Disclaimer:  nothing in this post should be taken or held as clinical instruction, clinical supervision, or advisory concerning patient care. 

Spiritual care is a clinical discipline.

• Spiritual care can be a clinical team member in the separate settings for physical health problems, psychiatric problems, or substance use disorders. 
• And spiritual care can be a member of an interdisciplinary team treating co-occurring conditions. 

The simple proof of the reality of this is seen daily in the routine work of systems that include spiritual care in their interdisciplinary process.  But there is one example I would like to show you, and this example might reveal a way to better utilize spiritual care even where it already exists and is integrated.

Imagine a treatment team in a residential addiction treatment program serving those with co-occurring psychiatric conditions.  And imagine that the treatment team consists of primary health clinicians, nurses, addiction counselors, clinical psychology, spiritual care, and a physician specializing in psychiatry.  And the team is reviewing how each patient is doing. 

The team leader asks, “How is (name of patient) doing?”

The assigned counselor says, “Good.”

After a moment, a nurse calmly states, “Not good.”

The team leader says, “Oh?”, as if to ask for more information.

The nurse says, “They’re not taking their medication for their bipolar disorder.”

To which the team leader then asks aloud to the team, “How do we understand this?”

The nurse adds, “They don’t believe in it.  Neither do their parents.”

After waiting and hearing no other input, the team leader then asks, “What’s our plan?” 

And at that point a pause in the team process ensues and an extended silence is held.  The silence is finally broken by the Spiritual Care team member who speaks directly to the prescribing psychiatrist, saying “Here’s the open door…”

And spiritual care then provides person-specific coaching to the prescriber in understanding the basic cosmology of the patient in real-world matters.  And quickly coaches the team and its members in identification and use of an open door in the patient’s world view. 

And we now return to our scenario.

Prescribing psychiatrist:  “Great.  Thanks.  I’ll be speaking with the patient and the family.” 

Team leader:  “Any other inputs to our plan?”

And hearing no other needed inputs to the plan, the meeting moves on.

In this way, spiritual care contributed to patient adherence to the plan.

Some systems limit spiritual care to the support of patients and family members in times of crisis and end-of-life matters. 

In doing so the system seems to function as if the basic bio-psycho-social-spiritual nature of all people is not understood.  And that the simple value of spiritual care in all care is not understood. 

Rather, it’s almost as if the “inter-disciplinary treatment team” is not about the person as a person, but is rather:

• built by clinicians centered in their clinical identities
• all about the mix of clinical disciplines that are present
• centered in the disorder.

It’s almost as if “inter-disciplinary” does not start with what a human being is in the first place (a bio-psycho-social-spiritual being).  And thus, the team is not formed in a way to include those 4 components of a person. 

If any of this is accurate, does it matter, and is it practical? 

In the industrialized medicine environment of today:

• there is so much attention paid to the “work relative value unit” of each clinician’s every working minute 
• there is great attention paid to squeezing out maximal precision and accuracy
• there is great strain to find what is “effective, efficient, necessary, and sufficient.”

And that environment of today leaves me amazed that:

• patient adherence to any plan for any condition is not improved by applying spiritual care from the bottom up in routine care
• spiritual care is not applied to understanding every patient with every kind of condition (especially chronic conditions)
• systems often believe that the way to improve patient adherence is by adding a top-down organization-wide mandate that everyone in every discipline across the system must learn and implement some aspects of motivational interviewing and doing that will “work”.

Suggested Reading

Goodheart, C. D. & Lansing, M. H.  (1997).  Treating People with Chronic Disease:  A Psychological Guide.  American Psychological Association.

Recovery journeys can be long and involve several attempts in order for people to resolve their problems. Treatment can be part of this for many, but there are multiple factors outside of treatment that also influence outcomes. One of these is housing.

Homeless people with substance use disorders have higher risks, exacerbated further if there are criminal justice issues. Recovery housing can provide a safe environment, support for abstinence and link people into education and employment opportunities. If houses are self-run, costs are low.

In their paper^[1] on sober living houses, Jennifer David and Jake Berman point out that it’s only relatively recently that researchers have begun to accumulate evidence on the efficacy of such residences. I agree; we have some black holes in our research on substance use disorders and recovery. There are a few of these residences in the Scotland, but little is known about them beyond experience and evaluations accumulated locally.

By using the narratives of residents, the researchers wanted to explore the experience of being in a sober living house from the perspective of the people in recovery. They interviewed 21 people (from the American Midwest) – so a small study, but the point was to find detail and nuance.

Out of this came four themes. 

1. The role of early trauma
2. The strengths of sober living
3. The challenges of sober living
4. Keys to sobriety

The role of early trauma

Residents related the impact of trauma and how it shaped their journey into addiction. This took many forms and the researchers note how abuse of drugs and alcohol were identified as both the cause and consequence of trauma. During the interviews, the salience of these experiences was apparent, as was their emotional impact on the respondents in recovery.

The strengths of sober living

The study participants were ‘overwhelmingly’ positive about ‘the impact of sober living on their lives and on their recovery up to this point’.

Sober living opened my eyes that others have the same struggle. I learned to open up. I’ve made friends for life.

Participant

Safety, shared goals and vision, unity and camaraderie were all found to appeal to the residents as advantages of sober living. Stigma and shame became less powerful and the group looked out for each other.

Everyone sticks together. If one of the sheep starts straying away the herd goes and rounds him back with the rest.

Participant

Mutual accountability was ‘an important driver of behaviour’ with a sense of responsibility for others being highlighted as key. This struck me as being very similar to living in a therapeutic community model of rehab. The principles are comparable.

The challenges of sober living

Those who were not ready to put the work in (in recovery terms) were felt to have a detrimental effect on others. The threat of relapse was a ‘critical challenge’. When others relapsed there was a vicarious suffering as the bonds that develop in a communal living houses can run deep. Dealing with death was also spotlighted as a difficult challenge. 

Some saw the sober house as ‘an artificial environment that protects residents from the real world’, and others saw it as ‘a transition rather than a protection’.

Keys to sobriety

The importance and value of attending mutual aid (AA) was mentioned in all the interviews, as was changing social networks and taking advantage ‘of the protection of sober living.

Reflections

The researchers identify the tension between the emergent benefits of sober living, versus the potential risk that being in such an environment may hold some people back from learning skills in the community. They call for more research on such transitions. They also emphasise the advantages reported by the residents of being members of AA. Reflecting on their findings on trauma in the interviewees, they speculate on whether there may be a ‘unique practice niche’ that deals with early trauma through a more targeted therapeutic approach in addition to being mutual aid group members. They also suggest we need to know more about ‘vicarious relapse’ which can be traumatic to others as well as the person who has relapsed.

Although a small study, the findings ring true from my experience. In the service I work in, our Oxford recovery house has evaluated well. Having said that, this whole area is very under-developed, with little in the way of recovery housing being commissioned (or even known about), though there is evidence that this is changing a bit for the better. 

As stronger and stronger evidence emerges of the value of community and connection as drivers of recovery, I hope we see more of this kind of practice and research in the UK. It’s certainly needed.

Continue the discussion on Twitter: @DocDavidM

Photocredit: istockphoto sundaemorning under license

^[1] Jennifer Davis & Jake Berman (2022) Living in a Sober Living House: Conversations with Residents, Substance Use & Misuse, 57:3, 402-408.

“Nothing happens. Nobody comes, nobody goes. It’s awful.” ― Samuel Beckett

We have never had a care system that provides people who need help with addiction the resources they need to heal. For me, one of the most poignant lessons in how hard it is to get people what they need to heal happened with PA Act 106 of 1989. Other states had done similar laws before we got around to putting one on the books here in PA. This occurred because some people decided to stop waiting. Once passed, the insurance industry here in PA largely ignored the law for many years. A lot of people died. I knew some of those who did. Families testified in front of our legislature and went to court to get the insurance industry to follow the law in respect to residential treatment. It went all the way to the State Supreme Court, who upheld a lower court decision affirming the law in 2009. It took action, not waiting.

For those who worked on this one facet of the law followed, it was a Sisyphean process measured in decades. It took a generation to get at least 30 days of care for the people whose insurance plans are covered by this law, which does not specify a maximum number of days. Neverminded that the NIDA has long noted that 90 days is the minimum dose of effective care for an average SUD. Almost nobody gets that with private insurance in America! Other elements of the law, including mandated family counseling and intervention services do not appear to be adhered to as I sit here today and write this. 33 years later, and we are still waiting for Godot. Even as our loved ones die. It is an outrage. Can you imagine if this was some other condition impacting one in three families and having this happen?

We keep waiting. As the Beckett quote above notes, nobody comes, nobody goes, it is awful. Seven years ago, I was part of a process in PA looking at barriers to SUD care that occurred as a result of a bipartisan effort to examine access to addiction treatment through health plans and other resources under the PA House Resolution 590 of 2015. We did just that, holding hearings across the state and listening to the community. As a taskforce, we recommended in this report that “health plans provided by employers to cover substance use disorder treatment, should identify that they are in fact subject to Act 106 on an individual’s insurance card to assist consumers and providers in efficiently accessing those services. The information provided to Pennsylvanians covered by Act 106 plans should delineate all services available including family and intervention services.” People cannot access a benefit that they do not know they have.

Yet, It is still not done seven year later; in the midst of the largest addiction epidemic we have ever faced, we cannot seem to get lifesaving information on the back of our insurance cards. Thousands of lives and tens of million dollars of public resources could have been saved if families knew that their insurance companies were legally required to offer these services by seeing it on the back of their insurance cards. Somehow, we miss such huge and simple opportunities to save lives and resources in ways that end up being measured so tragically. Our families deserve better.

Somehow we still do not have this life saving information on Pennsylvania insurance cards. I think it belongs there! I suspect a lot of families struggling with an addicted family member would agree if they even knew they were mandated under many insurance plans by this law. Family counseling and intervention services can get people into care earlier and help in the recovery process. The authors of Act 106 knew that when they wrote it into the law so many years ago. Let’s make sure every Pennsylvanian family who is eligible knows about this benefit. Those who have died no longer have a voice, they are counting on us. Let’s get it done in their names!

I do see a sliver of light on the federal side, perhaps we may not have to wait quite so long for our federal law to be enforced as in our state. Under the leadership of US Labor Secretary Marty Walsh, the highest government official in US history to be a person in open addiction recovery, we have finally focused on enforcing our national parity law with some vigor. Three weeks ago the US Department of Labor released this report to Congress. This is the most significant effort to enforce this federal law in the 14 years that the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) has been on the books. We can help by reporting concerns with our benefits by contacting the US Department of Labor about parity compliance at askebsa.dol.gov or by calling 1-866-444-3272.

What the report to Congress found was sadly predictable for those of us in the trenches. “Every plan and issuer that the EBSA (Employee Benefits Security Administration) sent a request to initially responded with insufficient information. “About one-third of those requests resulted in initial determinations of noncompliance.” This translates to thousands of families not getting the care that is required by federal law. According to the report, most of the companies audited had not even considered if they were in compliance with this 2008 law until they were audited.  

Some of the report points that stuck out to me:

• Too often, plans had not completed or started a comparative analysis until after EBSA requested one. In some cases, the plans had imposed barriers for years without analyzing compliance with the law.
• Approximately 40% of plans and issuers responded to EBSA’s initial request letter with a request for an extension of time to respond. This suggests that had not bothered to look to see if their plans were in compliance with the law.
• One of the entities reviewed had impermissible limitations in the form of MH/SUD continued-stay criteria requiring demonstrable progress for continued care coverage, as well as MH/SUD discharge criteria resulting in a loss of coverage if there was no significant improvement in their care or if they left against medical advice.
• A large, self-funded plan, with 7,600 participants, specifically excluded methadone and naltrexone as treatment.

As I was absorbing this report to Congress, I ran across this article on Vox news: Her son died after insurers resisted covering drug rehab. It tells the all too familiar story of a mother, Maureen O’Reilly who thought she had good insurance coverage for her son, Ed Fahy. He kept being denied the proper level of care he needed. He ended up getting stuck in the “Florida Shuffle” of patient brokering. According to the article, independent reviews found he did not get the right level of care. He died of a cocaine and fentanyl overdose in a Florida recovery house. The article notes that her insurance companies had run into trouble with the parity act discussed above. Mr. Fahy ran out of time. She is now suing the insurers after a host of denied care. Hopefully it will help save someone else’s son or daughter.

So many of us in this field see these types of stories year in and year out. Ignoring laws and denying care is a cost of doing business for far too many of these companies. Here in PA, perhaps someday we will get the insurance cards that identify that the insured are protected by a law passed when I was just 24 years old. It should have been easy, but it seems not. We should not continue to wait in the trenches for Godot. It is a time of action.

The only way that this story ends differently than Beckett’s play is if we stop waiting for Godot.  

Joseph Simon is grateful every day in his journey to recovery, for SMART and the tools to help him make the best healthy choices and live his Life Beyond Addiction.

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SMART Recovery welcomes comments on our blog posts—we enjoy hearing from you! In the interest of maintaining a respectful and safe community atmosphere, we ask that you adhere to the following guidelines when making or responding to others’ comments, regardless of your point of view. Thank you.

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Angie Chaplin feels a sense of pride every time she facilitates a SMART Recovery meeting. Pride in knowing that the tools and resources that have helped in her recovery are also helping others in theirs.

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Video storytelling is a powerful tool in recovery, and we are proud to share our SMART Recovery content free-of-charge, available anywhere, on any device. Our videos hope to inform, entertain, and inspire anyone in the recovery community.

Subscribe to our YouTube channel and be notified every time we release a new video.

PLEASE NOTE BEFORE YOU COMMENT:

SMART Recovery welcomes comments on our blog posts—we enjoy hearing from you! In the interest of maintaining a respectful and safe community atmosphere, we ask that you adhere to the following guidelines when making or responding to others’ comments, regardless of your point of view. Thank you.

• Be kind in tone and intent.
• Be respectful in how you respond to opinions that are different than your own.
• Be brief and limit your comment to a maximum of 500 words.
• Be careful not to mention specific drug names.
• Be succinct in your descriptions, graphic details are not necessary.
• Be focused on the content of the blog post itself.

If you are interested in addiction recovery support, we encourage you to visit the SMART Recovery website.

IMPORTANT NOTE:

If you or someone you love is in great distress and considering self-harm, please call 911 for immediate help, or reach out to The National Suicide Prevention Hotline @800-273-8255, https://suicidepreventionlifeline.org/

We look forward to you joining the conversation!

*SMART Recovery reserves the right to not publish comments we consider outside our guidelines.*

               As we enter the third year of battling the COVID pandemic and having to readjust our lives, a lot of us may be starting (or continuing) to get agitated, stressed, and anxious. We may begin feeling like things will never get better and that we should just give up. It’s certainly not easy to reframe our entire way of life to navigate a pandemic while in recovery, especially when so much of a successful recovery is owed to constant connection and communication with support networks around us. However, while difficult, it is not impossible to be strong and healthy in your recovery no matter the world’s circumstances.

We can begin to fight our negative thoughts and desires to return to use by continuing to prioritize staying connected to others, whether virtually or in-person – but we also need to realize the effect our personal ways of thinking can either harm or help us on our journey to recovery. With constant work taking place both outside and within ourselves, recovery becomes much easier to manage.

Practice Acceptance:

“Acceptance is the answer to all my problems today. When I am disturbed, it is because I find some person, place, thing, or situation—some fact of my life—unacceptable to me, and I can find no serenity until I accept that person, place, thing, or situation as being exactly the way it is supposed to be at this moment.” – pg 417 of the Big Book

The oft spoken phrase around the rooms is “practice acceptance”. While it may sound trite, it is the key to serenity. Pushing against our reality, refusing to accept our reality, this is the source of much friction and unhappiness. However, that pushing, and that refusal is what comes most naturally to an addict or alcoholic.  We must constantly remind ourselves of acceptance, and if necessary, repeat the phrase, “Acceptance is the answer to all my problems today”.

Prioritize Connection:

In today’s world, it has become increasingly difficult to stay connected and avoid feelings of isolation. This has led to relapse and overdose for many of those in recovery who slowly begin to feel anxious, lonely, and unsupported over time, slipping back into familiar patterns of using to cope. We may recognize the importance of attending meetings and staying in touch with a sponsor, but when many meetings are happening online, it is easy to feel “Zoom fatigue” and simply stop attempting rather than adjusting and making virtual connection work for us.

It takes a little extra work on our part, but we must be willing to challenge our beliefs about online meetings. Continue participating and sharing in your meetings, even if they must be via computer screen for the time being. The meeting space is not only for you – you must be there to support the others in your recovery network.

Avoid Complacency:

When someone in recovery leaves treatment, they can sometimes find themselves on a “pink cloud” of euphoria: proud of what they have achieved, connected to a support network with a sponsor and daily meetings, and strong in their sobriety. After a while, some of us begin to feel that maybe we have our recovery under control. We might think we’ve achieved ‘fully recovered’ status and do not need to continue dedicating as much time to our recovery.

Coupled with the collective anxiety and isolation felt during a pandemic, it can become easy and comforting to convince ourselves that it would even be okay if we had a drink or two, after being in recovery for several months or years. However, one can never truly be ‘fully recovered’ – recovery is a constant process, and becoming overconfident leads to complacency, which can lead to relapse.

“If nothing changes, nothing changes”:

In the popular A.A. book As Bill Sees It, written by Bill Wilson, the argument is made that successful recovery is simply not possible unless we are willing to undergo a personality change. Wilson writes: “anyone who knows the alcoholic personality by firsthand contact knows that no true alky ever stops drinking permanently without undergoing a profound personality change.”

This means understanding that having supportive people around you is not enough – there needs to be a change inside of yourself as well. Wilson continues: “We thought “conditions” drove us to drink, and when we tried to correct these conditions and found that we couldn’t do so to our entire satisfaction, our drinking went out of hand, and we became alcoholics. It never occurred to us that we needed to change ourselves to meet conditions, whatever they were.”

Outside conditions may produce triggers and negative feelings, but we have to be willing to work to change our responses to these conditions, because remaining stagnant and leaving our mental health unchecked is an easy gateway into relapse.

In a pandemic society, the traditional post-treatment advice – go to meetings, keep in touch with your sponsor, give back to your community with service work – may sound harder to follow. However, there is always a way to keep pushing forward and make recovery work for you, no matter your outside circumstances. Resist becoming complacent in your recovery. Keep recovery at the forefront of your mind and know when to ask for help. Show up for those in your network that are experiencing the same struggles as you. Together, we will be able to make the ‘new normal’ work and ensure the successful recovery of us and those we care about.

***

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

About Fellowship Hall

For 50 years, Fellowship Hall has been saving lives. We are 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.

SMART Recovery is excited to announce that the SMART Recovery Mobile App is now available for free download for Apple and Android phones everywhere.

Our designers, programmers, coders and UX team integrated everything they learned from our volunteers and beta testers to create a mobile app that’s easy to use by anyone, at any stage of their SMART Recovery journey.

After you download it, you’ll be met with a list of inspirational quotes that motivate and inspire. Then you can find meetings wherever and whenever they suit you. Add them to your calendar, click on zoom links, join meetings with just a tap; everything happens right there on your phone. 

No more looking for content and toolkit exercises through websites, YouTube pages, or multiple podcast platforms. All of SMART’s content is now surfaced and viewable in one place through the app – with easy-to-navigate play buttons, crisp layouts, and enterprise-level playback and buffering speeds.

In a world where 90% of the apps on your phone rarely even get opened, we believe we’ve designed an app that you’ll want to open and use every day. As time goes on, we’ll make improvements, issue updates, and add new features, all with an eye toward giving our SMART Recovery community the highest quality mobile app experience possible.

Ready to go? Just click on one of the buttons below to download the app and get started. Don’t forget to tell your friends and colleagues in recovery about the app so they can get started too.

The SMART Recovery Mobile App is an important milestone in our continued efforts to provide the highest quality services and accessibility in the digital age.

PLEASE NOTE BEFORE YOU COMMENT:

SMART Recovery welcomes comments on our blog posts—we enjoy hearing from you! In the interest of maintaining a respectful and safe community atmosphere, we ask that you adhere to the following guidelines when making or responding to others’ comments, regardless of your point of view. Thank you.

• Be kind in tone and intent.
• Be respectful in how you respond to opinions that are different than your own.
• Be brief and limit your comment to a maximum of 500 words.
• Be careful not to mention specific drug names.
• Be succinct in your descriptions, graphic details are not necessary.
• Be focused on the content of the blog post itself.

If you are interested in addiction recovery support, we encourage you to visit the SMART Recovery website.

IMPORTANT NOTE:

If you or someone you love is in great distress and considering self-harm, please call 911 for immediate help, or reach out to The National Suicide Prevention Hotline @ 800-273-8255, https://suicidepreventionlifeline.org/

We look forward to you joining the conversation!

*SMART Recovery reserves the right to not publish comments we consider outside our guidelines.*

Dr. Ashley Grinonneau-Denton is the founder and co-owner of Ohio Center for Relationship and Sexual Health in Cleveland, Ohio. She has a doctorate in marriage and family therapy and is a certified sex therapist.  

In this podcast, Dr. Ashley talks about:

• Being one of only 16 people certified in sex therapy in Ohio  
• The social and cultural aspects of Valentine’s Day 
• Not marginalizing sexual background of clients 
• Creating a sex positive environment   
• Behaviors involved with couples and their sexual health  
• Looking at all sides of an issue to see the client’s whole self 
• Her soapbox about labels  
• Getting to a healthy sexual life 
• How the intimacy conversation is changing with each new generation  
• The form and function in music and pop culture  
• Conducting virtual consultations (even before the pandemic)  
• Seeing co-occurring behaviors in clients that are making it harder for them to change 

Additional resources:

Click here to find all of SMART Recovery’s podcasts

PLEASE NOTE BEFORE YOU COMMENT:

SMART Recovery welcomes comments on our blog posts—we enjoy hearing from you! In the interest of maintaining a respectful and safe community atmosphere, we ask that you adhere to the following guidelines when making or responding to others’ comments, regardless of your point of view. Thank you.

• Be kind in tone and intent.
• Be respectful in how you respond to opinions that are different than your own.
• Be brief and limit your comment to a maximum of 500 words.
• Be careful not to mention specific drug names.
• Be succinct in your descriptions, graphic details are not necessary.
• Be focused on the content of the blog post itself.

If you are interested in addiction recovery support, we encourage you to visit the SMART Recovery website.

IMPORTANT NOTE:

If you or someone you love is in great distress and considering self-harm, please call 911 for immediate help, or reach out to The National Suicide Prevention Hotline @ 800-273-8255, https://suicidepreventionlifeline.org/

We look forward to you joining the conversation!

*SMART Recovery reserves the right to not publish comments we consider outside our guidelines.*

Therapeutic nihilism

“None of them will ever get better”, the addiction doctor said to me of her patients, “As soon as you accept that, this job gets easier.”

This caution was given to me in a packed MAT (medication assisted treatment) clinic during my visit to a different city from the one I work in now. This was many years ago and I was attempting to get an understanding of how their services worked. I don’t know exactly what was going on for that doctor, but it wasn’t good. (I surmise burnout, systemic issues, lack of resources and little experience of seeing recovery happen).

Admittedly, a part of me recognised an echo of the sentiment. I’d worked for many years in inner-city general practice and back then, to be honest, I did not hold out as much hope as I might have for my patients who had serious substance-use disorders. After all, the evidence in front of my eyes suggested intractable problems. All of that changed when I began to connect with people in recovery and started to understand the factors that promote it.

Palliation or something better?

I don’t think my colleague’s perspective was (or is now) the predominant view, but by no means is it unique either. An addiction specialist has fairly recently urged us to accept that some ‘do not have the luxury of recovery’, seeing it as ‘a convenient concept, but an unobtainable reality for many people who use drugs’, who are really in ‘palliative care’. I struggle with this perspective. Some would say it’s realistic. I think it’s pessimistic.

Of course, there are people whose chances of resolving their problems and going on to achieve their goals remain low despite support, but who gets to choose who gets ‘palliation’ and who gets something better? We don’t start out with palliation as a goal of cancer treatment; why should addiction treatment be any different? If our treatment offer is focussed on palliation and only the few – the worthy and fortunate – get to go further, we are letting people down badly. Professor David Best has pointed out that this sort of therapeutic pessimism is a major barrier to the effective implementation of a recovery model.

My assessment in my visit to that MAT clinic was that I could not work in a service where views like that, for whatever reason, had become acceptable and explicit. However, rather than be defeated, I found instead that this provoked an energy within me to try to make a difference.  That one incident, perhaps more than anything else (save my own experience of treatment and recovery), drove me to set up the service I now work in.

The clinical fallacy

While therapeutic pessimism undoubtedly exists, I am buoyed up by my past experience of working in teams in community settings where expectation of what is possible is much higher. I can think of many colleagues who set the bar high every day in their work, even when they are working in demanding circumstances.

While despairing and cynical views are not the norm, it is apparent though, for whatever reason, that some working in the field don’t hold out as much hope as they might. I’ve heard enough reports from individuals who feel they were discouraged or blocked from moving on towards their goals to know that it happens too often. 

This nihilistic view of the potential of individuals to resolve their problems and move towards their goals can be explained to some degree by something Michael Gossop called ‘the clinical fallacy’.  This is the situation in which the clinician sees all of the challenging presentations and relapses, while the people who resolve their problems move out of treatment and are not seen again.

The clinician is confronted continually by their failures and denied the benefit of seeing their successes.

Michael Gossop, 2007

This may explain findings from elsewhere which show that we professionals working with people who have substance use disorders consistently underestimate what our clients/patients are capable of. This is important. The clients of clinicians who are more positive do better^[1] and conversely negative or ambivalent attitudes in professionals are linked to higher risk of relapse.

Professor Best, interviewed by William White in 2012, referred to work he’d done in the UK, scoping out the aspirations of addiction workers for their clients. He had asked them to estimate what percentage of the people; they were working with would eventually recover. The average answer was 7%. Evidence actually suggests that over time most individuals are likely to recover. However, if I believe your chances of recovery are only 7%, then I’m instantly holding you back because of my own beliefs and behaviours – conscious and unconscious. My bar is set way too low.

An Australian study found that practitioners there were more optimistic believing that a third of people with a lifetime substance dependence would eventually recover. But this is still an underestimate.

In general, it is fair to say that SUs [service users] look for tough criteria to define ‘being better’ – perhaps tougher than their practitioners.

Thurgood and colleagues, 2014

Raising the bar

Eric Strain picked up this theme of aiming too low in a recent editorial in the journal Alcohol and Drug Dependence when he wrote:

The substance abuse field in both its research as well as treatment efforts is not giving due consideration to flourishing. We need to renew our efforts to give meaning and purpose to the lives of patients.

Eric Strain,

Saving lives and reducing harms rightly need to be our first concerns, but is there a danger that we stop right there because we see the risks of our patients or clients going further as being too high? This week I was talking to an experienced addiction psychiatrist, now retired. He told me that early in his career he gave up trying to predict who was going to do well and who was not. He’d seen people, ostensibly with little going for them, get better from what looked like intractable problems. He’d seen others with a great deal of recovery capital die from addiction, despite the best efforts of family and professionals to support them. It’s hard to make predictions perhaps, but not too hard to hold out hope for everyone.

The necessity of hope

There are actually reasons to be more optimistic anyway. As I say, long term follow-up studies and retrospective studies of people in established recovery suggest that most people can expect long term resolution of their symptoms although this can take some years and several attempts during which we need to focus on keeping things as accessible, supported, and safe as possible, underpinned at all times by hope that things can and will get better.

So what of hope? Hope can be described as an emotion, a cognitive process or a positive anticipation which helps to motivate goal-oriented behaviour. However we define it, it is essential for recovery from substance use disorder, yet it features little in textbooks, guidelines and academic studies.

The patchy availability of hope in ourselves, our services and our service users does need to be addressed. Hope is a catalyst for moving forward. Academics have found that positive expectancies, like hope, predicted higher levels of resilience against post-traumatic stress symptoms. Other researchers have identified the critical role of hope in terms of survival. 

The inclusion of hope in clinical practice shows considerable promise. Individual, group, and family therapy interventions that incorporate hope theory have been found to reduce symptomology and mediate recovery from various psychological and psychosocial conditions

Gutierrez & colleagues, 2020

It is apparent that hope is a necessary ingredient, not only for patients/clients to progress, but for professionals too if we want to be effective in supporting individuals towards their aspirations. I’m not suggesting we come at this with an unrealistic Pollyanna bent. Without manageable caseloads, support from colleagues, good clinical supervision and adequate resources – including joined-up care – compassion fatigue can set in and the therapeutic relationship can suffer. Hope, though vital, can ebb away.

“We must address issues around staff burnout, which I suggest is related to repeated exposure to client relapses without parallel exposure to clients in long-term recovery.” David Best, 2012

Prof David Best

The introduction of hope

In that conversation with William White, David Best encourages us to ‘inspire belief’ through a variety of interventions::

“The interesting issue for me is much less about what particular therapies and modalities we offer and more about whether we can inspire belief that recovery is possible, establish a partnership between the client and the worker to facilitate that change, mobilise recovery supports within the client’s natural environment, and link the client to those community resources. 

We also need to locate recovery within a developmental perspective that recognises the lengthy (and non-linear) journey that most people experience in recovery. This means there are plenty of opportunities for a diverse array of interventions and also that people will evolve in their needs and their resources as the recovery journey progresses.’

Lived experience and hope

Structurally, the goal must be to create recovery-oriented systems of care, but within our existing services, there is a straightforward way to infuse hope. We can do that by embracing lived experience and introducing it into what are normally professional settings. Connecting those we work with to others in recovery stimulates aspiration. It’s true that some professionals are resistant to this concept, but people with lived experience can be involved in treatment settings, acting as role models and beacons of hope to everybody’s advantage – staff and patients. They can also bridge the gap between treatment and recovery communities.

In a local evaluation of a peer support model introduced into a harm reduction service, benefits to the service users were apparent, with greater levels of engagement and a high approval rating of the intervention. What was unexpected though was the benefit to members of the staff team. Because they normally worked with people at a much earlier stage on the recovery journey, the staff were not used to seeing people who had moved on from their problems. That experience of working alongside people who self-identified as being ‘in recovery’ changed the beliefs of the team, raising expectation and hope.

In a study^[2] published this month which looked at the feasibility, accessibility and acceptability of peer navigators in roles that aimed to reduce harm and promote recovery (wellbeing, quality of life and social functioning), the researchers added to the growing evidence base that peers with lived experience can positively influence not only the reduction of harm, but also improvements in quality of life through various mechanisms including role-modelling.

Many participants also described less tangible but nevertheless important changes, including increased confidence and hope.

Parkes and colleagues, 2022

This was not all plain sailing, but staff noted how the peer navigators were able to spot things that staff didn’t, had tenacity with clients and could engage more ‘chaotic’ or ‘hard to reach’ clients.

What’s lovely about this open-access study is how easily the lessons can be adopted into practice. There are issues to be tackled and more work needs to be done on capturing outcomes, but this has the opportunity for us to tackle therapeutic nihilism within ourselves and within our services.

Recovery champions can convey the possibility that things can be different and offer living proof of that difference in their own lives.

Prof David Best

Generating hope

Peers with lived experience don’t just have the potential to introduce hope. Research also suggests that peer contact can help to reduce stigma. Visible recovery is generally inspiring, though some may be threatened by it. There is mostly a contagiousness about it which generates hope. I wonder if my colleague working in that challenging MAT clinic who came to believe that nobody would ever get better would have avoided therapeutic nihilism if she were buoyed up by working daily shoulder to shoulder with those with lived experience.

When we see burnout, despair and therapeutic nihilism we need a compassionate response, but more than this, we need to transform situations where hope has atrophied. Moving to peer support models in every treatment setting is surely an effective way to generate hope, not only in those who use our services, but also in ourselves.

Continue the discussion on Twitter @DocDavidM

^[1] Simpson. D., Rowan-Szal, G., Joe, G., Best, D., Day, E., & Campbell, A. (2009). Relating counsellor attributes to client engagement in England. Journal of Substance Abuse Treatment, 36, 313–320.

^[2] Parkes T, Matheson C, Carver H, Foster R, Budd J, Liddell D, Wallace J, Pauly B, Fotopoulou M, Burley A, Anderson I, Price T, Schofield J, MacLennan G. Assessing the feasibility, acceptability and accessibility of a peer-delivered intervention to reduce harm and improve the well-being of people who experience homelessness with problem substance use: the SHARPS study. Harm Reduct J. 2022 Feb 4;19(1):10.

Forward – I have known JohnWinslow for the better part of twenty years. I kept running into him in DC and in my travels around the country. He is a person in long term recovery for over 46 years, and he has been in the field of helping people recovery for the vast majority of those years. His work as a recovery advocate has taken him to the White House (twice). He served at ground zero at the World Trade Center after the September 11^th 2001 attack to support police and firemen during the recovery efforts. He has taught collegiate course on addiction, presented at the FBI Academy, served as President of the Maryland Addiction Director’s Council, and had the opportunity to open one of the first Recovery Community Centers in Maryland – the Dri-Dock Recovery & Wellness Center.

Over the years, John and I have had many an opportunity to break bread together at conferences and meetings around the country. He is a friend and a person I have found who is filled with recovery wisdom and a lot of insight into our history and the recovery movement. Recently, John announced his semi-retirement, and that Faces & Voices of Recovery was going to assume responsibility what is perhaps his greatest gift to the recovery movement, International Recovery Day. Knowing some of his history and contributions to the recovery movement, I asked him to do this interview. I am grateful he agreed to it!

Tell us about yourself and your work to support recovery over your lifetime

First and foremost, I am a person in long term recovery, I got into recovery on January 21, 1976. I was in my 20s. But one of the things that was part of my story years earlier than that was that my older sister was killed by a drunk driver when I was 17. She had been 19 at the time of her death. The intoxicated driver who crossed the center line was killed, my sister and others in the car he hit also died. It was devastating. I vowed never to drink and drive again. It is a testament to how strong a pull addiction can have. That vow only lasted only a few months. I drove intoxicated many times in those years, despite the loss of my own sister. I experienced a lot of consequences, and in my mid-twenties I started to realize that my addiction was probably going to ruin a relationship I cared a lot about. In 1975, I voluntarily admitted myself into the psychiatric unit a Perry Point V.A. hospital where I spent two months under my veterans’ benefits, having served during the Vietnam era. I recall that they suggested I may be an alcoholic and sent me to a 12-step meeting. At that time, I wanted nothing to do with any of it.

About a year later, I was experiencing increased difficulties due to my substance use, and it began to threaten my job- which happened to be working with munitions at Aberdeen Proving Grounds. Substance use and explosives are not a good mix! I had been coerced into receiving treatment through my employer (the federal government) at an outpatient program. Eventually they told me I needed more than they could provide. This time, they sent me to Caron Foundation, which at the time was called Chit Chat Farms. I was filled with despair, I felt defeated and alone, but following a head-on collision while heavily intoxicated I experienced a “moment of truth’ and became open to help in that moment. I had just turned 26 years old.

The Caron Foundation provided excellent treatment. The program made sure I had a sponsor and a connection to my local recovery community before I walked out of the door. They had warm handoffs in 1976! That was one of the things that saved my life. Some of my counselors in this era had very little formal education but had an amazing grasp of addiction and recovery, and were highly skilled at communicating about what I was experiencing and what I needed to do to get well. I am grateful for what they did for me.

In early recovery, I started to think about what I wanted to do with the rest of my life, and the idea of getting involved in helping others find recovery was something that really appealed to me. I took a job as a night counselor at Springfield State Hospital and enrolled in classes to become an addictions counselor, which at the time were known as “paraprofessionals.” I realized that there were very few people in my age group working in the addictions treatment field and I thought it would be valuable to serve as a power of example in showing others -particularly young people – that recovery was not just possible but could be a reality for folks of any age (young or old) struggling with addiction.

The Springfield Program for Addiction Recovery (SPAR) was run by Dr Sandy Unger who was an interesting person and a colleague of Dr Timothy Leary.  He was part of the Spring Grove Experiment to study the impact of LSD for use with persons with psychiatric disorders and to facilitate spiritual awakenings in patients experiencing Alcoholism. It was funded by the National Institute of Health. He was quite a character. He later married the office manager, and I performed the wedding song on my guitar at their wedding ceremony at his request.

During this period of my recovery, I met a number of people who had been around and in recovery since the 1940’s and early 1950’s, even people who knew and worked with Marty Mann. I saw Father Martin Chalk Talk on Alcoholism who immediately become my first Recovery Hero! I then started to run into him in my community and we became friends. He lived in a nearby town and I was honored when on one occasion in my first year of recovery he asked me to step in for him and help out with someone struggling with alcoholism when he needed to go out of town for a speaking engagement.

• Where you aware of Operation Understanding at the time it happened? What do you recall about efforts to normalize recovery in that era?

I don’t particularly recall it well. I was in early recovery at the time and just trying to figure out my own way. It was not until long after that I grew to appreciate the recovery movement and our rich history. At one point, a number of years later I moved up to Pennsylvania and worked at the Livengrin Foundation, which at the time was run by Mercedes McCambridge. Many people may now recall her from the clips of her brave testimony in front of Congress on recovery that Greg Williams and Jeff Reilly included in the Anonymous People as part of Operation Understanding. She let you know she was a star. According to Orson Wells, Mercedes was the greatest living radio actress, she has won an Academy Award for the movie All the Kings Men and was nominated for one for her work on Giant with James Dean.

Thanks to the Anonymous People, we are now much more aware of this period of our history. What people may not know is that she paid a price for her advocacy. Standing up and being open about being a woman in recovery led to her being blacklisted in Hollywood. She could not get work because she was open about her alcoholism. There were a lot of people in the recovery community who were opposed to living openly in recovery. There was a lot of controversy at the time about Dick Van Dyke being open about Alcoholism and the impact of public relapses on the perception of recovery. These early advocates paid a price for being open about addiction and recovery. We owe them a great deal for what they did for us.

• I have put some effort into interviewing people about the recovery summit in 2001. I don’t think you were there, but were you aware of it? When did you first start to see the influences of the new recovery advocacy movement in your community?

In the 1980’s-90’s I established a private outpatient addiction practice in Pennsylvania. During this era, we were seeing a lot of erosion of recovery efforts on a national scale. Lengths of stay in treatment centers were decreasing because of pressure from the insurance industry. There was such a focus on professionalism and documentation that the field became overburdened and set up barriers for our community to do the work of helping people get into recovery. We lost something in this era, the pendulum had swung away from recovery and the field became over-professionalized. Some treatment settings prohibited giving a client a hug or disallowed self-disclosure (talking about your own recovery). Brief therapy was all the rage, the notion that you could provide a handful of outpatient treatment sessions with a person, educated them about severe substance use disorder and recovery and they would be healed. The insurance industry loved it. The dots that connected treatment and recovery were severed. It was horrifying and something needed to be done to reconnect recovery with the treatment experience.

Some years later, my wife and I moved back to Maryland where I become the director of the Dorchester County Addictions Program. While there I became interested in developing community-based recovery support. I started to think about those old 12 step clubhouses, and I thought something similar could benefit my own community. With the support of State funding, I founded the Drydock Recovery & Wellness Center in Cambridge Maryland. I was heavily influenced by the work of Bill White and the concepts of recovery-oriented systems of care (ROSC) and recovery management. Soon thereafter, “The Anonymous People” movie was released, and it was a game changer! The movement became energized and focused on embracing many pathways to recovery. I am grateful to have seen and have been part of this positive emphasis on recovery and recovery community.

• How have views of addiction and recovery changed over the last four decades from your perspective?

Have people’s views changed? My short answer is yes and no. The work of Bill White, Greg Williams and so many others through the new recovery advocacy movement has definitely increased our capacity to talk about addiction and recovery openly. This has really increased public awareness of addiction and recovery. On the other hand, I’m sorry to say that I see a lot of disparaging, vile, hateful, ignorant, shaming, and judgmentally stigmatizing commentary concerning addiction and people suffering from and impacted by addiction on social media and other public platforms. It is heartbreaking to see how common are the misconceptions about who we are and what we experience. We have a long way to go to get to the point where society normalizes addiction and stops seeing it as a moral failing but instead something that is common, is treatable and from which recovery is the probable outcome given the proper care and community support in which people need to heal.

• You started International Recovery Day. Tell us about it and what it has accomplished.

I got the idea to start International Recovery Day (IRD) in the Fall of 2018. I was reading a bio on Marty Mann and all of her amazing advocacy pioneering work. I was simultaneously reading Bill White’s newly released Recovery Rising. In the back of my mind, I was also reflecting on Don Coyhis who was talking about the spider web of connection. I wanted to be part of reconnecting the dots and expanding recovery. I saw that we had through some of the new technology the ability to connect people in ways that was not possible before then. I started thinking about September being National Recovery Month which begins the day after we observe International Overdose Awareness. Many recovery-related events occur throughout the country (and now around the world) during this month. Holding International Recovery Day on the last day of the month (September 30^th) would provide a month’s ending crescendo as an opportunity to be the day to honor and celebrate recovery worldwide and offer a beacon of hope to all impacted by addiction.

I started to imagine a scenario where everyone in the world who’d been impacted by addiction could launch their own virtual recovery rocket and anyone could watch them online streaming across the globe. I thought it would be an amazing way to express unity and focus the world on recovery in a non-politized way. Over time, I sheepishly realized that the imagery of all these rockets may actually look like the virtual start of WWIII! Given that awareness, we shifted the concept from Recovery Rockets to that of Recovery Fireworks – thus averting another worldwide disaster – whew! Today, anyone can register for free to launch their own virtual Recovery Firework on September 30^th and watch it join with countless others around the globe rise up into the sky in celebration of recovery. https://internationalrecoveryday.org/

Purple is the color we embrace to symbolize the Recovery Movement.  I was involved in a community near mine who was using the color purple to show support for recovery, they used that color because of that scene in the Anonymous People when Chris Herren of the Herren Project was talking to the kids wearing the purple shirts to support drug free living at a High School assembly. This was part of his work on Project Purple. My wife suggested that we focus on having people light things up in purple. That is what we did!

Even though International Recovery Day is only a few years old, it has already taken off! The web site is available in many different languages to increase accessibility. “Recovery Lights Around the World” on September 30^th invites everyone to get out and light up your back porch, your City Hall, and/or your State Capitol building. So far, we’ve had countless buildings, bridges, and structures light-up in purple on the 30^th to include such iconic places as Niagara Falls, the Rock and Roll Hall of fame and Aloha Towers in Hawaii. Last year, over one fourth of all countries on the face of the earth participated in International Recovery Day. We are just getting started, our goal is to get every single nation of the world to participate. What a show of unity, diversity, and a testament to many pathways of recovery. I think we really can turn the world purple one day at a time!

• When we were at the CCAR Many Pathways to Recovery conference, you announced that Faces & Voices was going to carry International Recovery Day forward / What are your hopes for this change and what it signifies moving forward?

For the past few years, I’ve been thinking about how best to insure the future of International Recovery Day. I am getting older and it is important to me. I started talking to Bill White and a few other people about the idea of making sure it had a home long term that could increase its visibility and really expand it in the way to connect the world and show the power of recovery to heal. Through the process of reflection, meditation, and consultation it appeared that Faces & Voices of Recovery was the ideal place for it to go, given that they have the technical, staffing, financial, and networking resources to move I.R.D. forward in a major fashion. I soon discovered that Faces & Voices’ C.E.O., Patty McCarthy was thinking along the same lines. She invited me into conversation to discuss the possibilities, and the rest is history.

So, at the CCAR Multiple Pathways of Recovery Conference we made a formal announcement that Faces & Voices of Recovery was going to add it to its projects. Yes Bill, as you have joked with me about retiring, I am retiring in that I will be involved in IRD as an advisor, sort of semi-retired. I am very excited to see what it will evolve into and suspect that it may really help create a sense of world unity and connection in the global recovery community.

• You have been a major contributor to the recovery movement over your lifetime. What would you want young people to know about what you have learned along the way? What are your hopes for the next generation?

I have been thinking about this question since you first asked me to do this interview. I thought about my early years of doing the work and who I wanted to be like. As I have shared, I was blessed to have had some great mentors and role models. I felt a little overwhelmed and was trying to emulate all of these amazing people and also find my own voice. Early on in my career I had a colleague I looked up to by the name of Joe Massie. He was such a gifted counselor. They actually named an adolescent unit after him in Western Maryland. Joe was so well respected. He was very limited in his formal education, but he was a genius and a gifted communicator. I asked him about how I could honor all of the work of all of these people in my own efforts moving forward. He gave me the sage advice to just be myself. I have followed this advice even as I worked to understand, honor and preserve the work of my recovery heroes! 

One of the things I reflect on when I think of where we are now is that the whole movement has gotten a lot more complex. There arises a chorus of voices- from prevention, harm reduction, treatment, and recovery. It is my sense that not all of these groups fully understand what addiction is and the consequences of having a severe substance use issue. I think it is very important moving forward that anyone committed to doing this sacred work develop a deep understanding that moderation does not work for everyone and that there are those of us for whom recovery is a matter of life and death.

The things I would hope that the next generation reflect on are rather simple. Concepts that have served me and a lot of people in recovery quite well:

• Be yourself
• Take care of yourself
• Be humble
• Do no harm
• Do the next right thing
• Always take the high road and do the ethically proper thing.
• Put principles before personalities
• Be open minded

I did not invent these concepts. They were around a long time before I learned them. When I reflect on my recovery heroes and think about what they accomplished and how they did it, I see these same concepts as the things that they centered on in their own lives and in their own work.  That is my wish for the next generation. I know that if they do these things, dream big and keep focused on them, they will accomplish so very much!