Anita Everett M.D. DFAPA, Director, Center for Mental Health Services

National suicide rates are rising, and this is especially true for our nation’s youth suicide rate. Suicide is largely a preventable cause of death, and you are more able to help prevent it than you might think.

Suicide is the result of actions being connected to a self-harm idea.  Many more people think about suicide than those who die by suicide; however, no one dies by suicide without having thought about it first. There is a thinking-planning phase followed by an action phase. The thinking phase is different for different people: Sometimes it is recurring and intense. Other times it may be fleeting.

There is a suicide sequence that can be interrupted, and those interruptions can be lifesaving. There are several strategies for preventing suicide that have been developed for various settings.  Generally, there are several components in these trainings that aim to separate a person’s thinking of suicide from their acting on suicidal thoughts.

Being aware of signs that something has changed in a person’s life that might make them susceptible to suicide is an important initial step. One sign that a person might be having thoughts of suicide would be indications that they already might be engaging in self-harming behaviors. Non-suicidal self-harm often can be a precursor to a suicide attempt. Reaching out to the person in a caring, respectful way is a next important step.  The third step is to gently challenge negative thoughts that often accompany or precede suicidal thoughts, and the final step is to encourage the person to seek help or to take some other positive action.

An example of this type of training strategy is the be NICE program that has been widely used and promoted by the Mental Health Foundation of West Michigan. This suicide prevention program uses the acronym “NICE” to represent intervention steps.  Here, “N” is for noticing the people in your environment, and “I” is for inviting a person into a conversation that creates a safe space to talk about their worries.  “C” is for challenging them to think of themselves as worthy of treatment, and “E” is for encouraging them to feel empowered to get help.

Suicide is preventable. Negative thoughts don’t have to lead to painful actions. Working together, we can make a difference!

Guest blog by SMART Recovery Facilitator Ted Perkins As a veteran of the film industry who’s also a SMART Recovery meeting facilitator, I enjoy finding films that tackle the subject of alcohol abuse.  I’ve rented every film there is, from dark and daring classics like LOST WEEKEND and DAYS OF WINE & ROSES, to contemporary […]

This was originally published in a 2018 National Association of Social Workers’ Alcohol, Tobacco and other Drug specialty section newsletter. Bill’s recent post on moral injury got me thinking about Sandra Bloom’s concept of moral safety, which got me thinking about this article.

Before the pandemic began, we frequently talked about the workforce moral, social, psychological, and physical safety hazards being universal and serious enough to warrant workplaces thinking about their safety obligations in the same way they are obliged to provide PPE (personal protective equipment) in hazardous situations.

It may not be as timely as it was a few years back, but it’s adjacent to Bill’s post. So… I decided to share it here.

“The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet. This sort of denial is no small matter. The way we deal with loss shapes our capacity to be present to life more than anything else. . . . .  We burn out not because we don’t care but because we don’t grieve. We burn out because we’ve allowed our hearts to become so filled with loss that we have no room left to care.” (p. 52)

Rachel Naomi Remen (1996)

By now, readers of this publication may have become numb to the near daily stories about the opioid crisis. The scale and persistence of the crisis is staggering. From 1999 to 2016, the death toll climbed to 351,612 (Felter, 2018) and is continuing to accelerate rapidly. The publication STAT asked 10 public health experts to forecast the death toll for the coming decade—the average of their predictions was 500,000 deaths (Blau, 2017).

The crisis is eclipsing every other issue in addiction services. Many angles have been covered, including the scale of the overdose crisis, the role of race in the public policy response, the impact on child welfare, the suffering of bereaved mothers and their advocacy activities, the role of harm reduction, and on and on.

An important, but neglected aspect of the crisis has been its effect on the addiction workforce. What kind of toll do these deaths take on social workers and other addiction professionals? How can workers protect themselves from burnout and vicarious trauma? How can agencies protect and support their workforce?

With so little written on the subject, workers and agencies are left to find their own way to maintain professional wellness while serving people with Opioid Use Disorders (OUD), their families and their communities.

As the clinical director of a community-based addiction treatment and recovery support program, these questions became important. While we had some knowledge of burnout, vicarious trauma, and self-care, these matters became salient in new ways. This article shares some of our experiences in the face of the crisis.

Our program primarily serves people with high severity SUDs and services are organized around long-term engagement and facilitating involvement in the recovering community. It is common for us to stay engaged with clients for 18 months and many of them provide support to current clients for years and decades. We also have dozens of members of the recovering community visiting facilities every day. Historically, this had been a powerful protective factor against burnout—every day, staff see living proof every day that their work is important and effective.

As the crisis escalated, we found ourselves convening increasingly frequent sentinel event meetings (A meeting to identify the root causes of an unanticipated event involving serious injury or death.) for overdoses. Of course, we spent considerable time seeking better ways to meet the needs of our clients and prevent overdoses. At the same time, we found ourselves increasingly concerned about the effect these losses were having on our staff. We reached out to other programs to hear about what they were seeing and how they were supporting their staff. To our surprise, they were aware and concerned about overdoses as a national issue, but they were not directly affected to the degree that we have been. This led to a surprising realization—that our long-term engagement with clients, their families and our connections in the recovering community (our historical protective factors) are risk factors for burnout and vicarious trauma in this crisis. It seems we hear about every overdose, while other programs often don’t learn about overdoses that occur once patients leave their programs. Further, our deep involvement in the community means that we become a source of support for people throughout the recovering community, many of whom have never been clients. (e.g. volunteers, family members, attendees of education events, community members that support and sponsor clients, etc.)

It took some reflection to notice this and consider how to respond, and it was not always a planned, purposeful process. We eventually gravitated toward framing it as a safety issue for staff, as described by Bloom (2013). Bloom is an expert on trauma-informed care and describes a “safety culture” as an essential element of any trauma-informed system. A safety culture addresses four interacting safety domains: physical, psychological, social and moral (2010) Attention of parallel process is also critical, as systems in sustained close contact tend to develop similar patterns of thoughts, feelings and behaviors (2012). This means it is not possible to maintain a safety culture for clients without also maintaining a safety culture for staff.

Moral safety is probably the least concrete of these domains but it was one of the first domains on our radar. We were concerned about the moral distress that staff might be experiencing, including:

• a gnawing sense that they’ve failed their clients, client’s families, colleagues, community and organization;
• a vague sense that they could have and should have done more;
• wondering if we were living up to our organizational and personal values;
• ideas about what could be done to prevent overdose, but a sense that their supervisor or organization won’t seriously consider it; or
• a sense (real or imagined) that interrogation of our practices would not be accepted.

We sought to ensure moral safety by making a concerted effort to ensure open dialogue in sentinel event meetings. We developed a preamble to the meetings, stating and restating that the purpose of the meeting was to learn and improve, not to assign blame. We also tried to convey a desire to discuss anything that seemed relevant to anyone at the table—that nothing is taboo. Administration took the lead by asking challenging questions about agency policy and whether the problems we face demand new practices and an evolution in organizational philosophy.

It didn’t take long for social and psychological safety issues to emerge. Many of these questions were unspoken, but just beneath the surface:

• I’m a professional, should I be feeling this grief?
• What if I cry? How will others respond? What will they think of me?
• I want to reach out to the family. Is that about my needs, or theirs? If I share that thought, will others see that as a boundary problem?
• I’m angry at the client. If I share that feeling, will others judge me?
• I’m noticing some things I think I failed to do. What will others think? Will they blame me?
• I don’t know if I can keep doing this work. Will others think I’m weak or not committed?
• Do I know what I’m doing? Do we know what we’re doing?

We addressed these safety issues by expanding the sentinel event preamble to create an expectation of grief and inviting everyone to share their thoughts and feelings as addiction professionals and as human beings who have experienced a loss. It also reminds us that this experience of loss is not a problem to be solved. As such, our response will be to listen generously and care for each other, rather than attempt to fix it.

Again, it was important that organizational leaders modeled sharing their thoughts and feelings, even if it made them feel vulnerable. This made it possible for others to do the same. Many of us imagined that this might open floodgates and consume considerable time and resources. This has not been the case. It appears the most important element is creating space for staff to share their reactions and support each other. The result is actually the opposite of what we feared. Staff spend less time ruminating, they are less anxious, and are more connected to each other in ways that support each other’s wellness and growth.

This has not just been about protecting the wellbeing of our staff. As a result, we’ve been able to work together to adapt policies, develop new practices and improve existing practices to prevent overdoses, improve recovery monitoring and follow-up, improve collaboration with other providers, improve informed-consent, and identify and provide support for others affected by the overdose.

We don’t profess to have all the answers and are very interested in hearing how other agencies are weathering this crisis. Please consider sharing your experience below, if we get enough responses, we’ll publish a follow-up.

References

Blau M. (2017). STAT forecast: Opioids could kill nearly 500,000 in U.S. in next decade. STAT. Retrieved 11 June 2018, from https://www.statnews.com/2017/06/27/opioid-deaths-forecast/

Bloom, S. L. (2010). Organizational Stress as a Barrier to Trauma‐Informed Service Delivery. In Becker, M. and Levin, B. A Public Health Perspective of Women’s Mental Health, New York: Springer (pp.295‐311).

Bloom, S. L. (2012) Building Resilient Workers and Organization: The Sanctuary Model of Organisational Change. In N. Tehrani (Ed.), Workplace Bullying: Symptoms and Solutions (pp. 260-277). London: Routledge.

Bloom, S. L., & Farragher, B. J. (2013). Restoring sanctuary: A new operating system for trauma-informed systems of care. Oxford: Oxford University Press.

Felter C. (2018). The U.S. Opioid Epidemic. Council on Foreign Relations. Retrieved 11 June 2018, from https://www.cfr.org/backgrounder/us-opioid-epidemic

Remen, R. N. (1996). Kitchen table wisdom: Stories that heal. New York: Riverhead Books.

Helping Others, Why Sponsoring is Important to Recovery

Step 12 of Alcoholics Anonymous says:

“Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.”

At its core, this step reminds you to live your life by the principles of AA, and to also encourage others like you in need to discover the promises of the program. As you go through your recovery journey and work the steps, you will build the foundation for your life in sobriety.

However, you probably didn’t get to Step 12 by yourself. No, many individuals in the rooms of Alcoholics Anonymous and/or Narcotics Anonymous probably helped you along your way. From sponsors, to home groups, to just plain peers and friends, the fellowship found in 12-Step Programs is focused on learning for oneself and going on to give back. As you have improved your life greatly, it is important that you help others who are suffering.

It can also be beneficial to your long-term sobriety and recovery. Here are some ways giving back and helping others can support your recovery:

Builds Self-Esteem

To put it simply, giving back never feels bad. To have the opportunity to listen to others and to genuinely relate to their strife like no one else can is a beautiful thing. Throughout your time in recovery, you have made mistakes, and you probably had to seek the counsel and wisdom of others to overcome obstacles or to bounce back when you’ve taken a wrong turn. As you learned, you built on your experience and knowledge along the way. Passing this on to someone else can instill a sense of leadership and mentorship within you, and can build your confidence in your own ability while helping someone else simultaneously.

Fills Idle Time

An enemy to those in recovery can often be boredom or idle time. No matter how far you are along in your recovery, boredom can lead to those familiar feelings of loneliness, isolation, and depression from days of active use. Helping others by way of volunteering with or sponsoring other individuals in recovery fills up your time and gives you new connections to grab coffee with, go to meetings with, or plan other events with to keep your schedule full.

Can Prevent Return to Use

When cravings or thoughts about returning to use present themselves, it can be difficult to think clearly. You might find yourself glamourizing your past at times, struggling to remember why active use was so detrimental to your life.

Serving and helping others who are suffering may serve as a reminder to yourself when you were in the throes of the earliest parts of your sobriety and recovery, further reinforcing the importance of your dedication to a 12-Step Program and to your own sobriety.

Gives You a Sense of Purpose

Finally, helping others can give you a sense of purpose. Knowing that someone else might lean on you for support in their journey to stay well can make you feel a sense of accountability, a reason to get out of bed in the morning when that reason can be difficult to find or feel.

Helping someone else can make you feel needed, it can make you feel important…because you are.

Remember, helping others doesn’t have a requirement. Just showing up, living your life by the 12 Steps, being honest and open, and meeting all of those around you with love are the greatest acts of helping others that you could possibly participate in.

***

For more information, resources, and encouragement, “like” the Fellowship Hall Facebook page and follow us on Instagram at @FellowshipHallNC.

About Fellowship Hall

Fellowship Hall is a 99-bed, private, not-for-profit alcohol and drug treatment center located on 120 tranquil acres in Greensboro, N.C. We provide treatment and evidence-based programs built upon the Twelve-Step model of recovery. We have been accredited by The Joint Commission since 1974 as a specialty hospital and are a member of the National Association of Addiction Treatment Providers. We are committed to providing exceptional, compassionate care to every individual we serve.

I fucking HATE being honest with myself when it comes to shit that really matters.

That’s how it started; the most difficult email I’ve ever written.

I remember having to squint through endless tears to even see well enough to type out the words. Perhaps the memory is so vivid because it was just two weeks ago that I forced myself to write it. I had spoken to many women about my situation, but knew Julie, the founder of this blog, had experienced something very similar. I wanted to share my realization with her because I knew she would not only understand, but also hold me accountable.

I wrote:

I was really in deep denial about my motives for this custody modification. I truly believed I was only doing this for my daughter, but now can see that was bullshit. It was a decision based in self…

Earlier that day, I’d finally admitted to myself the real reason I had been so terribly consumed with constant feelings of guilt and shame.

The admission was the hardest truth I’ve ever had to face about myself.

My daughter is five and has lived with her father, full-time, since I checked myself into rehab for 28 days in October of 2012. Before that, I was a single mother, “living” in active alcoholism and putting her life and safety at risk daily. After my sister kicked us out because I couldn’t stay sober, I was served with custody papers. I was mortified. I had no clue what to do. I had no job, no home, no money, a DUI on record (with my one-year-old in the backseat), and I was STILL drinking…

I knew I was in no position to win a custody battle.

I consulted with my lawyer, decided to sign over temporary custody, and go to rehab.

If you had asked me then, I would have told you I did it out of a mother’s selfless love for her child. You probably would’ve called me “strong” or “brave,” but the truth is, I was thinking only of myself. I was scared. I wanted to run away and hide—and that’s exactly what I did for 28 days. I didn’t want treatment; I wanted an escape. It was completely and utterly selfish.

I was released from rehab on Halloween, and was drinking daily again by early December while my ex maintained custody. I attended outpatient treatment while still steadily drinking, and in February of 2013, I attempted suicide. That landed me in a mental institution for a week. I got out and carried right on drinking.

I carried around an extreme hatred for my daughter’s father for drastically reducing the time I was allowed to see my daughter. I denied my part completely. I was constantly demanding more visitation time, and truly believed I was entitled to and deserved it.

Did I mention my selfishness?

It took nearly dying on my bathroom floor to reach my bottom with alcohol. My sobriety date is December 23, 2013. In July, 2014, seven months sober, I decided I was ready to regain full physical custody of what was rightfully “mine”. I had earned it! That past October, me and my big-bad ten months of sobriety retained the services of the best family law attorney in town.

And then I went mad.

Recovery took a backseat to my custody case, and I became absolutely obsessed with “getting my child back.” I stopped doing pretty much everything I knew was necessary to stay sober and lost all perspective. I began an awful downward spiral. I became more selfish and self-righteous than ever. The words I spoke and texted to my ex during this period were accusatory, mean, and intrusive. They could have cost me my relationship with my little girl. I could not see any of that. In my mind, I was absolutely justified. I was doing what was right for my daughter.

Thank God for other women in recovery who had the balls to call bullshit, dish out some tough love, and be brutally honest with me. Thank God I reached out. I hated what they were saying, but after enough people said the same thing—after an abundance of prayer for clarity, self-awareness, and strength to be honest with myself—I was finally able to see the harsh reality. They were absolutely right. I was in NO position to have my daughter back. She was much better off where she was.

I knew what I had to do.

That’s not the kind of mother I want to be. And that’s not the kind of “love” my child deserves.

I confessed in the email. And I meant it.

It is difficult to explain how much finally being able to do this means to me. So many times I have told myself to just hold on…just hang in there until December. Maybe it’s sick, but I drew a lot of strength and hope from that…

I finished the email around 10:30 PM, and just sat staring at it. I knew clicking send could quite literally be the only way I’d ever follow through with my decision to do what was right. I knew I would receive the support, encouragement, and reassurance I so desperately needed, and I would be held accountable—to take all necessary action to prevent further harm.

Forty minutes later I committed and sent Julie the email.

This was a first for me. Not only had I been able to finally see the truth about myself, I was actually able to use that knowledge to fix a mistake and prevent harm to others. I was able to take my wants out of the equation and do what was right for my daughter. Not easy, but right.

The next morning I headed to my lawyer’s office as soon as their doors opened to drop the lawsuit. I went to work and forced myself to show up for my regular day. By 7:30 PM, I was curled up in fetal position on my bedroom floor. I was in full-fledged grief over the loss of the fantasy “future” I’d held onto for so long.

The following week was pure hell. Thank God for sober alcoholics; people willing to love me through darkness, until I can see the light.

Julie’s response to my email that night included, “Surrender doesn’t have to mean giving up. It can mean the difference between acceptance and change, and a lifetime of bashing our heads against a wall trying to move it. I love you so much. You are stronger than you know.”

Truer words have never been spoken.

I’ve heard that pain is the touchstone of spiritual progress, and that emotional turmoil must come before serenity. Today, I believe these claims to be 100% true. This experience has allowed me freedom, relief, and the unshakable faith that, no matter what, everything will be ok. I finally know in my heart and soul what the selfless love of a mother for her child feels like.

And it’s absolutely beautiful.

Thank you, God—for the blessings that follow pain- for hearing my pleas—and for placing amazing sober alcoholics in my life.

This post was submitted by Raegan.

Roxana A. Hernandez, MPH, Shayla C. Anderson, MPH, CHES, Mary Roary, PhD, MBA - Oficina de Equidad en Salud Mental (OBHE)

The term ‘recovery’ has come under a harsh microscope recently in academic and clinical settings. It has been interrogated, scrutinised, criticised, bloated and dissected. Reconstructed like Frankenstein’s monster, recovery is now seen to be a floating signifier, made of disparate bits that don’t necessarily fit comfortably together – a stumbling, lumbering construct. Is recovery becoming of little use to anyone and, quite possibly becoming a stigmatising and dangerous term?

Like Mary Shelley’s monster, you might expect recovery to be sitting bruised and battered now in the corner, bolted head in sutured hands, saying, ‘I shall collect my funeral pile and consume to ashes this miserable frame’.

But that’s not what’s going on. Recovery is not dead. It’s not pushing up the daisies.  If we think that, we’re looking in the wrong direction. Turning our gaze away, the black and white flicker of horror movie fades and is replaced by widescreen, Technicolor certainty. It turns out that recovery remains real, resilient and very relevant.

Glorious Gatherings

Today and tonight in thousands of mutual aid groups, in person and online, in 12-step mutual aid fellowships, in SMART and LifeRing, Women for Sobriety meetings and other gatherings, people who value recovery as part of their identity will gather to support each other and bolster their chances of success.  There is convincing evidence that, in terms of positive outcomes, their shared efforts do at least as well as, or better than, other professional established psychological interventions.

Many thousands more will connect in a host of ways with lived experience recovery organisations (LEROs) outside of mutual aid. Even in a wee country like Scotland we have scores of these, where individual and group recovery identity are not only core to meaning and purpose, but drivers of action. Fuelled by passion and altruism, members want to identify with others and support their peers to make gains across a range of life domains. Oddly, there is a dearth of academic interest in this remarkable phenomenon.

Recovery advocacy

Aside from these self-supporting communities of recovery, something else is happening. Those with lived experience of addiction and recovery who have not had their needs and goals met in our wider treatment and support systems are finding their voices and calling for change. A new recovery advocacy movement is emerging. Reacting to the patriarchal and out of kilter power relationships endured in some treatment settings, activists strive for something better. Recovery in this domain is visible, underpins the urgency of advocates and is a powerful catalyst for reform.

The proof of the pudding

Despite the criticisms of recovery, having a recovery identity has been consistently associated with improved outcomes in the scientific literature. Frings, Wood and Albery say in their paper published last month, ‘Recently, social identities associated with recovery have been linked with better recovery related outcomes such as treatment retention, abstinence and confidence in one’s ability to maintain treatment goals such as abstinence and harm reduction’.

In general, higher levels of recovery related identity, or increased differentiation between addiction and recovery related identities, are associated with positive outcomes.

Frings et al, 2021

Say Frings and colleagues, ‘Alongside AA, these effects have been observed amongst varied populations, including other group-based treatments such as SMART, and in both in-patient, out-patient and peer support settings.’

Helping or meddling?

Partly because of these effects, efforts to reconstruct the concept of recovery need to be carefully monitored. There are risks. Recovery is already a broad church, but in widening the doors further and further, we risk making the term meaningless. In addition, while dialogue is welcome, the motivations for the debate are not always clear or good. Some of us working in addiction treatment or research are threatened by people recovering in ‘non-medical’ ways.

At a conference I attended, a presenting medical colleague said, ‘If my patient goes from using crack cocaine seven days a week to six days a week, that’s recovery’. I’d say that’s progress, but recovery is not primarily about the removal of harms, it’s about the accrual of positives. 

I suspect that the debates that are currently happening over what recovery means seem of little relevance to wider recovery communities. Their members are not in a state of angst over the definition; they hold the identity and use it to further their own recovery and that of others. They have used the term for decades and are fluent in what it means in personal, functional and social realms. They know what it means. They are living it.

Recovery curators and crusaders

Recovering people are held up by hope, not distracted by definitions, yet their lived experience and credentials as experts by experience must surely be systematically included in this discussion. Recovering people do not own recovery, but for a very long time they have been recovery’s progenitors, curators, caretakers and crusaders. That hasn’t changed. It absolutely does need to be recognised.

Academic reframing of recovery based on data and sundered from lived and living experience risks creating a creature that everyone ends up unhappy with, and ultimately is unhappy in itself. Recovery is not dead. It’s alive, it’s alive! Not only is it alive, it is thriving and spreading with healing in its wake. Let’s acknowledge, value, and build on that and have people with a recovery identity included at the heart of the debate.

Continue the discussion on Twitter: @DocDavidM

Picture credit: Shutterstock PatriciaPix under license

By Roxana A. Hernandez, MPH, Shayla C. Anderson, MPH, CHES, Mary Roary, PhD, MBA - Office of Behavioral Health Equity

NADCP Launches Self-Paced E-Learning Center

Learn the critical foundations of treatment courts online!

Treatment courts work best when practitioners are well-versed in the foundations of effective programs. NADCP’s new online learning hub provides self-paced training courses designed to be engaging and informative to practitioners at any experience level.

All courses offered in the NADCP E-Learning Center are FREE and led by renowned experts in the treatment court field. Courses available now include:

• Essential Elements of Treatment Courts
• Medication-Assisted Treatment
• Veteran Mentor Coordinator
• Trauma Awareness: Critical Information for Veterans Treatment Court Teams

New courses will be added throughout 2021 and beyond. Get started expanding your treatment court knowledge today!

Explore E-Learning

Featured Course: Essential Elements of Treatment Courts

Are you looking for a new team member orientation? Updated from the popular Essential Elements of Adult Drug Courts online course, Essential Elements of Treatment Courts provides foundational training using the most up-to-date science and best practices. In addition, the new and improved Essential Elements includes modules specific to veterans treatment courts.  

The course is designed to educate new team members, as well as refresh experienced practitioners. Don’t miss this course for self-paced modules with experts covering:

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