One of the most troubling aspects of the modern-day“substance use disorder”treatment system is the stubborn reliance on a single pathway of recovery.
Namely, 12-step recovery. Mostly, AA and NA meetings/programs.
I found recovery through 12-step meetings and it is my preferred pathway to recovery.
However, in my professional work, I avoid pushing my recovery onto others. Sadly, the reality is, many providers still push 12-step only recovery.
YOU MUST COMPLY
Mandated programs and compliance programs almost always have a “recovery group” attendance requirement.
And far too often they sadly: ONLY ACCEPT 12-STEP RECOVERY GROUP ATTENDANCE.
This runs counter to all the facts and research surrounding recovery.
For example, let’s review the numbers.
THE NUMBERS
There are 22.35 million people in America who report having resolved a substance use disorder.
They “had a problem”.
They “no longer have a problem”.
I hope we can all agree, that resolving a SUD is a good thing. Regardless of how you get it done.
REQUIRED HELP
Of those 22.35 million people, 54% report that they had assistance in getting better.
In other words, 12,069,000 required help.
AA & NA
Of those 12,069,000 who got help, only 45% report that it came via AA or NA.
Therefore, 5,431,050 FOUND RECOVERY THROUGH AA or NA.
THE OTHER ALMOST 17 MILLION
THIS MEANS THAT 16,918,950 PEOPLE GOT BETTER VIA SOME PATHWAY OTHER THAN AA OR NA.
YET WE HOLD TIGHT TO THE IDEA THAT AA AND NA IS THE ONLY OPTION?
And we “professionalize” that by hanging steps in our treatment group rooms and mandating attendance to “12-Step Groups Only”.
FOR 12 STEP ENTHUSIASTS
Pause for a station break.
At this point, if you are a 12-step only enthusiast you have a couple options:
You can flat out deny the research and simply say “in my experience, this is the only way”. As if your experience speaks for the other 7 billion people on the planet.Or you can –
You could deny the math. But run the numbers, it’s indisputable.
WHAT DID BILL BELIEVE
Finally, even the founder ofAlcoholics Anonymous would reject this idea of “12-Step Only Recovery”.
Mr. Wilson would be appalled by the hubris and arrogance of promoting one way only.
Thank you to a global Alcoholics Anonymous expert, William White for the research:
“AA has no monopoly on reviving alcoholics”. (Wilson, 1944/1988, p.98)
“The average member of Alcoholics Anonymous does not suppose we have a cure- all”. (Wilson, 1945b, p. 239)
“In all probability, we shall never be able to touch more than a fair fraction of the alcohol problem in all its ramifications. Upon therapy for the alcoholic himself, we surely have no monopoly”. (Alcoholics Anonymous, 1955, p. ix)
“In no circumstances should members feel that Alcoholics Anonymous is the know-all and do-all of alcoholism”. (Wilson, 1965/1988, p. 332)
“Then, too, it would be a product of false pride to believe that Alcoholics Anonymous is a cure-all, even for alcoholism”. (Wilson, 1963/1988, p. 346)
“When you consider the ramifications of this disease, we have just scratched the surface. I think we should humbly remember this”. (Wilson, 1969, p. 9)
ON DOGMA & COERCION:
“It is a historical fact that practically all groupings of men and women tend to become more dogmatic; their beliefs and practices harden and sometimes freeze. This is a natural and almost inevitable process…. But dogma also has its liabilities. Simply because we have convictions that work well for us, it becomes very easy to assume that we have all the truth….This isn’t good dogma; it’s very bad dogma. It could be especially destructive for us of AA to indulge in this sort of thing”. (Wilson, 1965/1988, p. 333)
REASONING
It stands to reason that:
The science and evidence supports opening the door to “Alternative Recovery Programs”.
Bill Wilson would support alternative recovery models.
The questions that naturally arise are:
Why don’t more providers open the door to “Alternative Recovery Models”?
Why does the system allow such inappropriate conduct?
FOR THE RECORD
For the record, there are amazing programs in Greenville and the rest of the Upstate that completely support alternative pathways.
However, it is troubling that old school hold-outs are still permitted to operate.
However, it is truly poignant when you look at the characters, the story and this video through the lens of mental health, trauma, addiction, social decay, and post WW I desperation.
The Shovels
Tommy Shelby is the leader of the Peaky Blinders Gang and a World War I veteran.
He also is in a full blown post traumatic stress disorder flashback.
The “shovels against wall all through the night” is a reference to phantom German tunnel diggers. Left over from his war experience.
If you watch the series (Peaky Blinders) you also see Tommy is full of blind, uncontrollable ambition and dealing with the multi-generational trauma of a violent and addicted family.
Opium Dreams
All of this adds up to a dark world that Tommy Shelby (and many other characters) are trying to negotiate.
Tommy is smoking opium in a desperate attempt to shut it all out.
The drugs are not working for Tommy Shelby. He is, in summary, losing his shit…
Tommy’s Caring Housemaid:
“You are not yourself Mr. Shelby, we need to get you to a doctor”…
Tommy responds (greatest line ever):
“It’s just myself talking to myself about myself”….
IT’S JUST MYSELF…TALKING TO MYSELF…ABOUT MYSELF.
The Rescuer
And… a relationship is going to save him.
A woman is going to rescue him…
SHE IS GOING TO PULL HIM OUT OF HELL.
Tommy: “I don’t hear the shovels against the wall….”
I don’t know what it is about the scene with Grace… (what a name for the rescuer).
That scene, and the way it is cut up with this music (Pull Me From The Dark) is prolific. Moving. Troubling.
Tommy: “Will you help me”?
Grace: “Help you with what”?
Tommy: “With everything”….
Men Like Us!
And all the warnings:
“she’s one woman Thomas…” “Men like us Mr. Shelby we will always be alone”…
Men like us? What does that mean? Damaged goods?
Grace: “I warn you. I’ll break your heart”…
Tommy: “It’s already broken….”
And most ominous of all….
“aye…there’s a woman”….
It is a television show so it ends in the most dramatic way possible.
Grace takes a bullet for Tommy… But that’s not the point…
The Human Experience
This video captures a part of the human experience that I can relate to.
That I can FEEL… when I watch this. That need to escape….
I grew up in a home torn apart from pervasive violence and alcoholism in a community and culture where you never talked about anything uncomfortable.
Love & Hate
In the era of “corporal punishment” we all (the kids in the neighborhood) got beat down by our fathers.
Beat down when we did something wrong…sometimes even when we didn’t do anything wrong.
Even more problematic. How can you love and hate the same person?
Would be better for the violence to be a permanent condition….
And the shame. The shame of knowing that your home was …. different…
Saved By Her
I do find respite and hope in my wife… We met when I was just 17… I do think she saved me.
Is that “healthy” or “politically correct” or “gender role stereotype” etc…..
I could care less what anyone else thinks. I think she saved me.
And she nearly took a bullet along the way…. (metaphorically speaking).
According to Dr Gabor Mate, addiction is essentially an attempt to escape pain. Addiction involves much more than substance misuse.
Many objects and behaviors become addictive. The problem is you can’t permanently escape.
In addition, eventually, the payoff from escape will fade and the consequences will become steep.
Depression and other mental/emotional issues make the desire for escape even more profound.
When you look around and compare yourself to other people it can make you desire escape even more.
Because you tell yourself how terrible and crappy your life is compared to them.
Pile on more pain.
A Few Things
Clearly understand a few things. Their apparently perfect life involves plenty of pain and they are either:
Blindly and desperately trying to escape through self destructive behaviors themselves. In which case you can relate, as there have been times you have felt this way. In addition, you don’t need to envy them because they are in the middle of their own difficulty.
Working on themselves and therefore on the same journey as you. In the case they are on the same team and probably experience the same misgivings that you are.
Also understand that there COULD be better days ahead.
It’s sketchy for anyone to tell you this darkness will definitely pass.
But it is 100% true to say that it is POSSIBLE for less pain in the future.
A Few More Things to Remember
Perhaps there is great merit in struggling through.
Perhaps there is something larger at play. There is merit in trying to not give in. Your life in beautiful. Despite the way you fell or your perceived shortcomings. The good, the bad and the ugly.
My stuff is always upside down…. I’m always fighting escape.
The only thing I do right is I keep coming back for more… never give up.
I’m an expert at getting back on the wagon because I fall off so often!
I am certain that there is no certainty surrounding substance use disorders and their “cause”.
Despite popular opinion and what you hear out there in Expertville.
We are relatively clueless. SUD falls in a category of medicine called “intuitive medicine”.
Versus treating appendicitis, which is an example of precision medicine. (See below; SUD would fall similar to depression, since society doesn’t actually think it’s a disease it’s not listed on this chart).
Like any other disorder, SUD will manifest itself in a wide variety of ways.
The level of complexity with co-occurring mental health and underlying factors of trauma/adverse childhood events is an example.
I also believe their are vast differences in the neurobiological component.
We are not all physiologically identical. All who “cross the line” may experience a fundamental change in the brain, however, how we get there varies greatly from person to person.
Furthermore, many haven’t “crossed the line” but misuse is killing them anyway. Let’s be clear. You do not have to be an “addict” in order to destroy yourself with substances.
Therefore, restoration to health will vary greatly from person to person. The destination and the path will vary.
In addition, what you need early in your recovery will differ from what is needed down the road.
Other issues are likely to take center stage as you progress in your recovery.
Be creative and open to other wellness alternatives. Avoid getting stuck.
However, if it’s not broke don’t fix it. If you are feeling good keep on the same path.
When I was “out there” in active addiction I was vaguely aware of what “addiction” was.
My job exposed me to the mental health world as I worked in healthcare. I was not a clinician so my knowledge remained on a superficial level. However, I was aware that the Diagnostic and Statistical Manual (DSM) was the “book” used to diagnose both mental health and substance use disorders.
I had access to these manuals via my “psychiatrist co-workers” in the health system.
On many occasions,
I found myself looking over the criteria for substance abuse and dependency-as it was called at that time; 1998…
I would read the criteria and read it over and over again.
I would dissect the words and see if it applied to me.
I was not living under a bridge or eating out of a dumpster.
I had not been to jail.
I was losing my family…but I had not lost my family.
Most of my consequences were internal.
I was never sleeping.
I was “dope-sick”/experiencing withdrawal on most days but didn’t really know what was happening to me.
I was using opioid based pain pills that I was getting prescribed (from several doctors).
I never bought it off the street.
This allowed me to buy into the concept that “it was from a doctor and couldn’t be that bad”.
I was always running out early.
I was always terrified of running out early.
I had suicidal thoughts.
But no one really knew what was going on with me. Not even my family.
I was in an internal hell.
But it wasn’t dramatic and
I wasn’t a “scum-bag, liar, cheater, and thief” of an addict.
I was a pretty high functioning person who was quietly, yet desperately, dependent on substances to get through the day.
Oh…on a side note: alcohol was ever present and I was probably more dependent on that substance. It was just socially acceptable and therefore I didn’t identify it as the main problem.
The Manual Said
Man… I would look at that Diagnostic Manual and play with the criteria in my mind.
The manual said “inability to control use” was a symptom:
I would tell myself that really didn’t apply to me because “it wasn’t lack of control.
I actually wanted to drink 24 beers and eat 10 Percocet… so I was in control…it was my choice”.
The manual said “can’t cut down” was a symptom:
I would tell myself that I really could cut down if I wanted “I just haven’t decided to yet”…
The manual said “interpersonal problems due to using”:
I told myself that my wife had an attitude problem and it really wasn’t on me…
And I looked at this manual over and over…and as time went by I had more and more trouble writing it off. But I was always able to do so.
Because I was NEVER TALKING TO ANYONE ABOUT THIS.
I Never Discussed My Substance Use
My mom, my wife, told me to see counselors or “go to AA” and I flat out refused.
I was clueless as to what was happening to me…
I turned the book upside down to see if it made more sense from a different angle.
I couldn’t figure it out.
Once I went to an EAP counselor and I was just waiting for her to ask me about my use and give me some answers. But all we talked about was “stress” and “career planning”.
You see…she wasn’t a drug and alcohol “specialist”. So we didn’t go there.
I just simply never discussed my substance use with anyone despite the fact that it was destroying my life. And it got worse and I did temporarily lose my mind and my family and my sense of purpose and my future.
Why did it have to roll on so long????
Did I have to “hit bottom”?
Did I have to “become ready”?
Or
Would I have benefitted from a conversation.
I Found Recovery
As you can probably assume…I eventually found recovery and went back to school and got a graduate degree in Sociology with concentration in Addiction studies, became a therapist, went back and got an MBA with a concentration in healthcare management.
I jumped through a bunch of hoops a got licenses and certifications.
Started working in the field in 2001—basically as soon as I entered recovery. And I’ve learned a lot. Both personally and professionally.
Based on all this…What do I believe people need to know:
Substance use disorder. It is a real problem. It’s a brain issue. It’s not bad behavior or just a bad habit. It will get worse and it will not just go away on its own.
That said…it takes on many different variations. Just like other diseases there are different stages or different “species” of addiction. There is no such thing as a garden variety drug addict—as you so often hear people say. The word addict is demeaning and people say addicts are scumbags and liars and cheaters and thieves. That doesn’t help and it’s not accurate. It’s an individualized experience. Don’t buy into the hype.
Following logically behind premise number 2–there are multiple ways to “get better”. There is no one prescribed way to recover. It is an individualized experience
I wish someone would have engaged my family in the process. Families are profoundly impacted and deserve information. Families should be included not removed from the process. Unless their involvement is dangerous for the person needing recovery or for the family members.
You are allowed to talk to someone without making a commitment to quit everything all together and “never take another drink”. This would have been the most beneficial piece of information for me when I was “out there”. I stayed away from “addiction counselors” for years because I wasn’t going to “quit everything”.
You don’t automatically need to go to rehab. There is actually a clinical assessment process that indicates level of care. You would never know that based on the media and based on the behavior of some rehab marketers. But rehab is not always necessary.
There are many people in recovery who did not go to jail and/or ate out of a dumpster. We have allowed ourselves to become caricatures and we promote stereotypes of the scumbag drug addict. I’m sure this chases many people away from recovery. Don’t buy into that… it’s a very diverse crowd.
There is medicine available that can support recovery. Staying alive is first on the agenda. Don’t let uneducated and uniformed people tell you otherwise. It’s not the only option. But it is an option.
It may be hard to find people who are willing to meet you where you are at in the process of change. Keep looking. Professionals are wrong when they blindly confront you and prescribe one size fits all solutions. Don’t quit the process based on a bad experience. Find another meeting or another therapist or another program. Be your own advocate.
If you are using heroin or “pills from the street” (or apparently cocaine)–In today’s world of carfentanil and fentanyl please understand you are playing Russian roulette every time you use. It is better to seek help even if you are “not sure you are ready for recovery” and let a professional help you figure out options…than it is to continue on until you “hit bottom”. Hitting bottom today means death…too often.
YOU CAN GET BETTER…LIFE CAN BE BETTER.
YOU WILL BE ABLE TO SLEEP AGAIN…
YOU WILL BE ABLE TO LOOK AT YOURSELF IN THE MIRROR AGAIN.
FAVOR Greenville champions all Pathways to Recovery. This includes 12-step recovery meetings. We believe the fellowships of Alcoholics Anonymous and Narcotics Anonymous are a first option for many of our participants. In nearly all cases it is the first outside resource discussed via recovery planning. If people are willing, we run with the plan for meeting attendance. However, we do not believe that recovery is a one size fits all process and there are many ways to find recovery. All of these are worthy of celebration. We just want to see your life get better.
Therefore, when we shine light on one size fits all treatment, we are not doing so in reference to AA or NA. We are doing so in reference to the professionalization of 12-step recovery and a private system that, in many cases, denies the patient access or information regarding alternative pathways of recovery. With that in mind I wanted to put forth some random thoughts on multiple pathways.
1) Multiple Pathways Exist: Perhaps the most controversial thought concerns the fundamental reality that multiple pathways of recovery exist. Because of the stigma and shame surrounding addiction relatively little research has been done on recovery. Our culture, as a whole, considers addiction a “moral failing” so there is little demand or interest in gaining scientific insight into the recovery process. In addition, many professionals in the field have little concern with research on recovery. Especially if they have had their own personal experience in recovery. This leaves a void of knowledge which has, unfortunately, been filled with clichés and conventional wisdom. To paraphrase Randy Gage and his new book Mad Genius: this void has allowed the mysterious people in charge of the secret system that runs (addiction treatment) to simply proclaim there is only one way to recover. I don’t know how many individual people believe this. It is a very difficult thing to assert and still consider yourself a rational person. However, the herd mentality frequently kicks in and people jump on board with this type of claim even in the face of evidence to the contrary.
This void has allowed the mysterious people in charge of the secret system that runs addiction treatment to simply proclaim there is only one way to recover. No one knows who these people are. They are the ones who established all the things that have “always been done this way” (adapted from Randy Gage, Mad Genius).
Typically, the pathway most commonly promoted is 12-step recovery found in Alcoholics Anonymous or Narcotics Anonymous. AA and NA are the most well-known pathways and many have found recovery through these programs. In fact, they are the most common “formal” pathway of recovery. My concern has nothing to do with the programs of AA or NA. My concern is with the professionalization of AA and NA. I have heard professional counselors proclaim that AA is the only way to find recovery. I have heard stories of patients being required to complete steps while in facilities that claim to be licensed inpatient rehabilitation facilities. This is a big problem. If you find yourself in the presence of a therapist who says something along the lines of “you must do AA in order to recovery” you should look around for other options. Insurance should not be paying for 12-step sponsorship. The responsible thing, from a medical perspective, is to promote all pathways of recovery and develop aftercare plans that are truly individualized.
One of the problems with exploring pathways to recovery lies in the definition of recovery. Does it mean complete abstinence? Does it mean complete abstinence plus a defined program of self-improvement? Does it mean complete abstinence plus a “spiritual awakening”? Is mediation assisted treatment a viable pathway to recovery? What about the reality of substance use disorder full remission? In other words, a person had a substance related problem but no longer does. These individuals may or may not use, either way they are no longer destroying their lives. How do we characterize these individuals? I think that is a good thing if their lives are improving.
When you explore substance use in a realistic manner you find much complexity and nuance. If you are a self-help attendee, you have little responsibility beyond the black and white. A person is in recovery if they do “the program”. However, if you are a professional healthcare or treatment provider you have an ethical responsibility to explore all angles and gain a deeper understanding. For the sake of research there has been a general agreement on recovery as “remission of symptoms”. It is the most quantifiable variable and from a public health perspective the most important.
In addition to 12-step recovery, The Recovery Research Institute (RRI) out of Harvard lists the following as “clinical” pathways which have been proven effective: pharmacology, Acceptance and Commitment Therapy, holistic based recovery services, Community Reinforcement Approach, CBT based approaches, Contingency Management, Relapse Prevention Therapy, Motivational Interviewing/MET techniques, 12-step Facilitation, Behavioral Couples Therapy, and Family Therapy. Among “non-clinical” alternative services you find: Recovery Community Centers, Peer-Based Recovery Support, Education Based Recovery Support, Employment Based Recovery Support, and Faith-Based Recovery Support. Furthermore, alternative mutual support groups existing including: SMART Recovery, Rational Recovery, Women For Sobriety, HIP Sobriety, LifeRing, Secular Recovery Organizations and many others.
In addition, some achieve recovery or “remission” without any formal help. From the RRI:
“Some individuals can achieve substance use disorder remission without formal help from professional treatment or mutual-help organization participation”.
Again, because of the mysterious people in charge of the secret system that runs addiction treatment we have allowed our professional systems to ignore these facts. Even Bill Wilson knew there were many ways to recover. The following are all quotes from the esteemed Mr. Wilson:
–“AA has no monopoly on reviving alcoholics.”
–“The roads to recovery are many… any story or theory of recovery from one who has trod the highway is bound to contain much truth.”
–“Upon therapy for the alcoholic himself, we surely have no monopoly.”
–“In no circumstances should members feel that Alcoholics Anonymous is the know-all and do-all of alcoholism.”
Professional organizations, counselors and addiction treatment centers should be held accountable to standards that include a full menu of recovery options. Are we not “withholding” possible solutions when we discuss only 12-step recovery? This seems like an advocacy issue that those of us in the recovery management movement should take on.
2) It is likely that “new” pathways will be invented: As we often hear in the rooms of recovery, recognizing and accepting the problem is the first step. If we are in denial of the problem we can never find a solution. If we are unable or unwilling to look at the situation from a reality based perspective, we will never make a change.
I would argue we are in denial regarding this issue. 90% of the treatment programs in America operate from the same fundamental philosophy, and it is not working. As it currently stands only 10% of those in need are engaged in services. It is logical to assume that some of this is the result of a one size fits all approach. If we opened the door wider more people would walk into the recovery process. If we offer alternatives and programs that meet people where they are you will see improved engagement.
I also believe there is a shelf life on the current approach. I do not think this business model is sustainable and people will start to differentiate. Marketing programs that are all identical will not be effective as you get a more educated and knowledgeable patient base.
And I believe that as soon as we acknowledge the problem we will innovate and develop new solutions. It is already happening in small pockets around the country. Including Greenville, South Carolina. We will develop alternatives that we cannot even envision right now. Technology will help. However, I believe the real break-through will occur when we educate, train and supervise a new workforce. One that emphasizes engagement and connection over dogma and acute care rinse and repeat models.
We will realize that “the way we have always done things” makes no sense. We will rise up and challenge the mysterious people in charge of the secret system that run the addiction treatment system and develop new protocols, payment systems, and norms. We will develop an entirely new culture of professional recovery services. Twenty years from now people will look back on this day and time as the transformation point. They will wonder why it took so long to make changes.
3) Co-Occurring Recovery will be one of the new pathways: Double trouble or dual diagnosis groups have always existed. However, they are few and far between and they are not available for many in need. We know that upwards of 60% of those with a substance use disorder also suffer from some type of mental health issue. The days of mental health issues being cleaned up via the natural progression of recovery are over. We can no longer just wait for the person to sober up and see if the depression goes away. Some studies indicate trauma is present in up to 80% of women in recovery. Trauma symptoms can be made worse if mishandled and there will be a need for specialized support in these areas. This is all good stuff. We have advanced as a society. We are more informed and educated than we were in the past and our needs have changed. That is not unusual. It is predictable and healthy.
In addition, people with mental health issues sometimes struggle to fit into “regular recovery” groups. Medication is one reason. Social anxiety would be an example of another reason. It is likely that new recovery groups will spring up to meet the needs of participants with co-occurring disorders. At FAVOR Greenville, we are developing a curriculum that certifies a coach as a COD specialist. This will be a positive development in the fight against addiction.
4) Medication Assisted RECOVERY will be one of the new pathways: Despite the best efforts of many people in recovery, many people on medication assisted treatment have felt alienated from recovery rooms. I have no interest in entering into that debate in this blog post. It would require much more time than I have at the current moment. Suffice to say, there is likely to coalesce a specific recovery program for people on medication replacement therapy. A place where they can talk and share openly on all matters including the use of Suboxone or Methadone. We know this is a very contentious subject in some recovery rooms. At FAVOR Greenville, we welcome you into the recovery process no matter what stage you are in. We want you to keep coming back. Medication assisted or not. I believe we will see more specific programming and services related to medication assisted recovery. We know community is exceedingly important to the recovery process and it is going to be necessary to address this glaring issue as we move forward.
In closing I want to reiterate. At FAVOR Greenville, we are big fans of 12-step recovery. However, we are also big fans of SMART recovery, Women For Sobriety, FAVOR primary recovery, clinical recovery, medication assisted recovery, and any other recovery you can think of. Our interest is in seeing your life improve.
