing diverse pathways and styles of recovery seeing themselves collectively as “a people” with shared needs and aspirations. That “peoplehood” inspired subsequent calls for authentic and diverse recovery representation at all levels of decision-making within the AOD problems arena.
The 2001 Recovery Summit marked an early vision—the seed—of the integration of primary prevention, harm reduction, early intervention, treatment, and peer recovery support—a process that continues to this day through efforts to delineate roles and responsibilities as well as efforts of coordination and collaboration across this service and support continuum. Prior to the 2001 Recovery Summit, recovery never appeared on the alcohol and other drug service continuum. The emergence of peer recovery support services as a distinct service entity following the Summit constitutes a significant historical milestone.
What the 2001 Recovery Summit did more than anything was weld the personal commitments of individuals and programs into a national recovery advocacy movement. We had a name; a consensus on vision, goals, and tactics; and, most importantly, we had mutually supportive relationships across the country that bound us together in common cause. I look forward to our gathering this October to revision the future of recovery advocacy in the United States.
An Invitation to Return to Saint Paul
by: Philip Rutherford
Even before my arrival at Faces & Voices, I learned about the rich history and significance of the St. Paul summit that happened on October 5, 2001. While working at a Minnesota RCO, I attended an event put on by The Association of Recovery Community Organizations (ARCO) that was modeled after the original summit. At the time, it was called the ARCO Executive Directors Leadership Academy, and it transformed both my personal understanding of the recovery movement, and ultimately the trajectory of my organization. ARCO’s roots are connected to the powerful movement that arose from the St. Paul summit and that continue to propel the work of countless organizations today.
On October 3, 2021, at the River Centre in St. Paul, Minnesota, we will convene another summit to commemorate the passing of the 20th anniversary of that event. We will examine where we are today and look toward the future. The event will have plenary speakers like Bill White, Dr. Nora Volkow, William Moyers Jr. and Dr. Delphin-Rittmon, and will include six different tracks of learning concentrations around Advocacy, Peer Recovery Support Services, Capacity Building, Diversity, Equity, and Inclusion, Family and Youth, and Leadership Development.
Many things have changed about the recovery movement since 2001. At Faces & Voices, we see this event as an opportunity to celebrate the tireless efforts of those who have come before us, honor those in the trenches right now, and help clear a path for anyone who wants to join the journey. Similarly, some things haven’t changed, and we see this event as an opportunity to have frank and open discussions about where change is required.
If 2020 has taught me anything, it is to expect the unexpected, and as such, I’d be remiss if I didn’t mention COVID-19 and the possibility of rates of infection affecting our plans. The COVID-19 Delta and Lambda variants are influencing how the celebration will take place. We are closely monitoring guidelines and restrictions and will make decisions as the situation unfolds.
Unless restrictions prohibit us from gathering, we plan on hosting the conference in-person. We understand some people may be hesitant to attend, due to safety concerns.
If necessary, we will deliver a webinar-based, hybrid option to accommodate more people, so that we can still be together as a community for this important milestone. We will update you as we can. In addition, the River Centre has taken a number of precautions to ensure your safety.
Thank you for your patience and understanding during this time.
To make it a bit clearer, here are three possible scenarios as examples:
Scenario A– All is well. No mandates or city-wide orders in place regarding COVID
*Summit takes place as scheduled. Proof of Vaccine/Negative test results/mask required (with audit during event). We will stream only keynote events.
Scenario B– Positivity rates increase, moderate concern surrounding transmission. No mandates or city-wide orders in place regarding COVID.
*Summit takes place as scheduled. Proof of Vaccine/Negative test results/mask required (with audit during event). Social distancing rules will be enforced, hybrid conference occurs with streaming of each session.
Scenario C-All is not well, mandates or city-wide orders are in place regarding COVID
Summit takes place entirely in virtual space.
Gate: September 1 decision date
Nationwide positivity of >12% Scenario C
Nationwide positivity of 5-12% Scenario B
Nationwide positivity of <5% Scenario A
Regardless of the eventual format, we extend a warm invitation for you to participate. You can register by clicking HERE. Let’s go make some more history.
UPDATE: On September 1, 2021 Faces & Voices of Recovery made the difficult decision to move the event to a completely virtual setting.
When I remember the thousands who died, many whose stories were never recorded in history, I bow my head. And when my wailing is done, I get up and carry on, not in my name, but in theirs….When you know your history, you know your value. You know the price that has been paid for you to be here. You recognize what those who came before you built and sacrificed for you to inhabit the space in which you dwell. –Cicely Tyson (with Michelle Burford), Just as I am
We have not even to risk the adventure alone; for the heroes of all time have gone before us; the labyrinth is thoroughly known; we have only to follow the thread of the hero-path. And where we had thought to find an abomination, we shall find a god; where we had thought to slay another, we shall slay ourselves; where we had thought to travel outward, we shall come to the center of our existence; where we had thought to be alone, we shall be with all the world. –Joseph Campbell, The Hero with a Thousand Faces
Those seeking and in recovery owe a great debt of gratitude to earlier generations of people whose life discoveries opened and charted pathways to addiction recovery and built the recovery support organizations available to us today. Much of my (BW) past work focuses on excavating and celebrating the lost stories of these recovery pioneers.
The stories of many of our recovery ancestors remain publicly shrouded behind a veil of stigma. For generations, others who sought our control or cure spoke on our behalf while our own faces and voices remained hidden and silent. Actually, those who spoke for us spoke their stories—their perceptions of us and their work on our behalf, but authentic, first-person narratives of addiction and recovery remained obscured and sometimes misrepresented by such accounts.
Today, we are rediscovering lost recovery stories and declaring that we can now speak for ourselves. Every stigmatized and oppressed people must liberate their history and take control of their own stories. As the African proverb suggests, “Until the lion learns how to write, every story will glorify the hunter.”
We as a people can assure that the stories of our recovery ancestors are preserved and called forth at critical times to illuminate our present circumstances. Here are few potential possibilities.
*Designating and training archivists and archival skills within recovery-focused organizations
*Creating formal recovery archives for historical preservation and research
*Digitizing historical materials and creating virtual libraries filled with resources on the history of addiction recovery
*Creating and disseminating histories of recovery, recovery mutual aid and advocacy organizations, and key recovery figures via articles, books, films, plays, and photo exhibits.
*Creating and disseminating the history of recovery among special populations, e.g., women, youth, people of color, LGBTQ, etc.
*Preserving iconic historical sites
*Creating forums for communication between people interested in the history of recovery, e.g. AA History Lovers, NA History Lovers
*Creating oral history projects through which the stories of local recovery elders are recorded and preserved
*Hosting symposia on the history of addiction recovery and related organizations, and
*Ancestor consultations: Consulting with local recovery elders and regularly asking ourselves how recovery ancestors responded to challenges and opportunities similar to those we are currently facing.
Our recovery ancestors have provided a body of historical lessons. They have endowed an intellectual and emotional inheritance on how to best navigate the complexities, challenges, and opportunities within the experience of addiction recovery. They have also forged values and traditions that can best guide our collective life within recovery-missioned organizations. We honor our ancestors by letting their lessons inform our current circumstances. We show up to assert our own needs and aspirations, but we also show up to honor the ancestors that make our survival possible.
You cannot know yourself without knowing the history of your people. We bear the scarred wounds of past recovery generations—the emotional memory of objectification, demonization, maltreatment, and mass incarceration, but we also possess within us the inherited capacity to survive and thrive if we draw upon it.
We must all become students of our history as a people. Once we become students of history, the wisdom of our recovery ancestors lives inside us. We can then elicit the voiced guidance of our ancestors when we most need it. We are but one link in this chain of history. What we as a people achieve today are the fulfilled dreams of our ancestors. What we do today in preparing those who will follow us will shape the future of recovery for generations to come.
We must show up and do our part to prevent a break in this historical chain of personal healing and social progress. We do that for ourselves and in payment for our ancestors’ sacrifices. Our ancestors do not die until we last speak their names. In honor of what they have bequeathed to us and as aide to our own survival and health, we must continue to speak their names.
Posts from William White
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.
At the very heart of addiction lies the search for power, control, comfort, relief, and pleasure. At first, the drug is a secret superpower that heals, emboldens, and frees us, but as it feeds on us, it becomes stronger and we become progressively weaker. In the end, we worship the drug at the exclusion of all else as we become one with the drug. We are in its power, feeling more possessed that master of our fate. It is thus little wonder that the issue of personal power is at the center of multiple pathways of addiction recovery.
Mainstream 12-Step recovery, drawn from the experience of first-generation, predominately White male AA members who had lost their personal and cultural empowerment due to alcoholism and the Depression, rests on a deep acceptance of one’s powerlessness. Complete surrender to this state of powerlessness is the beginning and very crux of recovery within the 12-Step program. Later frameworks of recovery, drawn primarily from the collective experience of addicted women, people of color, young people, members of the LGBTQ community, and other historically disenfranchised populations, proffered the assertion of power and control as the central recovery catalyst. These later frameworks also emphasized much greater reliance on discovering power within oneself rather than sole reliance on power beyond the self. (For full discussion, see White and Chaney Metaphors of Transformation.)
Twelve-Step critics, drawn primarily from alternative recovery mutual aid societies and from the professional disciplines of psychology and psychiatry, allege that the core concepts and practices of 12-Step programs are disempowering at personal, cultural, and political levels. On the surface, it would seem that the effect of embracing powerlessness and extolling surrender would result in a lost sense of personal power, but early 12-Step members discovered a remarkable paradox. In the act of openly admitting their powerlessness over a drug (alcohol in A.A.) or a process (addiction in N.A.), they mysteriously acquired an unprecedented level of power and control over their lives. Early 12-Step literature speaks to this: “Such is the paradox of A.A. regeneration: strength arising out of complete defeat and weakness, the loss of one’s old life as a condition for finding a new one.”
Long-tenured members of AA, NA, and other 12-Step fellowships suggest that there is something quite liberating to peel away one’s drug dependence and shed the related monetary extortion and corruption of personal character. In their experience, freedom lies in the clarity that one has not been, is not, and can never be in control of the drug relationship. They argue that the only way to be free of Sisyphean attempts to control the drug relationship is to sever that relationship completely and irrevocably. They also note a sense of exhilaration in the full realization that all they can ever hope to be and do—both duration and quality of life—hinges on one single issue and related daily priority.
While different perspectives on power and powerlessness exist across religious, spiritual, and secular recovery mutual aid organizations, I am most interested in the contrast on these issues that exist between professional service organizations and recovery mutual aid organizations (and more specifically 12-Step organizations). There would seem to be some value in comparing what “empowering” alternatives 12-Step critics have to offer as a solution to severe substance-related problems. In short, what are the major differences in “power” across professional and peer support contexts? I would argue that the peer support context offers considerably more power and freedom than that found in the professional service relationship.
Twelve-Step members control the pace of emotional intimacy through their choice of meeting styles, meeting frequency, degree of socializing outside of meetings, and choice to have or not have a sponsorship relationship and with whom. In the professional context, the service professional prescribes the frequency and intensity of contact. Twelve-Step programs are accessible around the clock, including evenings, weekends, and holidays—something unheard of in the professional context. Twelve-Step programs are geographically accessible even when traveling the world; historically, the professional service relationship is rooted to a single location. There are no fees attached to 12-Step participation—only small volunteer contributions to support maintenance of the group. In contrast, professional recovery support can involve tens of thousands and potentially hundreds of thousands of dollars. Twelve-Step programs maintain no record of one’s support activities; professionals maintain extensive records that are not in control of the “patient.” Peer relationships within 12-Step programs rest on a foundation of reciprocity of support and equality of power; professional relationships are hierarchical with greater power placed in the role of the professional. Twelve-Step relationships are potentially enduring; professional relationships are almost universally time-limited and ever-briefer within the current service funding environment. Where 12-Step programs limit invasiveness and levels of personal disclosure (via discouragement of crosstalk and discouragement of taking other people’s inventories), professional treatment often involves pressure for a heightened degree of personal disclosure.
I do not intend to contrast 12-Step and other mutual aid groups and professional interventions into a binary either/or choice or in a contrasting superiority/inferiority judgment. Both have value as mechanisms of recovery support. I am simply pointing out that people have far more personal power in the recovery mutual aid context than in the professional context. Moreover, it is hypocritical for professionals to castigate 12-Step groups as “disempowering” only to offer an alternative in which individuals have far fewer choices and find themselves at the bottom of a hierarchical service relationship characterized by substantial fees, limited accessibility, and short duration of support followed by what many may experience as “clinical abandonment.”