The concept of karma holds that one’s fate in this life or future lives is not a random roll of the dice, but a direct product of one’s thoughts and actions. Rooted in many of the great religions and a central motif within Hinduism, Buddhism, and Jainism, karma is mistakenly confused in popular culture with the idea of good or bad luck. In contrast, karma suggests the presence of a universal principle of justice–that the decisions one makes or the actions one takes or fails to take have inevitable consequences. This principle can be found in many popular aphorisms:
You reap what you sow.
Violence begets violence.
They that sow the wind shall reap the whirlwind.
What goes around comes around.
Chickens come home to roost.
You get what you give.
Those who live by the sword die by the sword.
The principle of karma poses an interesting dilemma for people initiating recovery from addiction: How does one atone for the injuries one’s addiction-shaped actions and inactions inflicted upon others and the community at large? How does one balance the karmic scales to escape the whirlwind?
Most enter recovery with a karmic burden. Harm to others is a near-inevitable and -universal dimension of addiction—a progressive process of relational disconnection and self-absorption. Addiction, by definition, involves a prioritization of the drug relationship above all other aspirations, needs, commitments, and responsibilities. It is thus little wonder that the person at the doorway of recovery is haunted by ghosts of past harmful acts of commission or omission. The oppressive weight of guilt (I have done bad things) and shame (I am a bad person) can lead to self-sabotage for those who feel unworthy of the gifts of recovery. Such baggage must be shed to achieve sustained recovery and a reasonably fulfilled life.
It is common for people on the threshold of recovery to face resentment or rage from shredded promises; confront disappointment, distrust, and disdain in the eyes of others; and fear a backlog of consequences that could come at any time—all while experiencing cellular screams for anesthesia or stimulation. The question then becomes, “How does one step out of such quicksand into sustainable recovery, restore personal sanity, and repair relational trust?” Early Native American recovery circles, the Washingtonians, Fraternal Temperance Societies, Ribbon Reform Clubs, institutional support groups (e.g., Godwin Association, Keeley Leagues), Alcoholics Anonymous and other 12-Step programs, and the growing menu of secular and explicitly religious recovery mutual aid groups have all addressed this question.
Where some groups focused solely on achieving sobriety, on the assumption that with continued sobriety these broader concerns would take care of themselves, most recovery mutual aid groups, particularly those embracing religious and spiritual frameworks of recovery, emphasize the need for character reconstruction and restorative actions within the recovery process. Looking across such frameworks over a span of two centuries, one finds a consistent menu of suggested remedial steps aimed at balancing the karmic scales:
1) unflinching identification of harmful thoughts, feelings, actions, and inactions (self-inventory, humility);
2) private or public ownership of such harm (contrition, confession, self-forgiveness);
3) making amends to those harmed (restorative justice); and
4) unpaid acts of service to others and the community (generic restitution, gratitude, compassion, generosity, story reconstruction, and storytelling).
Accompanying such recommended actions have been admonitions that such actions be taken slowly, deliberately, repeatedly, and with the support of a community of shared experiences and aspirations. The message across generations is: The lived testimonies of millions of people in recovery suggest that positive changes in character and the quality of one’s relationships are both possible and common within the recovery process. The karmic baggage of active addiction can be progressively shed in recovery and replaced by a different kind of karma—one bearing the promises and gifts of long-term recovery. When the latter is achieved, people who were once part of the problem emerge as a vibrant part of the solution by balancing the karmic scales and becoming wounded healers and recovery carriers. Recovery pathways are also pathways of reconciliation.
Post Date December 8, 2017 by Bill White
“What is the best approach to the supervision of peer recovery support service specialists within the addictions field?” is a question that, at present, remains unanswered.
In earlier communications, I have disseminated papers that outlined the history, theory, and science of peer recovery support services; delineated the roles of addiction counselor, Twelve-Step sponsor, and recovery coach; detailed linkage procedures to recovery mutual aid organizations and other recovery community institutions; depicted the value of peers in pre-treatment outreach and engagement; described the integration of peer recovery support within professional treatment settings and recovery community centers; and reported on the integration of peer recovery support services within allied systems of care. Peer recovery support specialists—people credentialed by lived experience and on-the-job training—are now being integrated into a wide variety of settings and are delivering services across the stages of long-term addiction recovery. But questions remain about how such services are best supervised even as work progresses on defining the core competencies of peer supervision. A recent trend has been the requirement that peers be provided “clinical supervision.”
Traditional clinical supervision within the context of addiction treatment has many components, but at its core, and at its best, it provides oversight of the screening, assessment, diagnosis, treatment planning, and treatment delivery process, with a particular focus on the quality of the helping relationship. Modeled from supervision within the fields of psychiatry, psychology, and social work, addiction professionals and the individuals and families they serve have benefited greatly from this clinical supervision process. So why not extend this same clinical supervision to peer recovery support specialists? Here’s why.
Regardless of title (e.g., recovery support specialist, recovery coach, peer specialist, etc.), peer recovery support services are not a “clinical” activity in the sense that they do not involve processes of clinical assessment, diagnosis, treatment planning, or the delivery of professionally-directed treatment services. Any time they drift into this clinical domain, the peer helper is migrating beyond the boundaries of his or her education, training, and experience in ways that could inflict inadvertent harm to those being served. “Clinical supervision” of peer workers threatens to both turn them into wannabe therapists and pull them from activities for which they are best suited and which could have the greatest impact on long-term recovery outcomes.
My personal concern at the moment is that we as a field are not recognizing the difference between clinical supervision and the type of supervision needed for peer recovery support services. As noted, the former has a primarily intrapersonal focus. In contrast, the latter has a much great focus on the ecology of recovery—removing personal and environmental obstacles to recovery, assertive linkage to recovery mutual aid groups and other recovery support institutions, navigation of the larger culture of recovery, providing stage-appropriate recovery education to individuals and families, conducting ongoing recovery check-ups, and offering guidance to improve the quality of personal/family life in long-term recovery. While all helping roles involve emotional support, peer services are best delivered with an interpersonal focus that nests recovery within the context of family and community—including changing environmental conditions to enhance recovery outcomes. Supervision must help peer helpers forge links between personal needs and community needs—bridging personal/family support with advocacy at the community level and beyond.
Given these differences, I think the misapplication of traditional clinical supervision to the delivery of peer recovery support services will destroy the true potential of this role in supporting long-term recovery. What do you think?
Post Date December 1, 2017 by Bill White
When that doctor asked me, ‘Son, how did you get in this condition?’
I said, ‘Hey sawbones, I’m just carrying on an ole family tradition.’
–Hank Williams, Jr., Song Lyric, Family Tradition.
The intergenerational transmission of addiction and related problems has been documented for more than two centuries. Put simply, the children of alcohol and other drug (AOD) dependent parents are at increased risk of developing such problems, even when raised in alternative environments. Risks are amplified when combined with other factors, e.g., adverse childhood experiences, early age of onset of drug use, co-occurring medical or psychiatric disorders, enmeshment in drug-saturated social environments, and limited problem-solving assets.
In earlier publications, my co-authors and I have addressed the sources of such risks as well as potential strategies for breaking intergenerational cycles (e.g., see HERE and HERE). The challenge we faced in proposing potential solutions is linked to a much larger issue. The AOD research establishment has historically focused on illuminating the psychopharmacology of intoxicating substances, cataloguing the pathologies of acute and chronic drug consumption, and describing and evaluating the short-term effects of educational or clinical interventions designed to alter the course of substance use and substance use disorders (SUD). Absent from this research agenda have been rigorous studies to elucidate the prevalence, pathways, styles, and stages of long-term personal and family recovery across cultural contexts. Without such a recovery research agenda, some of the most important questions facing individuals, families, and communities remain both unasked and unanswered.
If, for example, we followed a large community and clinical sample of parents meeting diagnostic criteria for a substance use disorder (SUD) and examined the prevalence of AOD use, risky use, and SUD among their children, what would we discover with regard to the following five questions?
Does recovery of a parent reduce the likelihood of that parent’s children developing a SUD compared to parents who have not achieved recovery?
Does parental recovery increase the likelihood of recovery for any of their children who experience a SUD compared to children of parents who have not achieved remission?
Does parental involvement in professionally-directed addiction treatment or a recovery mutual aid group affect the intergenerational transmission of SUDs and the recovery prognosis of their children?
Does the participation of a child in his or her parent’s addiction treatment or in a family-focused peer recovery support group affect that child’s future vulnerability for experiencing or recovering from a SUD?
For parents who have experienced a SUD, are there parental actions associated with lower SUD risks for their children?
These are not obscure academic questions—the addictionologist’s equivalent of how many brain cells can dance on the head of a pin. They are instead questions of enormous concern to every parent who has experienced an alcohol or other drug problem and to every parent in recovery. It is time, no, past time, for such questions to be answered. If even partial answers to these questions are available, why have they not been widely disseminated to those most directly affected? Is anyone at the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism listening?
Apparently so. McCutcheon and colleagues have just published a NIAAA/NIDA-funded study in the renowned journal, Addiction, that is among the first to explore the questions raised above. The study examined whether the odds of remission from an alcohol use disorder (AUD) increased depending on the existence of relatives in AUD remission. The likelihood of remission was more than three times greater for those related to someone in AUD remission compared to those related to someone with persistent AUD. What remains unclear is whether this remission advantage is a function of heritable traits that increase remission probabilities (i.e., a form of biological recovery capital) or whether this advantage springs from social contagion (e.g., the influence of one family member in recovery upon another family member in need of recovery.) This is the most definitive report to date on the intergenerational transmission of increased odds of recovery from addiction. We have long known that the risk of addiction runs in families; there is now preliminary evidence that this is also true of addiction recovery. Future research may illuminate how the odds of transmitting such resilience may be increased.
Post Date November 17, 2017 by Bill White
Dr. John Kelly and colleagues just published (Drug and Alcohol Dependence, 181, 162-169) a landmark survey that measured the prevalence and pathways of alcohol and other drug problem resolution among adults living in the United States. Major findings from this study include the following.
Recovery Prevalence The just-published Recovery Research Institute (Massachusetts General Hospital) survey found that 9.1% of U.S. adults report they “use to have a problem with alcohol or drugs but no longer do.” This prevalence rate is comparable to earlier epidemiologic studies on rates of remission for alcohol and drug use disorders (See here for a review) and would translate to approximately 22.35 million U.S. adults who have resolved alcohol and other drug (AOD) problems. The rate of remission for substance use disorders in earlier surveys ranges from 5.3% to 15.3% of the adult population—an estimated 25 to 40 million U.S. adults (not including those in remission from nicotine dependence alone).
Variability of Problem Severity Approximately half of those who had resolved an AOD problem reported indicators associated with greater problem severity, e.g., early age of onset of AOD use, multiple drug use, and past arrest.
AOD Problem Resolution and Recovery Identity Of those who reported having resolved an AOD problem, only 46% identify as being “in recovery.” This suggests that people embracing a recovery identity (recovered, recovering, in recovery) are a subset of a much larger pool of people who have resolved AOD problems.
Duration of Problem Resolution Of those who had resolved an AOD problem, 35% reported duration of resolution of 5-15 years, and 29% reported having resolved the problem for more than 15 years. There is a substantial population of American adults in stable, long-term recovery from significant AOD problems.
Assisted versus Unassisted Recovery Of U.S. adults who have resolved AOD problems, 46% resolved these problems without professional treatment or peer recovery support and 54% reported using such supports. Significant differences exist between those with unassisted versus assisted pathways of problem resolution, with the latter associated with greater problem severity, problem complexity (e.g., co-occurring psychiatric diagnosis), and more significant consequences (e.g., criminal justice involvement).
Sources of Assistance The most commonly reported resources used to resolve AOD problems were mutual aid groups (45%) and professional treatment (28%), with 9% reporting use of medication support. While the majority noting use of mutual aid reported participation in Alcoholics Anonymous or Narcotics Anonymous, also evident were other Twelve-Step groups and an increasing variety of secular (women for Sobriety, SMART Recovery, etc.) and religious (e.g., Celebrate Recovery) recovery mutual aid groups. Of those who had resolved AOD problems, 22% reported using new recovery support institutions, e.g., sober residences, recovery community centers, and recovery ministries.
For nearly two decades, recovery advocates have championed two kinetic ideas: 1) Recovery is a reality (for individuals, families, and communities) and 2) There are multiple pathways of recovery and ALL are cause for celebration. The research of Kelly and colleagues offers substantive scientific evidence in support of both propositions.
Kelly, J. F., Bergman, B., Hoeppner, B., Vilsaint, C., & White, W. L. (2017). Prevalence, pathways, and predictors of recovery from drug and alcohol problems in the United States population: Implications for practice, research, and policy. Drug and Alcohol Dependence,181, 162-169.
White, W. L. (2012). Recovery/remission from substance use disorders: An analysis of reported outcomes in 415 scientific studies, 1868-2011. Chicago: Great Lakes Addiction Technology Transfer Center; Philadelphia Department of Behavioral Health and Developmental disAbilites; Northeast Addiction Technology Transfer Center.
Arndt, S., Vélez, M. B., Segre, L., & Clayton, R. (2010). Remission from substance dependence in U.S. Whites, African Americans, and Latinos. Journal of Ethnicity in Substance Abuse, 9(4), 237-248.
Calabria, B., Degenhardt, L., Briegleb, C., Vos, T., Hall, W. Lynskey, M., . . . McLaren, J. (2010). Systematic review of prospective studies investigating “remission” from amphetamine, cannabis, cocaine or opioid dependence. Addictive Behaviors, 35(8), 741-749.
Dawson, D. A., Grant, B. F., Stinson, F. S., Chou, P. S., Huang, B., & Ruan, W. J. (2005). Recovery from DSM-IV alcohol dependence: United States, 2001-2002. Addiction, 100(3), 281-292. doi: 10.1111/j.1360-0443.2004.00964.x
Grella, C. E., & Stein, J. A. (2013). Remission of substance dependence: Differences between individuals in a general population longitudinal survey who do and do not seek help. Drug and Alcohol Dependence, 133(1), 146-153.
Price, R. K., Risk, N. K., & Spitznagel, E. L. (2001). Remission from drug abuse over a 25 year period: Patterns of remission and treatment use. American Journal of Public Health, 91(7), 1107-1113.
Spinelli, C. & Thyer, B. A. (2017). Is recovery from alcoholism without treatment possible? A review of the literature. Alcoholism Treatment Quarterly, DOI: 10.1080/07347324.2017.1355219.
White, W. L., Weingartner, R. M., Levine, M., Evans, A. C., & Lamb, R. (2013). Recovery prevalence and health profile of people in recovery: Results of a Southeastern Pennsylvania survey on the resolution of alcohol and other drug problems. Journal of Psychoactive Drugs, 45(4), 287-296.
Post Date November 3, 2017 by Bill White
I received two emails this week, each posing the question: Are recovery management (RM) and recovery-oriented systems of care (ROSC) dead as organizing frameworks for addiction treatment and recovery support? For 15 years, these conceptual rubrics ascended as promising alternatives to ever-briefer, acute care models of addiction treatment. RM and ROSC were among the most important progeny of efforts to extend the organizing center of the addictions field from its historically dual focus on problems (etiological roots and resulting clinical pathologies) and interventions (competing methods of treatment) to a focus on lived solutions (i.e., lessons drawn from the collective experience of long-term personal and family recovery). Questions regarding the future of RM and ROSC are quite legitimate concerns.
RM pilots (see HERE and HERE) generated promising new approaches to treatment and recovery support spanning the arenas of early identification, engagement, and motivational enhancement; comprehensive and continual assessment protocol; partnership models of recovery planning; assertive linkage to indigenous recovery support institutions; the integration of professional and peer-based recovery support services; and post-treatment personal/family recovery check-ups. Most importantly, RM implementation efforts addressed support needs across the stages of recovery: 1) precovery, 2) recovery initiation and stabilization, 3) transition to recovery maintenance, 4) enhanced quality of personal and family life in long-term recovery, and 5) efforts to break intergenerational cycles of addiction and related problems.
The concept of ROSC provided a rationale and a framework for expanding recovery support resources beyond the treatment setting into the very fabric of local communities. ROSC promoted forging the physical, psychological, and social space (recovery landscapes) within which personal and family recovery could flourish. Adopted and adapted at the federal level under the leadership of Dr. Westley Clark at SAMHSA and drawing inspiration from early ROSC efforts in Connecticut and Philadelphia, significant resources were extended to seed ROSC-focused transformations in addiction treatment in the U.S.
The question at present is whether RM/ROSC-related innovations mark a sustainable shift in addiction treatment and recovery support, or if they are one more flavor of the month to be cast into the waste bin of a field known for such fleeting infatuations. The recovery orientation within national drug policy (at ONDCP, SAMHSA, and to the extent that it existed at NIDA and NIAAA) has rapidly dissipated under a new presidential administration whose drug policy efforts to date are marked by delayed promises, at best, and, at worst, a return to failed drug policies of the distant past. Also of concern is the disengagement of the first wave of RM/ROSC champions (e.g., McLellan, Lewis, Boyle, White, Kirk, Evans, Clark, Nugent, Botticelli, and Murthy) due to the assumption of new roles or retirement. The lost visibility of RM/ROSC initiatives at the federal level and the decreased visibility of RM/ROSC champions at a national level spark fears that these concepts will be relegated to a brief footnote within the field’s history.
But there is another side to the RM/ROSC story. The RM/ROSC initiatives launched at the federal level exerted a potentially enduring influence on the field. Addiction professionals from across the U.S. and around the world visited early RM/ROSC pilots in Connecticut and Philadelphia. The Center for Substance Abuse Treatment’s network of Addiction Technology Transfer Centers embraced RM/ROSC and the resulting RM/ROSC monograph series and related training events stirred innumerable state and local RM/ROSC initiatives. The results of these and related efforts are evident in the following:
Key elements of the RM/ROSC model are being positively evaluated by research scientists, e.g., the positive effects of post-treatment recovery checkups.
A second generation of RM/ROSC leaders is providing training and consultation services focused on RM/ROSC implementation across diverse clinical, cultural, and geographical settings.
New strength-based assessment instruments are being developed, e.g., the Assessment of Recovery Capital.
Peer-based recovery support services are being integrated into addiction treatment and allied health and human service organizations.
Traditional abstinence-based addiction treatment organization and harm reduction organizations are evolving from a state of stale rhetorical warfare to efforts of collaboration and integration—aided by staged models of addiction recovery.
Efforts are increasing to integrate addiction treatment and recovery support services within primary health care, the criminal justice system, and the child welfare system.
New financing models are being piloted that support the transition from acute care interventions to RM/ROSC.
Recovery community building efforts are progressing via the growth and diversification of recovery mutual aid organizations, the rise of new recovery support institutions, and the maturing of a new addiction recovery advocacy movement.
No matter what happens at the federal level, the essence of RM/ROSC will prevail, or if lost, be rediscovered in the future. Historically, when addiction-related systems of care collapse, people in recovery and their families and visionary professionals rise up and forge new systems of care and support.
Recovery is more than a personal and family experience; it is a catalytic idea that can transform addiction treatment, allied service organizations, and the communities in which such professional support is nested. The future of RM/ROSC is being written by heroes who are carrying forward this movement at a grassroots level. And change at the grassroots level is ultimately what RM and ROSC are all about. The stakes are enormously high, and the eye of history is watching.
Post Date October 19, 2017 by Bill White
Advocacy movements require transforming highly personal stories into the collective narrative of “a people.” Merging the individual stories into a larger collective mosaic allows people with shared characteristics and experiences to see their past and future as part of a larger drama. As Marcus Garvey suggests, individuals become a people only when connected to their shared historical roots.
So when did Americans in addiction recovery first begin to see themselves as “a people” with a shared heritage and destiny? The roots of such consciousness begin in the late 1700s within abstinence-based religious and cultural revitalization movements among Native American tribes, arise anew within the early American temperance societies, and extend into groups formed exclusively for the purpose of recovery mutual aid—the Washingtonians, recovery-focused fraternal temperance societies, the ribbon reform clubs, and groups links to the earliest addiction treatment programs (e.g., the Ollapod Club, Godwin Association, Keeley Leagues). Dozens of such groups predate the founding of Alcoholics Anonymous, other 12-Step groups, and their modern religious and secular alternatives.
Much of this history is recounted in three books: Slaying the Dragon: The History of Addiction Treatment and Recovery in America, Alcohol Problems in Native America: The Untold Story of Resistance and Recovery (with Don Coyhis), and The History of Addiction Counseling in the United States. Summations of the history of addiction recovery have also appeared in a series of authored and co-authored articles that are available for free download on my website. For readers interested in this history, I commend the following articles:
Addiction and Recovery in Native America: Lost History, Enduring Lessons (With Don Coyhis)
The History of Recovered People as Wounded Healers: I. From Native America to the Rise of the Modern Alcoholism Movement
The History of Recovered People as Wounded Healers: II. The Era of Professionalization and Specialization
Listening To Lazarus: The Voices of America’s first “Reformed Drunkards”
The Role of Recovering Physicians in 19th Century Addiction Medicine: An Organizational Case Study
Addiction and recovery among African Americans before 1900 (with Mark Sanders).
Addiction in the African American Community: The Recovery Legacies of Frederick Douglass and Malcolm X (with Mark Sanders)Pre-AA Recovery Mutual Aid Societies
Twelve Defining Moments in the History of Alcoholics Anonymous (with Ernie Kurtz).
Faith-based Recovery (with David Whiters)
Styles of Secular Recovery (with Martin Nicolaus)
Early recovery biographies, interviews with recovery advocacy leaders, and key documents related to the history of secular, spiritual, and religious recovery mutual aid groups are available by clicking HERE, HERE, and HERE.
One of the most significant historical trends within the history of addiction recovery is people in recovery beginning to see themselves as “a people” apart from affiliation with a particular treatment or recovery mutual aid enterprise. This rising ecumenical culture of recovery is marked by a new language of self-identification and expression; political mobilization; economic development; new recovery support institutions; and creative innovations in the arenas of music, art, literature, cinema, theatre, and new rituals of celebration and protest. Unraveling and extolling the history of recovery are part of this new recovery consciousness, which is itself a historical milestone. Researching and mining the lessons of history are legitimate forms of recovery activism. How might you help capture or pass on the stories that make up the history of addiction recovery?
Post Date September 22, 2017 by Bill White
I am soliciting your assistance in announcing the publication of my latest book, Recovery Rising A Retrospective of Addiction Treatment and Recovery Advocacy.
I have worked in the arenas of addiction treatment, recovery research, and recovery advocacy for nearly half a century and been blessed with opportunities to work with some of the leading policymakers, research scientists, clinicians, and recovery advocates of my generation. At this late stage of my life, it seemed a worthy effort to try to pass on some of the hard-earned lessons I have drawn from this work. Such was the inspiration for turning decades of professional journaling into a book of stories that highlight, through my own experiences, some of the major milestones in the modern history of addiction treatment and recovery.
Recovery Rising contains more than 350 vignettes with accompanying reflective questions that allow readers to explore their own thoughts and experiences related to the most challenging issues within the front lines of addiction treatment and recovery support. Recovery Rising is a sweeping story that readers may wander (and wonder) through at their leisure, pausing to reflect on the personal meanings that can be drawn from each vignette. I have tried to create the book I wish my professional elders had placed in my hands when I began this special service ministry. I hope you and others will find your life’s work affirmed in these pages and that a younger generation of addiction professionals and recovery advocates will feel the passing of a torch.
Recovery Rising is available through Amazon in e-book ($9.99) format and may be ordered by clicking Amazon or Amazon UK. A paperback format is coming soon.
Any help you can provide in letting others know about the release of the book via your professional network or social media will be deeply appreciated. A portion of the proceeds from each book will be donated to grassroots recovery advocacy organizations.