Background: History is incredibly important to how we understand ourselves, where we came from, where we stand now and to assist us in determining our pathways forward. Few things are more important to me than understanding the New Recovery Advocacy Movement and to support efforts to move us towards an expanded recovery community across America.  As addiction is arguably our most profound public health challenge, recovery in all its diversity offers the greatest hope of restoration at the individual, family and community level. 

This year marks the twentieth anniversary of the historic 2001 Recovery Summit in St. Paul Minnesota. I felt that one of the most important contributions I could do would be to collect some of the recollections and thoughts of recovery leaders who were present at this historic event. I have developed a series of questions I hope to ask as many attendees as I can locate over the course of the coming months. My goal is to document their recollections on what the summit meant to them, the accomplishments of the new recovery advocacy movement that rose out of this historic summit and thoughts for the future.

Bill White, the widely regarded recovery movement historian, writer, researcher, streetworker, counselor and elder stateman of recovery who started working in it in 1969 has generously agreed to be my first respondent. I am deeply grateful to Bill for his life work on addiction and recovery and for his willingness to mentor and support so many of us across this movement nationally, myself included.

Questions to Bill White and his responses:

I am a person in long-term addiction recovery who has worked in the addictions field for more than 50 years in such roles as outreach, counseling, clinical supervision, recovery research, and teaching. I have also spent most of those years researching and writing about the history of addiction treatment and recovery in the United States. I am currently Emeritus Senior Research Consultant at Chestnut Health Systems.

By the late 1990s, I was convinced the addictions field needed to shift its central organizing framework from a focus on addiction pathologies and brief clinical interventions to a focus on the prevalence, pathways, styles and stages of long-term personal and family recovery. I also was advocating the extension of brief clinical models of treatment to a model of sustained recovery management nested within a larger recovery-oriented system of care.  As a recovery historian, I had begun to document the rise of new and renewed grassroots recovery community organizations (RCOs) and what I was labeling a “new recovery advocacy movement.” In 2000, I began writing papers on this emerging movement, drawing on my experience working with these new RCOs and my consultations and presentations to those RCOs funded under CSAT’s newly developed Recovery Community Support Program (RCSP). At this time, I was also serving on the Board of Recovery Communities United in Chicago, one of the RCSP grantees.

In early 2001, I was asked by William Cope Moyers (Johnson Institute) and Jeff Blodgett (Johnson Institute’s Recovery Alliance project) to participate in a planning meeting to explore the possibility of a national recovery summit that culminated in the St. Paul Recovery Summit in October 0f 2001.    

I have vivid recollections of the wonderful presentations and the working sessions at the Summit, but those are not what most stand out for me. What mattered was that we were there together as “people in recovery”—an identity that transcended all other identities and boundaries. At that meeting, we became “a people” apart from our affiliation or lack of affiliation with any particular recovery mutual aid group or any other personal or professional identities we might claim. By the time I arrived in St. Paul in 2001, I had been in thousands of meetings without ever sensing that any of those events were history making.  The Recovery Summit in St. Paul was different. There was electricity in the air from the moment we gathered and I distinctly remember thinking at one point that what we were doing could mark a new chapter in the history of addiction recovery—a line in time between that in the future would demarcate “before” and “after.”  You see, many of us knew of each other but we had never gathered as recovery advocates. The energy generated by finally placing so many of us in one place was amazing. That energy and its resulting shared vision is what I most remember. 

The historical context was important. There was awareness of the failure of earlier organizational efforts such as the Society for Americans in Recovery (SOAR) and calls for extending the historical work of the National Council on Alcoholism and Drug Dependence (NCADD). The Summit was in many ways a call to take recovery advocacy into the 21st century. We had lived through the demedicalization, restigmatization and intensified criminalization of addiction in the 1980s and 1990s that resulted in the mass incarceration of addicted people. The Summit was a backlash against such practices led by people who offered living proof of an alternative. New grassroots and renewed RCOs were popping up around the country. The summit was an acknowledgement of their existence and an expression of their aspirations. Since 1998, The Center for Substance Abuse Treatment (CSAT) had provided seed money to a small cadre of RCOs via its Recovery Community Support Program (RCSP). The Summit was a way of extending that effort far beyond those few CSAT-funded funded RCOs. In some ways, the Summit was also a protest against the addiction treatment industry—the sense that people with severe, complex, and long-standing addictions were being recycled through brief episodes of care for financial profit of treatment organizations without regard to their need for long-term personal and family recovery support. Many of us had reaped the benefits of treatment, but we were also painfully aware of its limitations and the need for more vibrant and recovery-focused models of care. There were also groups like White Bison and the Recovery Association Project that were calling for us to move beyond clinical models of care to models of community organization and cultural revitalization. All of these influences stirred within the pot of the 2001 Recovery Summit.   

What we have witnessed in the 20 years since the St. Paul meeting is in many ways far beyond what we could have dreamed of at that time.

We have witnessed the international growth and diversification of secular, spiritual, and religious recovery mutual aid groups as well as innumerable special needs support groups.

We have witnessed the cultural and political mobilization of people in recovery and their allies at a level that would have been unthinkable in 2001. And we are doing this in diverse cultural communities—far beyond that found in earlier recovery advocacy efforts. That we would have so many RCOs in the U.S. and that we would witness tens of thousands of people in recovery marching in public recovery celebration events was beyond what we could have thought possible during our deliberations in St. Paul.

We have launched major anti-stigma campaigns, including interrogating and challenged the language and images through which AOD problems have been historically expressed. These campaigns have normalized addiction recovery and broadened the pathways of entry into recovery in communities across the country. Early kinetic ideas within the recovery advocacy movement have garnered wide cultural and professional acceptance, e.g., “Recovery is a reality for individuals, families and communities,” “There are multiple pathways of recovery and ALL are cause for celebration,” “Recovery flourishes in supportive communities,” etc.

We have seen a dramatic expansion in new recovery support institutions: recovery community centers, recovery residences, recovery high schools and collegiate recovery programs, recovery-friendly workplaces, recovery ministries, recovery cafes, recovery-focused sports and adventure venues, recovery-focused art and music festivals, and on and on. This is recovery community building at its finest. We had only a glimmer of that in 2001. The recovery advocacy movement has been the engine driving such institution building—a critical step for any sustainable social movement.    

We have witnessed a dramatic increase in recovery representation with alcohol- and drug-related policy venues and the parallel emergence of recovery as a new organizing paradigm within the alcohol and drug problems arena. That we would have authentic recovery representation at the highest levels of state and federal drug policy was only a dream in 2001. Today, we are closer to that dream than ever before.

We have witnessed substantial work in extending acute care (AC) models of addiction treatment to models of sustained recovery management (RM) nested within recovery-oriented systems of care (ROSC), with a particular emphasis on precovery outreach and post-treatment recovery support checkups and support.  Peer-recovery support services provided across the stages of recovery mark a new conceptualization of the traditional addiction treatment continuum of care.

We are today witnessing efforts to integrate primary prevention, harm reduction, early intervention, primary treatment, and long-term recovery support services. We are now placing recovering peers in hospitals emergency rooms and other settings where addicted people experience their greatest vulnerability for harm.   

We have helped through our advocacy efforts to expand recovery research funding through NIH, inspired a vanguard of research scientists to focus their careers on recovery research, and supported the work of such new institutions as Harvard’s Recovery Research Institute.

I believe all of the above rest on the vision and strategies emerging from the 2001 Recovery Summit in St. Paul. These are all things I did not think I could witness in my lifetime.  

The original vision was pretty bold and comprehensive but there were areas of shifting emphasis in the years that followed as the movement matured. I think the most important of these was more fully embracing affected families within leadership roles within the movement, more intensified efforts to extend recovery advocacy within communities of color, and a greater emphasis on environmental strategies of recovery support. The latter was helped by exploration of such concepts as recovery capital, community recovery, and recovery contagion as well as through efforts to inject a recovery orientation within prevention and harm reduction services.

When a social movement articulates many goals, there is always a danger that one goal comes to dominate the whole movement. I am concerned that the rapid growth of funding for peer recovery support services could obscure and minimize our work in other areas, particularly recovery advocacy. And, of course, there are always the dangers of professionalization and commercialization of social movements as well as the danger that such movements can be hijacked by more powerful forces in their operating environment. When a movement achieves success, there are efforts to expand (dilute) its boundaries to serve other interests. We see this with the ever-expanding definition of recovery, and with treatment and other traditional organizations competing for funds devoted to peer recovery support services. During rapid expansion, there is always the risk of bad actors exploiting the movement for their own ends with the movement being then harmed by unethical and criminal conduct. Funding availability within emerging social arenas in which there is little regulatory oversight or lack of a strong ethical foundation is a psychopath’s dream. I still worry about the influence of the treatment industry on recovery advocacy. If we simply regress to the marketing arm of the addiction treatment industry or become a superficial appendage providing post-treatment recovery support, the new recovery advocacy movement will have failed and new advocacy efforts will be needed in the future. And of course, we always have the challenges of organizational sustainability, leadership development, and leadership succession. These are normal risks shared by all social movements. 

I want them to know that those of us at the 2001 Recovery Summit were there to accept a torch passed to us from recovery advocates of earlier decades. We have tried to faithfully carry that mission forward and now place it in the hands of new generations. I want them to respect what their recovery ancestors have done without being bound by that history. I also want them to remember that recovery advocacy is not a program of personal recovery and that history is strewn with the bodies of those who thought otherwise. This work cannot be done without a foundation of care for self and care for those closest to us: We cannot carry light into the community while our own home is shadowed in darkness. We must continue to assert the primacy of personal recovery as the foundation for recovery advocacy. We set out in 2001 to change the world and in a real sense we have achieved that and in doing so experienced meaning and purpose in our own lives. We could not do more than wish recovery advocates of the future the same.  

References links to the 2001 St Paul summit –

I’ve been watching a really interesting twitter discussion about the conceptual boundaries of recovery. One branch of the discussion got into recovery as a process and as an outcome. It reminded me of this post from 2019.


Yesterday, we began to revisit the concept of recovery-oriented harm reduction. Why recovery-oriented harm reduction and not just recovery? 13 years ago, recovery-oriented harm reduction was thought of as a bridge between harm reduction and treatment or recovery. Today, in some circles, it might invite questions about why one would want to maintain a distinction between harm reduction and recovery.

Defining harm reduction

Harm Reduction International defines harm reduction this way:

Harm reduction refers to policies, programmes and practices that aim to minimise negative health, social and legal impacts associated with drug use, drug policies and drug laws. Harm reduction is grounded in justice and human rights – it focuses on positive change and on working with people without judgement, coercion, discrimination, or requiring that they stop using drugs as a precondition of support. Harm reduction encompasses a range of health and social services and practices that apply to illicit and licit drugs. These include, but are not limited to, drug consumption rooms, needle and syringe programmes, non-abstinence-based housing and employment initiatives, drug checking, overdose prevention and reversal, psychosocial support, and the provision of information on safer drug use. Approaches such as these are cost-effective, evidence-based and have a positive impact on individual and community health.

Harm reduction emerged in response to the failures of medical, public health, and addiction treatment systems to meet the needs of people currently using alcohol and other drugs. Harm reduction saves lives and has challenged other systems (like my own) to face their shortcomings and biases and improve our services. Harm reduction is an essential part of the service continuum and its existence has created pressure to improve the care delivered by other systems.

Defining recovery

There have been several proposed definitions of recovery by academics, professional associations, panels, federal agencies, and state agencies. The trend among these definitions is toward more porous conceptual boundaries and greater inclusion. The first wave of attempts to define recovery seemed to originate from a sentiment like the following, “There are people out there who are doing what you call recovery. They just are not doing it in 12 step groups or they are using medication to assist their recovery. They are just using another pathway to get to the same destination (i.e. outcome). To exclude this people from the boundaries of recovery is inaccurate and wrong. And, by the way, you might want to wrestle with whether there are ways in which your thresholds are too low (e.g. tobacco use and other unhealthy behaviors). Recovery is less about the pathway and more about the destination/outcome.” The best example of a definition arising from this wave is from the Betty Ford Consensus Panel:

Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.

The next wave of definitions seemed to arise from something like, “What you’ve thought of as recovery is way too narrow. It shouldn’t be confined to addiction. There’s a whole spectrum of problems and changes within the context of those problems that constitute recovery. It’s not a outcome at all. It’s a process, and anyone engaged in a process to improve their wellness is in recovery. Recovery is the pathway not the destination/outcome.” SAMHSA’s definition is an example of this is type:

A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

Another, more recent, example is from the Recovery Science Research Collaborative:

Recovery is an individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness.

Process, direction, outcome?

Long before researchers and scholars took an interest in recovery, recovering people have described recovery as a process. What’s interesting here, is that I think recovering people have thought of recovery as a process and a destination/outcome. Some might think of it as a process that leads to an outcome, while others might think of it as an outcome maintained by a process. Whatever the case, both elements are considered essential. The Betty Ford Consensus Panel definition integrates a lifestyle (destination) that is voluntarily maintained (process). This more recent wave of definitions emphasize a process and a direction (“improvement . . . striving . . . full potential” and “sustained efforts to improve wellness”) rather than an outcome or destination.

Does it matter?

In is paper on the conceptual boundaries of recovery Bill White observed:

Defining recovery also has consequences of great import for those competing institutions and professional roles claiming ownership of AOD problems. Choosing one word over another can shift billions of dollars from one cultural institution to another, e.g., from hospitals to prisons. Medicalized terms such as recover, recovery, convalescence, remission, and relapse convey ownership of severe AOD problems by health care institutions and professionals, just as words such as redeemed and reborn, rehabilitate or reform, and stop and quit shift problem ownership elsewhere. It is important to recognize that rational arguments for particular definitions of recovery may mask issues of professional prestige, professional careers, institutional profit, and the fate of community economies. The answer of who has authority to define recovery will vary depending on the question, “define for what purpose?” Given that defining recovery could generate unforeseen and harmful consequences, efforts to define recovery should include broad representation from: 1) individuals and family members in recovery, 2) diverse recovery pathways and styles, 3) diverse ethnic communities, and 4) policy, scientific, and treatment bodies, including leaders of the major institutions that pay for behavioral health care services.

So . . . yes, it matters. A lot. To a lot of people and a lot of interests. I don’t presume any nefarious motives. I imagine everyone believes their definition will ensure more people recover or will protect recovery from a harmful erosion of its boundaries. In some cases, they wish to extend it to include mental illness and other problems. In other cases, they wish to include people who are taking steps toward change, but have not yet crossed the threshold into traditional notions of recovery. Others want to secure the status of MAT patients within the boundaries of recovery. Others see opportunities for stigma reduction and political action by enlarging the number of people in recovery. Others see opportunities to address the needs of people with lower severity problems. Others may see progress on stigma reduction benefiting people in recovery but neglecting people who still use alcohol and other drugs. Others see the concept of recovery as imbued with moral panic and wish to challenge that. There have been attempts to address some of these issues and bridge the divide between harm reduction and recovery. Scott Kellogg has proposed a model he calls gradualism. He describes it as follows:

[Gradualism] seeks to create a continuum between the world of harm reduction interventions and the abstinence-oriented treatment field. Again, this approach differs from other calls for integration (Denning, 2001; Marlatt et al., 2001) because there is a much greater emphasis on making abstinence the eventual endpoint of most harm-reduction enterprises. This paradigm would combine the harm reduction emphases on outreach to the addicted, incremental change, and gradual healing with the abstinence-oriented therapeutic perspective that the use of substances in an addictive or abusive manner is antithetical to the growth and wellbeing of humans.

Bill White has proposed the concept of precovery, which he described this way:

Precovery is a recovery incubation period arising during active drug use that moves one from the center of addiction to the edge of addiction. Experiences within this stage prepare us for the potential break-up of the person-drug relationship and move us close enough to the recovery territory to feel its contagious pull. Brief sobriety experiments within this boundary region do not constitute sustainable recovery, but they have the potential to incrementally move us to the center of the recovery experience and the physical and cultural world in which that experience is nested. The center of recovery is a region of stability and safety within the recovery process.

These models embrace harm reduction, but not as recovery. They embrace harm reduction as a path to recovery.

Why does it matter?

Why does it matter if harm reduction is placed inside the definition of recovery? There are a few concerns:

Tomorrow’s post will revisit the parameters of recovery-oriented harm reduction.

UPDATE: One more relevant thought from a recent post. I believe, if these new definitions take root, recovering people will feel a need to establish typologies of recovery or select a new word to convey the identity they share. Productive discussion around typologies is likely to become very challenging. The need for typologies stems from the desire to distinguish one type from another, and use them. How might they be used? They would likely be used to organize research and programming around each type. This means these typologies would be used in inclusion/exclusion criteria for everything from research to treatment to recovery housing to collegiate recovery programs to physician health programs to state or unstated hiring practices. And, if there was success in establishing typologies, wouldn’t that bring us back to our starting point?

Previous posts in this series

We should fight to ensure our patients and this field does not accept anything less than flourishing – that should be the goal we bring to our work in research and clinical practice.

Eric Strain

I grew up in Glasgow, a city whose motto, as every schoolchild was taught, is ‘Let Glasgow flourish’. I think primary school was probably my first introduction to the word flourish which my dictionary tells me means ‘to grow luxuriantly, to thrive, to be in full vigour and to bloom’. 

Tyler Vanderweele widens this definition[1] and makes the point that, applied to human lives, flourishing encompasses happiness and life satisfaction, meaning and purpose, character and virtue, and close social relationships. 

When I reflect on this deeper meaning, the elements chime with me. These are the things that matter most to me. They certainly matter to the patients I look after and support who are trying to achieve recovery from substance use disorders. Most people would probably agree; these things are important.

It’s puzzling then that much of the biosocial literature looking at recovery from physical and mental health conditions does not consider such issues, concerning itself with narrow end-points and measurements, perhaps because these are of more interest to researchers than they are to the people with the conditions, or simply that they are easier to study.

Eric Strain took up this theme recently in a valedictorian editorial[2] in the journal Alcohol and Drug Dependence on the subject of purpose and meaning in the context of opioid deaths. He expressed his concerns:

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.

While praising the essential goal of reducing opioid overdose deaths, Strain argues that this is ought to be a starting point – not an end point. 

If a patient with a significant leg wound has the bleeding stopped with a compress, the medical field does not declare victory. Providers clean the wound, stitch it, arrange for physical therapy for the leg, and work to maximize the functioning of the person.

His wish is that we focus on helping not just to reduce drug deaths, but on helping people grow and flourish. Perhaps with the recent debates over the definition of ‘recovery’ and the controversies surrounding it, we could focus on flourishing as a concept.

With the patient’s consent, I have a series of pictures on the noticeboard in my office which capture images of an ex-service user at three stages in his recovery journey. The first was taken on the day of admission to rehab, the second on his discharge and the last a couple of years later. It’s hard to believe it’s the same person, such is the physical transformation. 

Now while this is impressive, it’s not nearly as impressive as the things the picture cannot capture – his wellbeing, his enthusiasm, his self-esteem, the pride in his business, his willingness to help others, the quality of his relationships – all as important to him as his physical health and appearance.

So, how much flourishing really is going on in treatment settings? Professor David Best recently wrote[3]:

Recovery is frequently blocked not through failings of the person themselves but through the stigmatising attitudes of a range of ‘professionals’ who stymy the ambitions of their clients and whose own scepticism about recovery colours and corrupts their work.

Now, I am fortunate to work in a wider NHS treatment environment and also with voluntary sector partners where I am much more likely to see the opposite of this, but sadly, I have also heard stories more widely (some very recently) from patients and their advocates of blocks to recovery and therefore, blocks to flourishing. Lack of hope and ambition for clients/patients is often at the heart of such barriers, though so are issues of work overload and inadequate resources.

In medical school, I learned that health is not merely the absence of disease. In the same way, recovering from substance use disorders cannot only be about reduction in deaths, essential though that is, or reduction in crime, reduction in substance use, reduction in blood borne virus transmission etc. As I’ve argued before, we have to square worthy public health goals with what matters to the individual and their family – namely, the key elements of flourishing. These are the positives that need to accrue at the same time as the negatives recede.

In a 2017 article in the Journal of the American Medical Association[4], Vanderweele and colleagues point out that focussing on the health of the body might conflict with other goals that are actually important to individuals. They also argue for the value of the benefits of population-level flourishing and of making flourishing relevant to clinicians too, to prevent burn-out.

There are tools to measure flourishing which could compliment those which capture recovery capital and outcomes, but it is the concept and potential of moving to a model predicated on the value of flourishing that engages me. In Scotland, much effort has gone into developing a trauma-informed workforce. I wonder if we did the same with flourishing in mind – a flourishing-oriented professional group perhaps – if we would see transformation in both the workforce and in the quality of service-users’ lives.

Professor Best reminds us that recovery is often achieved through ‘an intense series of interactions that generate hope and trust.’ This week I’ve seen several rehab patients with non-addiction related health issues. When seeing them I think I’ve been interested, cheerful and thorough, but now I wonder what would happen if I had gone into every consultation with that goal in mind – the generation of hope and trust and a desire to see them flourish beyond helping them solve their minor ailments. 

I realise I sometimes fall short in this regard, but also that it won’t be that difficult for me to do a bit better. What if all of us in the field took that approach with everyone? What if we did not accept anything less than flourishing as an outcome? I think this might have a profound effect not just on those we work with, but on ourselves too.

Continue the conversation on Twitter @DocDavidM


[1] VanderWeele TJ. On the promotion of human flourishing. Proc Natl Acad Sci U S A. 2017 Aug 1;114(31):8148-8156.

[2] Strain EC. Meaning and purpose in the context of opioid overdose deaths. Drug Alcohol Depend. 2021 Feb 1;219:108528.

[3] Best, D. 2021 Research and the Recovery Movement. https://www.rec-path.org/blog/research-and-the-recovery-movement-science-and-advocacy

[4] VanderWeele TJ, McNeely E, Koh HK. Reimagining Health-Flourishing. JAMA. 2019 May 7;321(17):1667-1668.

I appreciate the reflections in Dr. Jana Burson’s most recent blog post.

In particular, the following caught my attention:

“I hear abstinence-only proponents criticize medications for opioid use disorder, and I think to myself, ‘If you only knew how much some people benefit from methadone/buprenorphine, you would change your mind.’ When I hear people who support medications for opioid use disorder talk badly about 12-step recovery, I think the same thing. ‘If you could only see the great benefits some people get from these recovery meetings, you wouldn’t be so harsh.'”

The above excerpt reminds me of those early members of Alcoholics Anonymous who were referred to as ‘bridge members.’ These individuals had experience with addiction to alcohol and addiction to other drugs. As a result, they were able to serve as a bridge between the “straight alcoholic” and “straight addict,” despite the differences that tended to separate them (cultural, legal/illegal status of their conditions, lived experiences, and relationship to society).

I appreciate Dr. Burson’s reflections on navigating the tensions between her professional training, personal recovery, and professional practice. And of serving as a bridge between different recovery experiences.

Science evolves through collaboration, debates, support, and refutations between scientists. This fact is no less true in the science of recovery. Recent discussions regarding new boundaries in the definition of “recovery” illuminate the mechanics of what scientists, clinicians, and people in recovery feel are essential characteristics of recovery. As one of the authors regarding the Recovery Science Research Collaborative definition of recovery, this article will enter into the fray that Dr. Coon has done such a good job narrating and challenging here at Recovery Review. In doing so, I hope to offer some guidance to this process while also allowing this public debate to continue unabated and uncontested in so far as my own opinion is concerned.

Andreas Vesalius (Flemish, Brussels 1514–1564 Zakynthos, Greece)
De humani corporis fabrica (Of the Structure of the Human Body), 1555
Italian,
Woodcut; Overall: 15 9/16 x 10 1/2 x 3 1/4 in. (39.5 x 26.7 x 8.3 cm) page: 15 1/4 x 10 1/4 in. (38.7 x 26 cm)
The Metropolitan Museum of Art, New York, Gift of Dr. Alfred E. Cohn, in honor of William M. Ivins Jr., 1953 (53.682)
http://www.metmuseum.org/Collections/search-the-collections/358129

I want to highlight that the recent debates between Kelly & Bergman and Witkiewitz et al. regarding the definition of recovery mark an official epoch in recovery science development. I would say that this current debate signals an official departure of recovery science; we are emerging out from underneath the shadow of addiction science. In this sense, we should pause and celebrate. It’s happening y’all!

In our 2017 paper on the definition of recovery, one of our main hopes involved shifting the impetus for defining recovery back to the independent scientific community, away from government agencies and the treatment industry. For too long, the scientific study of recovery was hindered by these forces. In the past, meaningful research on recovery required vast amounts of energy to escape the gravitational pull of private industry, non-profit treatment monoliths, and government authority of organizations like the NIH and SAMHSA. This was particularly true if scientists wanted to access funding for research. Millions of dollars were available to study addiction as a social problem, but to study recovery meant one had to take on articulations of recovery that were either reductive, too diffuse, or one-dimensional.

What’s important to consider is that while we are creating and debating a definition to be used for scientific purposes, such definitions should inform, reflect, and compel us toward the lived experience of survivors and the ways in which they themselves would define recovery.

Scientists with lived experience in recovery were indispensable to this effort. What’s important to remember about the RSRC definition is that the collaboration itself was composed of an interdisciplinary partnership whereby most of the contributors to the definition have personal recovery experience, either as people in recovery or with family ties to those with addiction and recovery experiences. Those without personal experiences had long time experience working within organic, clinical, and community recovery spaces. Their authority stems from a fusion between their scientific careers, professional practice, and lived experience. And the message of their 2017 paper is clear: any definition of recovery must be accompanied with data that is holistically informed and crosses multiple life spheres.

The current debate notwithstanding, the general equation for accurate capture of recovery should include personal variables, social variables, ecological improvements, ideally captured over longitudinal time. In short, improvements in the relationship with the self, improvements with the relationships with others, and the subsequent positive alterations to one’s life conditions, all captured longitudinally, offer the ideal framework for research design.

Recovery is a relational event; we must understand that how we define recovery also defines those relationships. Functional improvements are essential, as are long-term health outcomes. Still, neither is more important than how the individual senses their own healing and how that healing is perceived by those whose lives revolve around such an individual. And, as a scientist, whether we can measure this relational space is our methodological challenge. However, this challenge does not give us the right to define things that are easily manageable and intellectually satisfying to ourselves, our institutions, or our funders. The experience of recovery (ie., what we are trying to study) is felt at the kitchen table, in playing catch with one’s children, in showing up to a previous commitment, being emotionally available to support a partner or friend. Recovery experience involves feeling good about these events, in seeing life around oneself improve due to intentionally seeking to improve one’s health as a way of life.

White (2007) noted the tremendous amount of vested interests reliant on the definition of recovery. From treatment to enormously influential governmental and non-governmental organizations, how scientists define recovery affects treatment design, funding, insurance reimbursement, outcome benchmarks, and a whole host of other systems. Given these stakes, in recent years, scientists have noted two key facts. The first is the importance of utilizing lived experience in recovery conceptualization, definition, and measurement. The second is the emerging necessity for the study of recovery to evolve into a branch of science that separates the analysis of recovery from the science of addiction pathology.

Elementary to the justification of recovery science as a distinct branch separate from addiction science is the fact that while addiction itself is a pathology denoted by biological, psychological, and social forms of dysfunction. Recovery, on the other hand, is highly relational, social, and cultural. And while physical and psychological improvements occur (or assisted with therapy and medication), such improvements are often secondary “side effects” to intentional social, relational, and participatory community actions. It is important to understand that social involvement, social health, a sense of connection and meaning are all primary goals for those seeking recovery.

To put it another way, while it is essential to understand the manner and means by which an individual is stricken by addiction, such information is not necessarily a requirement for recovery to occur. This feature of recovery is unique. This uniqueness is because recovery occurs in the real world entirely outside of the clinical and scientific space as a cultural and community effect. People recover all the time without knowing the precise nature of their problem. And yet, if we want to inform the world as to what recovery entails, we must not look for answers stemming from our own understanding of addiction per se. Furthermore, when theories and definitions keep us from seriously considering the experience of recovery in-situ, we must consider the value of such concepts and what our motives may be for using them. Often, this reflexivity has to be an intentional part of the methodological process.

Recovery is enacted, embodied, and lived. Recovery is not a benchmark or an outcome, but rather, recovery is a verb, a state, and a way of being.

Even when recovery is assisted through clinical or medical intervention, recovery manifestation predominantly occurs outside of these spaces. Recovery support occurs through informal social networks, non-professional recovery communities, and public, non-profit organizations. Recovery is not reliant on clinical, medical, or even scientific understanding of recovery itself for healing to occur. To summarize precisely: recovery is defined, enacted, facilitated, and sustained by many forces outside of academic, clinical, and medical space. As such, scientists, medical researchers, and clinicians have been obliged to create fusions with social institutions outside their zones.

However, at times in the past, scientists and medical practitioners have taken this as a license to validate or invalidate forms of recovery experience, to define recovery for their own purposes. This encroachment is a fundamental ethical concern that recovery science must closely monitor. This monitoring and policing of our propensity to encroach on recovery community and culture is our principal ethical obligation.

With the rising opioid crisis, we saw a renewed influx of money and interest into the recovery space. We saw medical professionals for the first time taking seriously the needs of people who struggle with addiction. And while these are significant developments, they do not supplant the existing institutions, communities, definitions, and conceptualizations that have classically defined recovery– any changes in such descriptions and conceptualization must ultimately come from those who have survived addiction disorders (i.e., lived experience). And more precisely, medical professionals and clinicians seeking to address the issues wrought by the pathology of addiction should not be confused or conflated with the lived experience of recovery. This is particularly true of medical specialists- meeting the medical needs of an at-risk population in the midst of a wave of overdose wrought by a tainted drug supply have little experience or authority to weigh in on what qualifies recovery more broadly. Specialization should not be mistaken for generalization.

No matter how well-intentioned scientists may be, and no matter how intimately they may be familiar with recovery, they should be cautious about straying too far from how the people they study define their sense of healing and how these survivors have achieved that healing. This scientific humility will go a long way in the future. The science of recovery requires a de-colonial mindset for the researcher. In this way, recovery science itself requires an ethical reliance on recovery values themselves. We must be honest, self-reflexive, open-minded and we must be concerned and committed to those we study in greater proportion than our own desires for research success. We cannot impose artificial constructs on a community that would disavow such constructs. Why? Because it is a form of oppression and erasure of which western science has a long and tragic history. Let’s not make the same mistake here.

In closing, I would offer a helpful consideration. First and foremost the challenges of capturing lived experience, cultural practices, and social healing are not without precedent. Rather than asking how we can study recovery in ways that may be acceptable to science, journals, funders, and the like, we should instead ask ourselves how we can study recovery in ways that are acceptable to those who are living the experience itself. There is a tremendous amount of scholarship around this, but many of us will have to step outside the rigid structures of our disciplinary fields in order to do this. As an example of broadening our repertoire, it may be time to polish off the ideas of moral psychological realism that posit theory and definitions should come from real-world experience and daily life, and event sampling techniques.

At any rate, as always, I am reinvigorated by these recent debates and I look forward to watching this unfold among my esteemed colleagues and peers.

We only keep what we have by giving it away.

Altruism helps the giver. It’s at the heart of mutual aid and lived experience recovery organisations. This study from a few years back explores some of the issues in family recovery groups.

The researchers in this Finnish research looked at communication and support in Al-Anon groups, a 12-step mutual aid network for family and friends of those with alcohol use disorders. In Finland, 97% of Al-Anon members are female and three quarters are partners of problem drinkers. The academics conducted the research through questionnaires (169) and 20 interviews. In the survey they focussed on two questions:

  1. What elements of supportive communication are viewed as important?
  2. Why are they important?

Four themes came out of the questionnaires that were explored in the interviews:

What insights did the researchers get? Well they found that the feelings of ‘otherness’ caused by being in a family suffering with a loved one’s alcohol problems were addressed by being part of a support network where the positive community aspects of Al-Anon came into play. It was important to members that there was parity between members which helped with feelings of inferiority. In addition the taboo and stigmatised nature of alcohol use disorder in society meant that there could often be few ways to seek support, but Al-Anon provided it. 

Sharing experience was key to healing. Storytelling allows the processing of information but sharing aloud also lets folk analyse feelings and ‘normalise’ difficult experiences. Our narratives are powerful things.

Ultimately the findings underpin an established truth; that, ‘the good of others is the good of oneself,’ a theme that must underpin effectiveness in all the mutual aid groups. The author conclude that the groups give permission for members to ask for help. By helping others, they themselves benefit. There is a functional role created by being a member; you can become and feel useful. Finally, there is the teaching that the only person you can change is yourself, and that is seen as empowering.

This is an study likely to be relevant elsewhere. It takes communication as a theme and explores its agency in Al-Anon groups, identifying and highlighting how human contact and storytelling, ancient and enduring elements of humanity, make practical differences to the lives of families suffering from alcohol use disorder. There is evidence here of the easing of stigma and of the building of self-esteem and empowerment.

There is some evidence that altruism is in some part genetic, but there’s something about warmth, concern and gracious consideration in this paper that makes me want to shy away from a reductionist, scientific explanation. I think the support given to help individuals and families suffering from alcohol use disorders or other drug addiction comes, at least in part, from love. 

Continue the discussion on Twitter @DocDavidM

This is an updated version of a previously published blog

In their 2020 Commentary published in The Journal of Addiction Medicine (a journal of the American Society of Addiction Medicine aka ASAM), Kelly and Bergman state that:

“Individuals with regular and increasing very heavy alcohol consumption cannot be considered as maintaining ‘recovery’ due to toxicity and intoxication-related risks”. 

Why did they publish a commentary about recovery and very heavy drinking being incompatible?

The commentary by Kelly and Bergman is their response to an article published earlier in 2020 in the same journal.  It’s an article by Witkiewitz and others titled, “Can Individuals With Alcohol Use Disorder Sustain Non-abstinent Recovery?  Non-abstinent Outcomes 10 years After Alcohol Use Disorder Treamtent.”  In their article Witkiewitz and colleagues state,

“Nonabstinent AUD recovery is possible and is sustainable for up to 10 years after treatment.  The current findings align with recent proposals to move beyond relying on alcohol consumption as a central defining feature of AUD recovery.” 

Among other points, Kelly and Bergman note:


It looks to me like this is a full-blown open discussion of a recovery definition by academic researchers in the top peer-reviewed literature.  I don’t think the discussion is over with, and it should be fascinating. 


I could say a lot of things about a recovery definition that ignores the presence of drinking and that even ignores drinking at the level of very heavy drinking.  And I could say a lot of things about the Kelly and Bergman response.  For now, however, I’ll go a different direction and make some comments of my own that apply to the topic overall:

  1. I wish Kelly and Bergman would simply say “damage” or “additional damage” instead of “collateral damage” when describing the mental and emotional trauma experienced by those in the home, caused by someone who continues to drink.  To me, “collateral” makes family members sound peripheral rather than sound like people.
  2. The Dry Drunk Syndrome can be terrifying for everyone experiencing it – drinker and family members alike.
  3. Symptom suppression is not enough.  Recovery must be in the “do-direction”.
  4. Very heavy drinking is a danger to self and others. 
  5. It’s interesting to see a recovery definition that seems to come from the perspective of research data alone and removed from clinical experience and lived experience. 
  6. If we are coming at this from a clinical perspective, I wish we would include a focus on prognosis.  That is to say, how do we expect the person to do?  Or, “Are people getting better, or not?”  To me, that is the central question. 
  7. For example, if we are dying now or later from continuing cigarette smoking while drinking nothing, or drinking less, or showing improved psychosocial function, while meeting a new and improved recovery definition, while we continue our very heavy drinking, are we content with that?

For those that are interested, I’ll note that the Kelly and Bergman commentary has already produced a formal and published letter to the editor from Witkiewitz and colleagues. All three references are down below.


I might post more on this down the road.


References

Kelly JF, Bergman BG. A Bridge Too Far: Individuals With Regular and Increasing Very Heavy Alcohol Consumption Cannot be Considered as Maintaining “Recovery” Due to Toxicity and Intoxication-related Risks. J Addict Med. 2020 Oct 14. doi: 10.1097/ADM.0000000000000759. Epub ahead of print. PMID: 33060467.

Witkiewitz K, Wilson AD, Roos CR, Swan JE, Votaw VR, Stein ER, Pearson MR, Edwards KA, Tonigan JS, Hallgren KA, Montes KS, Maisto SA, Tucker JA. Can Individuals With Alcohol Use Disorder Sustain Non-abstinent Recovery? Non-abstinent Outcomes 10 Years After Alcohol Use Disorder Treatment. J Addict Med. 2020 Oct 14. doi: 10.1097/ADM.0000000000000760. Epub ahead of print. PMID: 33060466.

Witkiewitz K, Wilson AD, Pearson MR, Roos CR, Swan JE, Votaw VR, Stein ER, Edwards KA, Tonigan JS, Hallgren KA, Montes KS, Maisto SA, Tucker JA. A Bridge to Nowhere: Resistance to the Possibility of Some Heavy Drinking During Recovery and the Potential Public Health Implications. J Addict Med. 2021 Feb 10. doi: 10.1097/ADM.0000000000000796. Epub ahead of print. PMID: 33577228.

Join us on Monday, April 12th, at 1:00 p.m. ET for the new 2021-2022 Strategic Plan presentation.

Board President Bill Greer and Executive Director Mark Ruth will lead the discussion, sharing information on SMART Recovery’s new plan that includes:

The Zoom event is free with registration. The Zoom link will be emailed to you a few days before event.

We hope to see you there!


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Those who cannot remember the past are condemned to repeat it.” – George Santayana

The other day I was on a zoom call and I could see a poster of local recovery history behind one of the persons I was talking to. I asked about it, and he told me he had stumbled on the poster when a local agency was cleaning out a condemned building. They were going to throw it out. He salvaged it for a local recovery community center because he was in the right place at the right time. I gave him a brief history of what I recalled about the place and the historical significance it held. It was one of the first alcoholism councils in the nation, the Bethlehem Council on Alcoholism. It was started in in 1950 and was renamed before being disbanded in the 1990s. As I got into recovery in the mid-1980s, I knew people who had worked there and how it related to a lot of the local service system.

They were our local pioneers, and it linked back to 1944 and Marty Mann and National Committee for Education on Alcoholism. The very notion that Alcoholism was a disease, and to educate the public on the fact that alcoholism is not a moral failing was a radical concept. I thought back to some of the people I had the opportunity to meet in my early recovery and their significant life contributions to these early efforts. I got help through one of the organizations that came out of this era and later ran it. Their efforts before I was born helped save my life. They developed services for “our people” because no one else cared, a theme that repeats through history as Bill White wrote about.   

So what are we doing to lift young leaders onto our own shoulders? What will they know about how we got here or how to use that knowledge to make educated decisions about where to go next?

We have done a very poor job of transferring our own history on any level, local, state or nationally. We do not transfer knowledge about what we have learned along the way in any organized fashion. As a system, we do next to nothing to groom young leaders with heart for the work to carry the mission forward. We do almost no succession planning. We do not groom younger leaders into roles in which they learn in depth about our systems, our history and our successes and failures. We fail to understand that people with lived recovery experience are the backbone of our care system and we must include them as vital to preparing for future needs.

Forgetting our past and failing to prepare for our future.

Teaching about our collective failures could well save a lot of future pain and suffering so they learn from our mistakes without having to repeat them. Without the life work of Bill White, we would not even have a place to look to go to and examine our history and benefit from the wisdom of the people who have forged ahead of us. His interviews, monographs and papers provide context and insights that would otherwise be lost history. The truth however is that most of our young leaders do not even know of his work or the historic struggles they overcame to realize even the limited successes we see in front of us today.

And now we face an ever-deepening workforce crisis in the SUD care system. We know it is there, SAMSHA recently completed a report showing we need major recruitment across all Behavioral Health Sectors just to stay even with pre-COVID care demand. A decade ago, our annual workforce turnover rate was between 19% and 50%. Since then, annual total US workforce turnover has increased 88%. This Behavioral health study, published in 2020 suggested a 45% annual turnover rate based on its sample. HRSA is going to be doing an additional study.

We are collectively failing in recruitment, retention, and succession planning. Even as treatment and recovery services have never been more needed and institutional knowledge is walking out of doors across our care system.

We are failing in our field stewardship responsibilities to mentor and develop new recovery leaders. Well respected, and deeply contributive organizations whither and fail when new leaders were not properly groomed and steeped in our history or trained to understand the nuances of the work. They do not know what they do not know. A form of Institutional amnesiaAccording to this article, less than half of our Behavioral Health Organizations have any kind of succession planning in place. That we fail to try to develop new leaders to understand the challenges we faced, and the value of historic knowledge is nothing short of a crime.

Most of the perennial studies I have seen over the last few decades raise remarkably similar points about the barriers. It is time to move to solutions. Perhaps we can move more resources into workforce retention and leadership development. We can start with the recognition that people in recovery are the foundation of the SUD workforce. We can build recovery capital by investing in leadership programs that mentor new recovery leaders in every state across the nation. If we do this, we will invest in those with heart, those who stick and stay across an entire career.

Some questions to consider:  

In short, our entire substance use care workforce dynamic can be summed up under the perspective that our futures are inseparably entwined, and we are not investing in it in meaningful ways. We will sink or swim together and unless we put a lot more effort in, my sense is we shall sink. Our future is a collectively bound. We fail when we forget the past and do little to prepare for the future. Let’s do the former rather than the latter.

If there is anything more important that preparing our to sustaining efforts to expand recovery than steeping new leaders in our history and helping them prepare for our future, I do not know what it is.

What is needed:

If any readers in policy positions who want to focus work on this issue or get some of us formerly young leaders who still have heart for the work to put effort here, please count me in. It is one of the things I wish to devote my remaining time on. I want to be part of the solution.

I owe it to those whose shoulders I am perched on, I suspect I am not alone.

The best time to do this was twenty years ago, the second-best time is right now.

Additional Reading links:

Leadership in Addiction Treatment: The Coming Crisis – William L. White (2002) – Link HERE

Calling a New Generation of Leaders – William L. White and Lonnetta Albright (2006) – Link HERE

Staff Turnover in Addiction Treatment: Toward Science-Based Answers to Critical Questions – William L. White, MA and Bryan R. Garner, PhD (2011) – Link HERE

Time to BLOOM — Grow your Recovery Support Network!

If it’s something weird and it don’t look good
Who ya gonna call?
Ghost Busters!

Well…not exactly. Who are you going to call in moments of need throughout your recovery? Who will you call when things are going well? A strong support network is essential to successful long-term recovery. It is important to surround yourself with individuals that understand your situation and support your recovery.

At the beginning of your recovery, you might find that your approach to friendships and relationships has changed for you. You also probably had to leave some of the relationships from your days of active addiction behind you. This doesn’t mean that you’re destined to a life of less connection — no one recovers alone. Learning how to build your network takes time, but here are some helpful hints to get you started:

Actively Attend 12-Step Program Meetings

Many Alcoholics Anonymous and Narcotics Anonymous meetings are currently virtual, but that doesn’t mean you can’t still actively participate in the 12-Step Communities. So long as you have a desire to pursue sobriety, you are welcome in the rooms of AA and NA.

If you’re new to the sphere of 12-Step meetings, stay after and talk to some of the others in attendance, whether that’s in person or in the chat of the Zoom meeting. Those in recovery are almost always eager to help others, and remember—they were once new, just like you. Much like your recovery, sometimes the first step of reaching out when building connections is the hardest part, but it does get easier with practice!

Find a Sponsor

You must find someone with experience and empathy to assist you as you work through the 12-Steps. A sponsor is someone that you feel comfortable being completely honest and open with. As another individual who has worked through the same disease as you, they should understand you and be close to you in your recovery in a way that few others could be.

This is the person who can encourage you when times are tough, and guide you when you feel lost. Those moments will present themselves throughout your recovery journey, and it is important to seek the mentorship and connection of a sponsor in your fellowship. Continue on with attending meetings and connect with as many individuals as possible. As you build relationships, you will know when you’ve found the person who is the right fit.

Reconnect and Rebuild Healthy Relationships

Finally, encourage your family and friends to educate themselves in regard to the disease of Substance Use Disorder. If you are fortunate enough to have maintained a relationship with your loved ones after your time in active use, turn your attention toward improving those relationships through your program of recovery. If you are not in contact with loved ones due to mistakes made during active use, work with your sponsor and in your program on making amends to those individuals you might have wronged.

It may take some education, time, and consistency, but surrounding yourself with your loved ones who want the best for you in your recovery can be an incredibly valuable source of support in your network. Your loved ones can find resources to learn more about your recovery at https://al-anon.org/ or https://www.nar-anon.org/.

***

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.

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