The history of addiction treatment includes a pervasive and cautionary thread: the potential to do great harm in the name of help. The technical term for such injury, iatrogenesis (physician-caused or treatment-caused illness), spans a broad range of professional actions that with the best of intentions resulted in harm to individuals and families seeking assistance. My recounting of such insults within the history of addiction treatment (see here, here, and here) also includes the observation that such harms are easy to identify retrospectively in earlier eras, but very difficult to see within one’s own era, within one’s own treatment program, and within one’s own clinical practices.
The challenges for each of us who work in this special service ministry and for the specialized industry of addiction treatment include conducting a regular inventory of clinical and administrative policies and practices to identify areas of inadvertent harm, altering conditions linked to such harm, making amends for such injuries, and developing mechanisms to prevent such injuries in the future. In my own professional life, many of the projects in my later career were products of such an inventory and served as a form of amends for actions I took or failed to take in my early career due to lack of awareness or courage. (See here and here for two vivid examples.)
There have also been times I have taken the larger field to task for practices I deemed harmful. I have suggested at times that what were perceived as personal failures to achieve lasting recovery could be more aptly characterized as system failures (See here). I have suggested at times that the field was becoming addicted to professional power and money and that the field itself was in need of a recovery process that should include processes of rigorous self-inventory, public confession, and amends (See here and here).
The shift from acute care models of addiction treatment to models of sustained recovery management (RM) and recovery-oriented systems of care (ROSC) involves dramatic changes in clinical practices, including a shift in the basic relationship between the service provider and service recipient. The service relationship within the RM/ROSC models shifts from one dominated and controlled by the professional expert to a sustained recovery support partnership, with the provider serving primarily as a consultant to the service recipient’s own recovery self-management efforts. Those who have made this relational shift inevitably look back on areas of potential harm that emerged from the expert relational model they once practiced. And then the question inevitably arises, “How does one make amends for past harm in the name of help within the context of addiction counseling?”
Chris Budnick, an addictions professional in North Carolina and founding Board Chair for Recovery Communities of North Carolina, Inc. (RCNC), recently responded to that question by preparing a formal letter of amends to the individuals, families, and communities he has served. Below is the text of that letter, which was presented at the North Carolina Recovery Advocacy Alliance Summit, February 24, 2016. (The link to the video is: https://www.youtube.com/watch?v=A5MYhZbnhfU)
My name is Chris Budnick and I am a Licensed Clinical Addiction Specialist. I first began working in the addiction treatment and recovery field in 1993.
There are many components involved in the broad issue of substance use disorders and recovery. Employers, first responders, the criminal justice system, policy makers, politicians, companies, advertisers, treatment providers, addiction professionals, the recovery community, families, and the individual with the substance use disorder. Of all these components, individuals with substance use disorders face the greatest scrutiny, stigma, discrimination and blame. For too long they have stood alone bearing the full brunt of this responsibility while systems of care and policies impacting housing, education, and employment have largely conspired to undermine any chance of sustaining recovery.
Last week I found myself approaching a police department to apologize for failing them. When they reached out to us in the middle of the night seeking services for a young woman we told them “no.” “We can’t help her tonight.” She was killed within hours of this decision leaving behind a 2-year-old daughter. I told the officer that we pledge to do better.
This experience has nudged me to put to paper ideas that I’ve articulated and ideas I’ve only contemplated. I feel compelled as an addiction professional to make amends and pledge to do better.
While I have changed my attitudes and practices over the years, I have not spoken up to say I’m sorry. So here are the things I want to make amends for:
I’m sorry for all the barriers you confront when trying to access help.
I’m sorry for contradictory “sobriety” and “active use” requirements you encounter when trying to access services.
I’m sorry for the harm that has come to you, your family, your unborn children, and your community when you have not been provided services on demand.
I apologize for expecting that you will provide all the motivation to initiate recovery when I have assumed no responsibility for enhancing your readiness for recovery.
I am sorry for creating unrealistic expectations of you.
I’m sorry for provider success statistics that have misled you and your family.
I’m sorry that I have discharged you from treatment for becoming symptomatic. I’m even more sorry, though, for abandoning you at your time of greatest vulnerability. And I am sorry for how this failure has contributed to the heartbreak of your loved ones.
I am sorry for abandoning you when you have left treatment, either successfully or unsuccessfully.
I am sorry for the irritation in my voice when you have returned following a set-back because you didn’t do everything that I told you to do.
I am sorry for my arrogance when I’ve assumed that I am the expert of your life.
I am sorry for privately finding satisfaction in your failure because it reinforces the fallacy that I know best and if you just do as I say, you’ll recover.
I am sorry for not celebrating as enthusiastically your successes when you have achieved them through a different pathway or style then me.
I am sorry for being a silent co-conspirator for the stigma that has resulted in systems of punishment and discriminatory policies and practices.
I’m sorry for turning you away from treatment because you’ve “been here too many times.”
I’m sorry for not referring you to different services when you have not responded to the services I offer.
I am sorry for allowing you to take the blame when treatment did not work instead of defending you because you received an inadequate dose and duration of care.
I am sorry for reaping the benefits of recovery yet failing to do everything I can to make sure those benefits are available to anyone, regardless of privilege, socio-economic status, education, employability, and criminal history.
I’m sorry for being an addiction professional who has not provided you with the recovery supports needed to sustain recovery. More importantly, I apologize for conspiring through silence and inaction with a system that ill prepares you to achieve success.
I’m sorry for not calling to check on you when you don’t show up for treatment. I’m sorry for not calling to support you after you leave treatment.
I’m sorry for letting society maintain the belief that you used again because you chose to.
I’m sorry for not fighting for adequate treatment and recovery support services. All persons with substance use disorders should be entitled to a minimum of five years of monitoring and recovery support services.
I’m sorry for not advocating for you to have opportunities to gain safe and supportive housing and non-exploitive employment.
I am sorry for being so self-centered that I only think about you in the context of treatment while failing to fully understand the environmental and social realities of your life and how they will impact your ability to initiate and sustain recovery.
I am deeply sorry to your loved ones who have been robbed of chances to have a healthy member of their family. I am deeply sorry to your community, who has been robbed of the gifts that your recovery could have brought them.
I’m sorry that systems of control and punishment has been the response to communities of color during drug epidemics.
I am sorry that through my silence and inaction that I have contributed to belief that persons with substance use disorders are criminals and should be punished.
I am sorry for not speaking as a Recovery Ally to families, friends, neighbors, colleagues, policy makers, and public officials about why I support recovery.
I’m sorry for all the things that I have left off this list because I’ve failed to regularly solicit your feedback about how effective I have been in supporting you in your recovery.
This sorrow is the foundation of my commitment to improve the accessibility, affordability, and quality of addiction treatment and recovery support services and to create the community space in which long-term personal and family recovery can flourish.
Licensed Clinical Addiction Specialist
This is a remarkable statement worthy of emulation. I look forward to the day when leaders prepare such a statement of amends to individuals, families, and communities on behalf of American addiction treatment institutions. I look forward to the day when clinical humility becomes a foundational ethic guiding the practice of addiction counseling.
Post Date April 29, 2016 by Bill White
Until recently, the public faces of addiction recovery in the United States have been those of privileged white men and women. When I began to reconstruct the history of recovery on America more than four decades ago, I was struck by the absence in the historical literature of accounts of recovery within communities of color. I vowed early in my own historical research to help fill this void. Through my collaborations with Don Coyhis and Mark Sanders and the contributions of other advocates and scholars, progress has been made in reconstructing the history of recovery within Native American and African American communities. These contributions include a newly posted paper acknowledging African Americans who have made significant contributions within the history of addiction treatment and recovery in the United States. (See here). Needed research on the history of recovery in other ethnic communities remains at its infancy.
To the extent that existing findings from Native American and African American research can be extended to all communities of color, several conclusions are worthy of note.
Historically, portrayals of the etiology of alcohol and other drug (AOD) problems within communities of color have been rooted in allegations of genetic inferiority (e.g., “firewater myths” portraying Native Americans as inherently vulnerable to alcoholism), psychopathy (sin/evilness), and cultural inferiority (e.g. community disorganization). Such portrayals have been part of the larger ideological rubric supporting the decimation and colonization of these communities. The cultural legacies of such portrayals include generations of stigma (e.g., the “drunken Indian” stereotype), racial shame, and a fundamental misconstruction of the sources of, and solutions to, alcohol and other drug problems in communities of color.
Communities of color have not been passive victims in the face of alcohol and other drug (AOD) problems; there are long histories of indigenous resistance and recovery movements within these communities.
Indigenous resistance and recovery movements within communities of color have been most often led by people in recovery who linked addiction to broader issues of oppression and linked their own personal recovery to the broader cultural, political, and economic liberation of their people.
Within communities of color, the healing of the individual, the family, and the community are inseparable.
The ultimate solutions to AOD problems within communities of color lie within these communities and within larger processes of cultural renewal and community revitalization.
Addiction treatment and recovery support services within communities of color are best framed within a broader concern for the global health of these communities, rather than within a singular focus on AOD-related problems.
Addiction treatment is at its best when it aligns itself with culturally indigenous pathways of recovery and indigenous healing rituals.
The history of resistance and recovery within communities of color stands as testimony to the cultural forces of prevention and healing that remain powerful, but underutilized, antidotes to AOD problems.
It is time that both addiction and recovery were presented in a rainbow of colors. Below is a partial chronological listing with links to some of the published work to date resulting from these collaborations.
Coyhis, D. & White, W. (2002) Addiction and recovery in Native America: Lost history, enduring lessons. Counselor 3(5):16-20.
White, W. & Sanders, M. (2002) Addiction and recovery among African Americans before 1900. Counselor, 3(6):64-66.
Coyhis, D. & White, W. (2003) Alcohol problems in Native America: Changing paradigms and clinical practices. Alcoholism Treatment Quarterly, 3/4:157-165.
White, W. (2003). Native American resistance to alcohol problems since first contact. Well Nations Magazine, 4(23) & 4(24). Posted at http://www.whitebison.org/magazine/2003/volume4/vol4no23.html
Coyhis, D. & White, W. (2006) Alcohol problems in Native America: A new and provocative history. Counselor, 7(4), 54-56.
Coyhis, D. & White, W. (2006). Alcohol Problems in Native America: The Untold Story of Resistance and Recovery-The Truth about the Lie. Colorado Springs, CO: White Bison, Inc.
Sanders, T., Sanders, M. & White, W. (2006). “When I Get Low, I Get High”: The portrayal of addiction and recovery in African American music, Counselor, 7(6), 30-35.
White, W., Sanders, M. & Sanders, T. (2006). Addiction in the African American community: The recovery legacies of Frederick Douglass and Malcolm X. Counselor, 7(5), 53-58.
White, W. (2008) The Native American Wellbriety Movement: An Interview with Don Coyhis. Wellbriety Magazine, 9(10), 2-10.
White, W., & Sanders, M. (2008). Recovery management and people of color: Redesigning addiction treatment for historically disempowered communities. Alcoholism Treatment Quarterly, 26(3), 365-395.
Evans, A.C., Achara, I., Lamb, R.& White, W. (2012). Ethnic-specific support systems as a method for sustaining long-term addiction recovery. Journal of Groups in Addiction and Recovery. 7(2-4), 171-188.
Sanders, M. & White, W. (2016). African Americans who made (and are making) a difference in promoting resistance to and recovery from alcohol and other drug problems. Posted at http://www.williamwhitepapers.com/pr/2016%20African%20American%20Pioneers%20in%20Recovery.pdf
Post Date April 22, 2016 by Bill White
Essentially, it is thought that the negative effects emanating from group trauma experiences are not only transferred across generations, but that these effects accumulate, such that events occurring at different points in history are part of a single traumatic trajectory.—Amy Bombay, Kimberly Matheson, and Hymie Anisman Wakiksuyapi, those carrying the historical trauma, can transcend trauma through a collective survivor identity and a commitment to traditionally oriented values and healing. Maria Yellow Horse Brave Heart
Historical trauma and historical unresolved grief (as that experienced in the Jewish Holocaust, in the genocidal and cultural wars against the Indigenous tribes of North America, and in the historical enslavement of African peoples) are recently introduced concepts that convey the enduring effects of mass disconnection from culture, family, and self (Brave Heart, 2000).
Historical adversity, such as that currently underway in Syria, involves the simultaneous experience of mass deaths, loss of homeland, dislocation and dispersion, economic hardship and exploitation, abandonment by the world community, and the resulting destruction of family/cultural ties and identity-shaping stories. Such trauma involves a colonization of homeland and culture and can also involve a colonization of the mind.
Research on historical trauma underscores the potential intergenerational effects of such adversity upon individuals, families, and cultures, particularly when remnants of institutional violence and oppression remain in the emerging social, political, and economic environment. Recent studies of survivors of the Jewish holocaust and survivors of Indian Boarding Schools vividly reveal how the effects of historical trauma can amplify the effects of contemporary stressors across generations and be manifested through increased rates of guilt, depression, suicidality, substance use disorders, aggression, pessimism, apathy, sleep disorders, and interpersonal conflicts.
The mechanisms of such intergenerational transmission have been extensively catalogued and span multiple dimensions. Physiological mechanisms include the transmission of trauma and stress vulnerability via epigenetic inheritance. Psychological mechanisms include the collective memory of and preoccupation with traumatizing events or a shared “conspiracy of silence” related to such events, amplification of responses to current injustices, survivor guilt, self-blame, increased risk for personal trauma, low self-esteem, internalized aggression, and enhanced risks from self-medication. Social mechanisms of transmission include the disruption of family, extended family, and kinship networks; loss of positive cultural identity; suppression of cultural coping styles and rituals; lack of parental role models; impaired parenting across generations; and potential enmeshment in subcultures (e.g., drug, criminal) that undermine personal hardiness. Religious mechanisms include the loss of religious traditions and healing rituals and vulnerability to charismatic cults. Political and economic mechanisms include political and economic marginalization and the loss of personal and tribal agency.
Collectively, these factors can create a snowball effect of stress proliferation and impaired coping capacities across generations, including the intergenerational transmission of alcohol and other drug problems and their progeny of related problems. But history does not dictate personal or collective destiny. Recent research on historical trauma reveals the capacity to transcend such effects through open acknowledgement of the traumatizing events, restorative justice (cultural acts of apology and restitution), forgiving the unforgivable, rituals of inter-group healing, and intra-cultural strategies aimed at intergenerational resistance, resilience, and recovery. The story of historical trauma is incomplete and is itself wounding if it fails to include the elements of survival, strength, and the potential for healing and health in spite of prolonged adversity. This brief essay will focus on these healing processes that tend to unfold in four overlapping stages.
Intergenerational recognition is a breakthrough of awareness of the links between the past, present, and future. Recognition involves full admission and acceptance of prevailing problems and their interconnection, a new vision of solutions, and discovery of the laws of change that govern the journey from problems to solutions. Recognition involves the discovery that solutions lie both within the self, family, community, and culture and in the mobilization of resources between and beyond these realms. Resistance, resilience, and recovery begin with processes of truth-seeking and truth-telling across the generations.
Intergenerational resistance is a culturally-, politically-, economically-, and religiously-aware refusal to continue family and tribal legacies of alcohol and other drug problems. It is a refusal to expose oneself to that risk. It is a personal declaration, “Here it stops!” Addictive disorders result from a collision of vulnerability and exposure. Resistance is the conscious refusal to be exposed.
Intergenerational resilience is a refusal to develop a severe alcohol or other drug problem following alcohol or other drug use exposure. It is an assertion of health in the face of adversity and risk, e.g., a drug-saturated family and social environment. It is the embrace of alternative styles of coping and an alternative identity. It is the conscious mobilization of internal and external resources to neutralize the mechanisms through which intergenerational alcohol and other drug problems are transmitted. It is the advent of new personal and family traditions of coping and health. Intergenerational resilience is the process of aborting alcohol and other drug problems before they have an opportunity to fully develop.
Intergenerational recovery involves initiating or sustaining a family history of recovery to break intergenerational cycles of alcohol and drug and related problems. It is the unequivocal admission of one’s own problems within a larger historical context and a sustained commitment to enhance intergenerational health and positive connection to community. It is a personal declaration that this new tradition starts with me!
In the face of historical trauma and historical unresolved grief, manifested in generations of alcohol and other drug related problems, we have observed seven steps essential to promoting intergenerational recognition, resistance, resilience, and recovery for individuals, families, and communities.
Awakening and Collective Commitment There is a period of consciousness-raising through which new stories (oral histories) arise that acknowledge prolonged AOD problems and place them in their larger historical trajectory. New and renewed leaders voice unspeakable truths framed in a message of hope for the future and a vision of how to create such a future. The healing vision of the future extends to the seventh generation. “I stories” of injury and healing (personal narratives) are reframed through a new and larger “we story” of injury and healing (collective story of a people). Anger, guilt, shame, and fear are openly acknowledged. Personal and collective survival are extolled and rendered heroic—tapping new strength within and beyond personal and tribal identities. In light of these truths, drinking and drug use are framed as forms of personal and cultural capitulation/suicide; sobriety is framed as an act of personal, family, and cultural resistance and a strategy of survival and protection of oneself, one’s family, and one’s culture. The personal healing of historical trauma requires escaping one’s own encapsulation and standing with others in a cultural circle.
Mass Mobilization There is a call to action that reaches the hearts of the people, first in small numbers and then in every-increasing waves. Personal self-consciousness gives way to a new collective consciousness and commitment to action. The expansion of resources for healing self and family are extended to visions of a healed community and a healed history. A revitalized culture is birthed via history, language, symbols, art, literature, music, and ritual. Collective identity solidifies into awareness that new activities constitute a potentially historic movement. Personal and family identities are strengthened by this renewed cultural identity.
Personal and Collective Mourning The past is mourned so that a future can be forged. Tears must wet the early trail of new beginnings. The sites of past trauma are revisited. Rituals of personal and collective grief are created and repeated so the unspeakable past is never forgotten. Injuries of the past are linked to continued injuries in the present, as well as awareness that inherited styles of coping may not fit new realities. The wounds of men, women, and children are distinctive, creating the need for them to heal separately before they can heal together.
Forgiving the Unforgivable To move beyond the enduring wounds of the unspeakable past and its contemporary legacies, ways must be found to forgive the unforgivable. Self-destructive rage over past injury must give way to healing across the boundaries of victim grief and perpetrator guilt. (We become what we carry!) The heart of the perpetrator must be found within the heart of the victim; the heart of the victim must be found within the heart of the perpetrator. Forgiveness of others begins with forgiveness of self.
Achieving a New Harmony. Historical balance between the peoples is achieved through acts of restitution and new rituals of reconciliation. Mechanisms of restorative justice are explored and acted upon. Without acts of, and the experience of, justice; replicating cycles of the past cannot give way to new forms of relationships. We-they polarizations give way to a larger understanding of the human family. Interpersonal contacts between cultures increase exponentially and are ritualized and harmonized.
Wellbriety2Acts of Empowerment, Service, and Advocacy There is a mass transformation of helpees into helpers. The wounded are rechristened as healers and charged with the responsibility of sharing their resilience and recovery (experience, strength, and hope) stories with others. Personal dependence (isolation and victim-stance) gives way to mutual dependence (restoration of an ethic of collaboration and community service). Mutual help through the sharing of stories is an act of service, but also assures cultural continuity—a ritual that is as much cultural communion as communication. Collective action, in the form of political advocacy, becomes a ritual of personal and cultural empowerment—a positive antidote to internalized anger and apathy.
Cultural Revitalization Cultural development begun in the stage of mass mobilization takes on increased attention and depth, including expansion of historical research; language reclamation and purging of stigma-laden words and images; embrace of ancestral and new rituals; adoption of ancestral forms of self-presentation via hair, dress, jewelry; culture-laden art, theatre, and film; and expressive styles of music and dance. A stage of community building is evident in new and revitalized institutions, emboldened by sober leadership, that support the health of individuals, families, and the community. Collectively, this revitalized culture and these support institutions constitute a healing forest that mends the wounds of the people and frees their capabilities.
Acts of Celebration Ancestral community ceremonies (gatherings, memorials, communal rituals, power songs, dances) are renewed and new ceremonies are birthed that celebrate cultural survival and vitality. Kinship bonds are strengthened. Cultural values of survival are elevated and extolled through acts of storytelling. Stories of suffering are transformed through a process of cultural alchemy into stories of heroic survival and strength. Connections between youth and elders are strengthened by the transmission of historical memory and through mutual identification. Problem visibility is replaced by celebration of personal, family, and community solutions. The public nature of these celebrations also progressively alters how communities view those who have experienced historical trauma. A new empowering narrative revealed in these events alters perception of self and one’s own culture and also alters how one and one’s community are perceived by others, shedding legacies of stereotypes, stigma, discrimination, and personal shame.
Red Road to Wellbriety
The seven processes above are critical to the promotion of intergenerational recognition, resistance, resilience, and recovery across diverse communities and cultural contexts. Such processes are a reaffirmation of the inextricable link between personal and community health as set forth in The Red Road to Wellbriety: “…the individual, family, and community are not separate; they are one. To injure one is to injure all; to heal one is to heal all.”
We had this vision of empowering young people, of carrying a message of hope, not proposing we have the best way to recover, not endorsing a certain kind of recovery, but just lifting up all these great things that we’d experienced and heard about…Our really big vision is a world where all young people in or seeking recovery can achieve their potential in life….We wanted to be supportive of any way a young person could find recovery. –Justin Luke Riley, 2014, Counselor
Recovery advocacy is not new. The roots of such advocacy reach into the nineteenth century and, since the mid-twentieth century, the National Council on Alcoholism and Drug Dependence (NCADD) and other organizations have worked tirelessly to alter addiction-related public perceptions and public policies. Those efforts culminated in the rise of a new recovery advocacy movement in the opening years of the twenty-first century with new grassroots recovery community organizations networked through the leadership of Faces and Voices of Recovery. What does stand as fundamentally new is the cultural and political mobilization of the largest cohort of young people in recovery in history—mobilization best exemplified in the activities of Young People in Recovery (YPR).
http://www.williamwhitepapers.com/blog/wp-content/uploads/2016/04/YPRBlogPhoto2resized.jpgFounded in 2011, YPR’s mission is to create recovery-ready communities through policy advocacy and the development of recovery support resources in employment, housing, and education. That mission is achieved through the activities of its 120 chapters in 37 states that are supported by a 20-member governance board, 10 full-time and 15 part-time team members, and an annual budget of $2 million. YPR work is amplified through key affiliation agreements with the Association of Recovery Schools, a consortium of recovery highs school programs; R5 / Value Up School Climate System, a school-based substance use prevention and anti-bullying program; and Rise Together, a recovery advocacy initiative for young people.
YPR activities are guided by five foundational ideas drawn from the experience of its members and local chapters. 1) Young people can and are achieving long-term recovery from alcohol and other drug problems. 2) There are multiple pathways of recovery for young people, and ALL are cause for celebration. 3) Young people and their families must recovery together. 4) Young people in recovery and affected families are joining together for mutual recovery support to advocate for pro-recovery social policies and expansion of recovery support resources. 5) The recovery advocacy movement is for everyone: people in recovery, family members, allies, and supporters.
These foundational ideas are expressed through YPR national and chapter program and activities that include the following:
Policy advocacy (e.g., congressional testimony), including sustained support for parity legislation and passage of the Comprehensive Addiction and Recovery Act (CARA),
Rise Together, a school-based prevention curriculum and recovery advocacy program,
Project AMP, a collaborative project with Center for Social Innovation funded by the Conrad N. Hilton Foundation that provides mentoring-focused prevention and early intervention services,
Project PHI, an adolescent preventive health initiative,
Bridges Project, funded by the Colorado Office of Behavioral Health, provides community resource linkage services in two counties to transition-age youth who are aging out of the child services system,
EPIC program, a peer delivered curriculum consisting of housing, education, and employment workshops designed for young people during and following addiction treatment,
Project Catalyst, a transitional-aged youth and young adult peer recovery support specialist training program, offered in collaboration with the Association of Persons’ Affected by Addiction to young recovery leaders in Texas,
PUSH program, a collaborative recovery support project with United Healthcare that serves transition-age youth in Wichita, Kansas,
Choice in Recovery – Many Pathways Initiative, a community education project hosting forums on local recovery support options,
Phoenix, an educational and peer recovery support program for criminal justice-involved youth,
Lynx, a community education and recovery support linkage project for youth seeking or in higher education, and
EDGE, for exploring diversity, and gender equality.
All of these projects provide resources to equip and empower youth in or seeking recovery. In 2014, YPR was privileged to receive the Emerging Young Leaders Award from the National Association of Drug & Alcohol Addiction Counselors (NADAAC).
There was a time in the not so distant past that a young newcomer entering the rooms of recovery mutual aid fellowships was likely to receive a cool welcome from a crusty oldtimer proudly boasting that he had spilled more booze on his tie than the youngster had ever drank (or an equivalent comment for drugs other than alcohol). The message conveyed was a jarring suspicion that the young person simply had not earned the right of admission. In the face of such attitudes, both addiction and recovery statuses were too often withheld or begrudgingly granted to the young person seeking help.
That era is rapidly fading as the largest generation of recovering young people in history rise to shape the future of recovery (and of addiction treatment) in America. YPR stands at the forefront of this movement. Far too many people have entered recovery with only limited years remaining in their lives to clean out the addiction debris, forge a new life, and share their experience, strength, and hope with others in need. Today, young people entering recovery will have decades of life, service, and advocacy ahead of them. What a difference this is making for them, their families, and the world!
Those wishing to support the work of YPR can do so by clicking here: http://youngpeopleinrecovery.org/donate/
Of Related Interest
White, W. (2013). Young people in recovery: An interview with Justin Luke Riley. Posted at http://www.williamwhitepapers.com
White, W. (2013). A passion for youth recovery: An interview with Stacie Mathewson. Posted at http://www.williamwhitepapers.com.
White, W. (2014). Young people in the new recovery advocacy movement. Counselor, 15(2), 64-69.
Today, large addiction recovery celebration events have become an annual public ritual in many communities. Recovery rallies that a decade ago attracted a few hundred now attract tens of thousands of individuals and families in recovery and their allies. The modern era of mass recovery celebrations (at a public level rather than in closed recovery fellowship conventions or conferences) began with two iconic events in 1976: Operation Understanding and Freedom Fest.
Operation Understanding, sponsored by the National Council on Alcoholism (NCA), was the brain-child of NCA’s Walter Murphy, who believed that a televised event in which prominent people disclosed their long-term recovery from alcoholism would exert a profound effect on public perceptions of alcoholism. On May 8, 1976, in Washington, D.C., 52 prominent citizens from all walks of life publicly proclaimed their recovery from alcoholism. Those present included political leaders (Senator Harold Hughes, Congressman Wilbur Mills), physicians (Dr. John Mooney), authors (William Borchert), journalists (Adela Rogers St. John), film stars (Lillian Roth, Mercedes McCambridge), television celebrities (Dick Van Dyke, Gary Moore, Jan Clayton), an astronaut (Buzz Aldrin), professional athletes (Don Newcomb), a Native American Tribal leader (Sylvester Tinker of the Osage Nation), and key alcoholism policy advocates (Marty Mann). For people in recovery and those working in the treatment field in 1976, Operation Understanding would be forever fixed as a flashbulb memory—something we did not expect to see in our lifetimes given the stigma attached to alcoholism at that time. It was a turning point in the collective consciousness of America, forever breaking the stereotype of alcoholism as the “hopeless Skid Row wino.”
Operation Understanding was quickly followed by a mass public recovery celebration event held June 26, 1976, at the Metro Stadium in Bloomington, Minnesota. Led by Wheelock Whitney and Chair Bill Milota and emceed by Dick Van Dyke, more than 20,000 recovering men and women attended Freedom Fest. The daylong event included a hot air balloon race; musical entertainment provided by Michael Johnson, Natalie Cole, and Tony Orlando; educational workshops; and numerous speakers, including Senator Harold Hughes, Senator Walter Mondale, Senator Hubert Humphrey, Carl Eller; Fran Tarkenton, Janet Woititz, and Don Shelby. Songwriter Hal Atkinson contributed a song, Together, celebrating the theme of Freedom Fest. The film One Day commemorated the event.
During this same time, a small group of volunteers near Philadelphia began a grassroots effort to raise awareness of issues associated with alcoholism and other drug addictions and the importance of advocacy, education, and prevention. The spirit of this group, emboldened by the national mobilizing efforts, was contagious, and grew into what is now the The Council of Southeast Pennsylvania and its recovery community initiative, Pennsylvania Recovery Organization –Achieving Community Together (PRO-ACT) with over 60 professionals and 400 volunteers. The Council is one of the most vital and respected alcohol and drug advocacy, prevention, and recovery support organizations in the nation. This year, the Council, an affiliate of the National Council on Alcoholism and Drug Dependence (NCADD), will celebrate its 40th Anniversary by launching a year-long public awareness campaign honoring those from the original Operation Understanding event. The “Thriving in Recovery” campaign kickoff will be a gala on May 5th at Normandy Farm Hotel and Conference Center in Blue Bell, Pennsylvania. Over the last year, the Council has been capturing stories of local individuals who are thriving in recovery. The intent is to show that, while recovery is hard work, long-term recovery is a reality for over 23 million other Americans. In addition to raising funds and awareness, the gala program will feature an award ceremony and reflections on Operation Understanding by William Borchert and others. For more information about the campaign or this event, go to http://www.councilsepa.org or call 215-345-6644.
Events like the above organized by people in recovery serve many purposes. They provide a forum for recovering individuals and families to collectively honor their survival and health. They illustrate and celebrate diverse pathways and styles of long-term addiction recovery. They challenge the stigma, stereotypes, and pessimism long associated with severe alcohol and other drug problems. They provide a venue for advocating pro-recovery social policies and programs. They expand the community space in which recovery can flourish. And they send a beacon of hope into the community that no one need die from addiction, that permanent recovery is possible, and that individuals and families in recovery can live full, meaningful, and contributing lives. As we celebrate the anniversary of the first of these iconic recovery celebration events, it is fitting that we pause to honor the brave men and women who first stepped into the public light to share their experience, strength, and hope with the world.
By the late 1990s, tremendous strides had been achieved in elevating the accessibility and quality of addiction treatment in the U.S., yet leaders in the field were beginning to suggest the need for a radical redesign of addiction treatment—a shift from acute and palliative care models of intervention to models of assertive and sustained recovery management (RM) nested within larger recovery-oriented systems of care (ROSC). In 1998, I began work with Michael Boyle on the Illinois-based Behavioral Health Recovery Management (BHRM) project—a project specifically charged with exploring the potential of adapting chronic care models drawn from primary medicine to enhance the quality of addiction treatment. The papers on RM emanating from the Illinois project garnered considerable attention and led to early consultations with the State of Connecticut and the City of Philadelphia–early pioneers in RM-focused systems transformation processes. The early BHRM work also led to an invitation from the Center for Substance Abuse Treatment’s (CSAT) Great Lakes Addiction Technology Transfer Center (ATTC) to author and co-author a series of monographs on RM & ROSC. I could not be more delighted that the most central of these monographs have now been assembled into a two-volume set of books (available in hardcopy and as e-books) through support from the Center for Substance Abuse Treatment’s ATTC Coordinating Network. Also of note is that all royalties from these books will be paid directly to support the work of Faces and Voices of Recovery.
The first monograph, Recovery Management, was published in 2006 and contained four essays. Recovery: The Next Frontier, originally published in Counselor in 2004, described the emergence of recovery as a new organizing paradigm for addiction treatment and non-clinical recovery support services. The Varieties of Recovery Experience, co-authored with Dr. Ernest Kurtz and published in abridged form in the International Journal of Self Help and Self Care, summarized what could be gleaned from history and science about the pathways, stages, and styles of long-term addiction recovery. Recovery Management: What if we Really Believed Addiction was a Chronic Disorder? was a preliminary attempt to outline the changes in service practices implicit within RM models of care. And Recovery Management and People of Color, co-authored with Mark Sanders and originally published in Alcoholism Treatment Quarterly, was a first attempt to explore application of the RM/ROSC model to historically disempowered communities.
Wide dissemination of the first Great Lakes ATTC monograph on recovery management generated considerable interest from the field and led to two follow-up monographs in 2006 and 2007. Recovery: Linking Addiction Treatment and Communities of Recovery, co-authored with Dr. Ernest Kurtz, offered concrete suggestions for addiction counselors and recovery coaches on how to best link those they served with recovery mutual aid societies and other indigenous recovery support institutions. The third monograph, Perspectives on Systems Transformation: How Visionary Leaders are Shifting Addiction Treatment Toward a Recovery-Oriented System of Care, focused on the RM/ROSC implementation process through a collection of interviews offering national (Dr. H. Westley Clark), State (Dr. Thomas Kirk), municipal (Dr. Arthur Evans, Jr.), program (Michael Boyle), recovery community (Phil Valentine), and ATTC (Lonnetta Albright) perspectives on the implementation of RM/ROSC principles.
These first three monographs can be ordered by clicking Recovery Monographs, Volume I.
One central question loomed as RM/ROSC language and approaches spread through the field: What is the evidence-base for this proposed redesign of addiction treatment? The fourth monograph, Recovery Management and Recovery-Oriented Systems of Care: Scientific Rationale and Promising Practices, was released in 2008 to answer that question. It describes promising practices in such critical treatment performance areas as attraction, access, screening/assessment, engagement/retention, team composition, service relationship, service dose/scope/quality, locus of service delivery, linkage to recovery communities, and post-treatment monitoring and support.
If there was a single area within RM/ROSC proposals that captivated the field’s attention and often emerged as the most visible element of RM/ROSC transformation efforts, it was the reintegration of people in recovery into the addiction treatment arena in both volunteer and paid roles at all levels of the system. Such integration generated mountains of emails and calls about how to achieve such integration and the evidence-based approaches to such efforts. In response, the fifth monograph, Peer-based Addiction Recovery Support: History, Theory, Practice, and Scientific Evaluation, was published in 2009. This monograph achieved two goals. It addressed what was known at that time about peer-based recovery support services from the standpoint of history and science, and it described in considerable detail how peer-based recovery support services were being implemented within addiction treatment and recovery community organizations across the United States.
In 2010, a major question arose about the implications of RM/ROSC for medication-assisted treatment. This question prompted collaboration with Lisa Mojer-Torres (the “Rosa Parks of Medication-Assisted Treatment”) in co-authoring the sixth monograph, Recovery-oriented Methadone Maintenance (ROMM). The ROMM monograph was widely disseminated and led to numerous follow-up presentations and papers. Two other monographs and a book (Addiction Recovery Management coedited with Dr. John Kelly) followed this first series, but I will always think of these first six monographs as my foundational writings on RM/ROSC.
Monographs four through six can be ordered by clicking Recovery Monographs, Volume II.
The RM/ROSC monograph series was done in tandem with numerous other efforts to enhance long-term recovery outcomes in the U.S. Of particular note is the now iconic paper on addiction as a chronic disorder led by Tom McLellan that was published in the Journal of the American Medical Association in 2000. There were also CSAT monographs and monographs from other ATTCs during these same years that played an important role in promoting RM/ROSC system transformation efforts And the increased focus on long-term recovery would not have been possible without the research studies of Michael Dennis, Mark Godley, Susan Godley, James McKay, Christy Scott, and others focused on extending the effects of addiction treatment through assertive approaches to post-treatment continuing care.
There are many people to thank for their support of this monograph series, but none more important than Dr. Westley Clark, Lonnetta Albright, Dr. Michael Flaherty, and Dr. Arthur Evans, Jr. whose leadership and support were beyond what words can adequately express. RM/ROSC offered a new vision and new service technologies that promised to transform addiction treatment from an almost singular focus on recovery initiation to a system capable of supporting enhanced stability and quality of personal and family life in long-term addiction recovery. It will be up to future generations to judge how close we as a field came to fulfilling that vision.
William L. White
Emeritus Senior Research Consultant
Chestnut Health Systems
Punta Gorda, Florida
Defining addiction as a “chronically relapsing” condition, in spite of its advocacy by leading organizations in the addictions field (see top link, 2nd link),has generated unintended but harmful consequences. Such language should be abandoned and replaced with words that more accurately depict the variable course of substance use disorders (SUDs) and that are more personally and professional empowering.
Our hearts go out in compassion, respect, support, and admiration for people who share their struggles with cancer, heart disease, diabetes, and other medical conditions that require prolonged if not lifelong monitoring and active management. Because a personally positive attitude and family and social support can play crucial roles in bolstering recovery, health professionals do everything in their power to provide optimal hope and encouragement for recovery from these medical conditions. Even when it is statistically unlikely that a patient will be able to survive or return to previous levels of health and functioning, she or he is given words and images of hope. Less than fifty years ago, a diagnosis of cancer was so threatening that those six letters were left unspoken in many households and were socially taboo. Today, society has begun to automatically pair the word “cancer” with “cancer survivor.” It is now commonplace for people to live, and live well, transcending diagnoses of cancer, heart disease, diabetes, asthma, and numerous other complex and life-threatening health conditions. The expectation of surviving and thriving in the face of such conditions has blossomed into a something of a cultural phenomenon.
Unfortunately, when the medical illness is a substance use disorder (SUD), affected individuals and families are often not afforded such optimistic language and images of hope. Until the recent rise of a new addiction recovery advocacy movement, the public faces and voices of “addiction survivors” were rare in the United States, due primarily to the social and moral stigma attached to addiction. The language that accompanied a SUD diagnosis often conveyed the overwhelming expectation–inferred, and often voiced–that recovery from addiction was the rare exception to the rule. Nowhere is such pessimism more evident than in the characterization of addiction as a “chronically relapsing” condition. We offer the following objections to such language.
The lapse/relapse language within this phrase is historically rooted in morality and religion, not health and medicine, and comes with considerable historical baggage (See related blog). The lapse/relapse language in the alcohol and drug problems arena emerged during the temperance movement and was linked in the public mind to lying, deceit, and low moral character—a product of sin rather than sickness. The application of the lapse/relapse language to other medical conditions once linked to personal culpability, such as tuberculosis, cancer, epilepsy, and schizophrenia dissipated as more objective and morally neutral language (e.g., recurrence) was embraced and the etiology and course of these disorders became more clearly understood. Hopefully, the same will be true with SUDs.
The phrase “chronically relapsing” applied to SUDs misrepresents the natural course of SUDS by misapplying findings from clinical research populations and clinical experience with the most severe, complex, and chronic SUDS to the larger pool of SUDs found in the community. Recovery, not prolonged disability and death, is the norm for the long-term course of most substance use disorders. (See here for a review of more than 400 scientific studies confirming that conclusion.) More than 23 million Americans have achieved remission from substance use disorders, and surveys of people in recovery reveal dramatically improved health, functioning, and quality of life. Such findings are cause for personal, public, and professional optimism—not the pessimism conveyed by the “chronically relapsing” language. Recognizing that vulnerability for recurrence is a common dimension of substance use disorders marked by high severity, complexity, and chronicity does not mean that such conditions warrant hope-suffocating language. Such individuals can and do achieve long-term recovery without further episodes of recurrence or with only a few brief episodes of such recurrence.
The characterization of all SUDs as “chronically relapsing,” by inadvertently portraying a SUD as a hopeless condition, is personally disempowering, serves to lower personal expectations of sustainable recovery, and fails to convey how an individual’s daily decisions and lifestyle management can lower the risk of future SUD recurrence. Our concern is that the christening of a SUD as “chronically relapsing” and categorizing individuals as “chronic relapsers” by medical authorities becomes, not an inherent condition of a SUD, but a self-fulfilling prophecy when embraced by professional provider and patient. As with many other health conditions, recovery from a SUD requires assertive and continued management, and resources to support such long-term recovery management are increasingly available. It is time the definitional language of “chronic relapsing disease/condition” was abandoned and replaced with language that conveyed the reality of recovery without repeated activation of addiction, and that there are personal actions that dramatically reduce the risk of recurrence. It is time those in recovery from addiction joined the family of other “survivors” recovering from health conditions that positively respond to assertive and ongoing recovery management.
The “chronically relapsing” characterization of SUDs obscures the large population of individuals who achieve remission from such disorders with no experience of repeated reactivation of the disorder. (Sustained monitoring programs for airline pilots, physicians, and nurses often find 80%+ of them initiating and sustaining recovery from addiction without continued episodes of alcohol or drug use and its consequences.) The “chronically relapsing” language also obscures the high levels of social functioning and social contribution achieved by individuals in long-term recovery. It instead conveys, at best, the image of people in SUD recovery as inherently fragile, “white knuckling” their way through life, on the brink of resumed alcohol and drug use at every moment. Such a caricature may find some truth for those in the earliest days of SUD recovery, but is challenged by the majority of people who live quite comfortably in long-term SUD recovery, many achieving productive and purposeful lives of social contribution.
The characterization of SUDs as “chronically relapsing” contributes to social stigma, discrimination, and the social abandonment of people experiencing such disorders. If the commonly expected outcome of a SUD is not recovery, but repeated and prolonged acute episodes, then persons with a SUD become less viable candidates as intimate partners, parents, friends, employees, college applicants, loan applicants, renters, applicants for health and life insurance, or recipients of government benefits. Characterizing individuals with a SUD as “chronically relapsing”—socially interpreted to mean biologically or psychologically inferior/damaged, provides justification for addiction-related social stigma, sequestration of persons with a SUD from community life, and, at the historical extreme, campaigns of extermination, e.g., inclusion in mandatory sterilization laws, prolonged incarceration, or campaigns of genocide against people with SUDs (as occurred in Nazi Germany).
The “chronically relapsing” language fuels therapeutic pessimism among providers of SUD treatment and serves as a smokescreen for ineffective and financially exploitive approaches to addiction treatment. Professionalized addiction treatment has become disconnected from the larger and more enduring process of addiction recovery, disconnected from indigenous recovery community organizations, and disconnected from regular contact with legions of individuals and affected family members in long-term recovery. With an ever-briefer model of addiction treatment, such professionals are prone to see a core of individuals with histories of multiple treatments as a norm confirming the “chronically relapsing” declaration. Addiction treatment organizations whose owners view persons with SUDs as a crop to be harvested for financial profit can provide inert, ineffective, and even harmful treatments multiple times to the same individuals while masking their ineffectiveness and profiteering behind the “chronically relapsing” depiction of the disorder. Under such circumstances, people with severe and complex SUDs and little recovery capital can repeatedly undergo treatments that have little evidence of producing sustainable recovery while being personally blamed for such outcomes (i.e., “not working the program correctly”). The “chronically relapsing” and “chronic relapser” monikers perpetuate ineffective and exploitive treatment by miscasting flaws in treatment philosophy, design, and execution (system failures) as problems stemming from the condition (“It’s the disease, not our treatment approach.”), and problems of patient compliance (personal failures).
The “chronic relapsing” portrayal of SUDs also exerts its effects on policy and public resource allocation. Why would politicians or the public allocate their limited resources to people perceived as having so little hope of achieving recovery? People experiencing and recovering from SUDs and their families will never be a political constituency of consequence as long as they are pictured as permanent burdens on community resources rather than as people who can and do achieve stable health, work productively, pay taxes, vote, and voluntarily serve the communities that have supported them. The addiction treatment advancements made to date have flowed from Mrs. Mary Mann’s declarations in 1944 that people with such health conditions can be helped and are worthy of help—a portrayal far different than that conveyed by the “chronic relapsing”/”chronic relapser” labels.
The recognitions that severe substance use disorders mimic characteristics of other chronic health conditions and could benefit from sustained recovery management rather than serial episodes of acute stabilization have been critical milestones in the advancement of modern history of addiction treatment. But such sustained care and support is at its best when it is hope-infused and stripped of language that adds to the burden of stigma facing individuals and families in recovery. While care must be taken in the characterization of SUDs as a potentially “chronic” condition for some persons (for some of the same above reasons–see such concerns expressed here, here, and here), it is time “relapsing condition” and such pejorative, objectifying labels as “chronic relapser” were forever deleted from the lexicon of addiction medicine and addiction treatment.
Post Date-March 18, 2016 by Bill White