This week in Scotland we’ve been reeling from the impact of the publication of the 2019 drug-related death statistics. The awful graphs are everywhere, their bright colours standing in sharp contrast to the horror they relate. Our feelings clamour for attention, a powerful mixture of anger, grief, bewilderment and shame.
The newspapers are full of reaction to the statistics; front page bold headlines shout in outrage, editorials call for action. The stories lead on TV news broadcasts. Every morning and evening this week on my commute I’ve listened to radio broadcasters on BBC Scotland debate the issues and heard people, some of whom I know – experts and those with lived experience – interviewed for their reactions. Conversations with colleagues are dominated by the subject.
It’s been an affecting experience, but it’s reminiscent of something – something that disturbs me. It’s reminiscent of the reaction to last year’s drug death statistics publication. The worry I have is that after a fortnight of clamour, the dust settles, the feelings are emolliated, and other issues take the lead in the newspapers and on the TV. Then, if nothing changes, we go through the Groundhog Day again in the autumn of 2021. That would be heart-breaking.
Something changing?
Despite these fears, there are grounds to be a bit more optimistic. I do think the response this year is different. There is an urgency, a collective outrage, a widespread determination to make things different. There is an edge to this that is making us put our shoulders back, grit our teeth and hold our heads determinedly high in spite of the shame.
Journalists, broadcasters and national bodies have given a voice to those not normally heard – the families of victims, those suffering from addiction and those in recovery. This has happened to some extent before, but this year the voices are louder, clearer, more stirring. Out of this I can see a resolve developing that is different to what’s gone before. It’s encouraging.
There’s more though: a potential gamechanger – something I don’t think we’ve seen or heard before. Our First Minister (FM), Nicola Sturgeon, has said with frankness that what’s happening is ‘indefensible’ and that she would take criticism ‘squarely on the chin’.
Every person who dies an avoidable death because of drug abuse has been let down.
Nicola Sturgeon
She also said
We have much to do to sort this out – and sorting it out is our responsibility.
Alan Massie, commenting in the Times, describes this response as ‘unprecedented’ and ‘unusually candid’.
Action
Ms Sturgeon is going to attend the next meeting of the Drugs Deaths Task Force and will report back to parliament by the end of January. When pressed in parliament about poor rehab access, she said she was ‘not satisfied” that the number of rehab beds available was “necessarily sufficient or that they are being used sufficiently”. I hope she’s saying that because she’s been briefed on the Residential Rehabilitation Working Group’s report, published a couple of weeks ago.
Scotland’s had a historical blind spot with regard to residential rehabilitation, but here’s further evidence that things are changing. The Residential Rehabilitation Working Group was set up by Public Health Minister, Joe Fitzpatrick at the end of the summer this year. We were told to start from the underlying principle that everyone who needs rehab should have access to it – a clear commitment to improving things.
The rehab group was allowed to be independent and experienced no interference or even influence by government. Our recommendations were entirely our own and the report was published in full. These recommendations have been welcomed and some resource already allocated to take them forward. Rehab is not the solution to drug-related deaths, but it will have a part to play.
Shared responsibility
While Nicola Sturgeon has taken responsibility for our drug deaths crisis, I don’t think the responsibility is hers alone to shoulder. We all have a part to play. The causes of drug (and alcohol) related deaths are complex and manifold. The solutions need to be diverse.
Harm reduction interventions need to be widely available, accessible, delivered efficiently and proactively and evaluated and improved. Harm reduction services also need to have porous borders with treatment and recovery services and have hope embedded in the form of peers in recovery working within teams. A recovery-oriented system of care sees interventions not in silos, but in a continuum with the individual’s needs at the centre and the person on a journey. The person’s goals, not the professional’s goals (which can be at odds) should be paramount.
Treatment needs to be a full menu of evidence-based, joined-up interventions, accessible when needed, which is funded according to the need of the nation. If we have more than three times the drug death rate of England, the first step needs to be to increase the resource to meet our need. When the last round of cuts came, in my service we were asked to work harder with less resource, which we did for the sake of our patients, but we need so much more than the expectation of workers knuckling down with goodwill.
Research
The part that communities of recovery and those with lived experience can play in alleviating the crisis needs to be better recognised. So much of our research is focussed on the problem and interventions to try to ameliorate the problem. I have no beef about the importance of that. But are we missing a trick?
We have thousands of people in Scotland in long term recovery from substance use disorders. What worked for them? What barriers did they face? Why did they not die from addiction? Why don’t we know the answers to these questions? Those answers will help us. Perhaps some resource needs to be focussed on solutions already experienced. Perhaps then the solutions will grow for others.
Hope instead of despair
Finally, I think that we as citizens and communities need to take responsibility too. It’s our nation’s problem. The risk factors for addiction – trauma, stigma, poverty, lack of opportunity, intergenerational substance dependence, lack of hope etc. – these are not just the responsibility of government. Each of us who feels sorrow and shame over the current emergency can play a part in addressing these. Many already are.
The best way to not feel hopeless is to get up and do something. Don’t wait for good things to happen to you. If you go out and make some good things happen, you will fill the world with hope, you will fill yourself with hope
Barack Obama
Photo credit: istockphoto.com/ZargonDesign (under license)
December 17th, 2020
He who shows himself at every place will someday look for a place to hide. –African Proverb
Earlier blogs in this series explored the benefits and limitations of public recovery disclosure, the potential risks to multiple parties involved in such disclosure, and the ethics of recovery disclosure. In this final blog in the series, we explore guidelines for individuals and organizations aimed at minimizing risks related to public recovery disclosure.
The Decision to Disclose
Before disclosing our recovery status or details of our addiction/recovery experiences at a public level, we suggest giving careful thought to such questions as:
- Is this the right time in my recovery to share my recovery story at a public level? Will this strengthen my recovery or would it be a diversion from more critically needed recovery activities?
- Are there any negative effects for myself, my family, my community, and organizations within whom I am associated that could result from sharing my story in public or professional settings?
- Could such story sharing subject me to discrimination in housing, education, employment, health care, or social and business opportunities? Could it have any legal ramifications?
- Do I have a support system that could help me manage any such effects if they should arise?
- Will I be sharing my story alone or alongside other people in recovery?
- Do the potential benefits of public disclosure as a community service outweigh the potential personal risks?
- Who is controlling how my disclosure will be used and is there an explicit right for me to have the final edit on what elements of my disclosure are presented?
Purpose of Public Disclosure
Many people in recovery will have shared their recovery story with family and friends, with medical and treatment professionals, and with other people in recovery before the opportunity for public recovery disclosure arises. Public disclosure is different from any of these preceding situations and involves a different purpose and style of storytelling.
Public recovery storytelling is about service to a larger cause than self. It is the use of self and one’s own story as a catalyst for personal and social change. With each story sharing opportunity, we prepare ourselves by asking key questions. What do I want members of this audience to understand, feel, and do? How can I present my story in a way that will achieve those goals? How can what I do today contribute to the larger goals of the recovery advocacy movement?
It is important that addiction treatment and recovery community organizations provide a process of informed consent when inviting individuals to share their stories in public and professional contexts. This involves a clear statement of the potential benefits and risks of public disclosure and screening out individuals for whom such disclosures present an unacceptable level of risk. Asking individuals currently receiving services to participate in public story sharing or marketing activities is coercive and exploitive.
Disclosure Preparation
Many of the risks involved in public recovery story sharing can be avoided with adequate orientation and training. Messaging training has been an effective tool used by Faces and Voices of Recovery and other recovery advocacy organizations to prepare people for this unique service ministry. Messaging training spans both the intent and content of public story sharing and the mechanics of effective story sharing (e.g., language, tone, adaptation for different cultural contexts and audiences, etc.). Pursuing these activities within an established recovery community organization helps assure peer and supervisory support for the “ups and downs” of such sharing experiences.
Public Self-disclosure and 12-Step Anonymity
AA, the precursor of all 12-Step programs, promulgated a tradition of personal anonymity at the level of press as both a protective device for AA and as a spiritual principle. Public disclosure of recovery status and sharing one’s recovery story without reference to affiliation with a particular 12-Step program complies with the letter of 12-Step traditions (See Advocacy with Anonymity), but it may not always meet the spirit of the Traditions. This could occur when advocacy is used as a stage for assertion of self (flowing from ego / narcissism / pride and the desire for personal recognition) rather than as a platform for acts of service flowing from remorse, gratitude, humility, and a commitment to service. For members of 12-Step fellowships, adhering to anonymity traditions (in letter AND spirit) in public recovery story sharing is recommended as a protection both for 12-Step programs and for the protection of the recovery advocate.
Timing of Disclosure
Our capacities (energy, abilities, competing needs and demands) for recovery advocacy ebb and flow over time. It is appropriate to ask ourselves if this is the optimal time for public recovery story sharing, whether this is the first time we have such opportunity or whether we need to take a break from such activities during times of personal distress or competing demands that require our focused attention. Warning signs indicating the latter include losing emotional control over the content of our story sharing (via unplanned expressions of frustration, resentment, anger, sorrow) or experiencing boredom or a loss of energy in our public story sharing. Difficult experiences and emotions can be referenced strategically within our talks (once we have emotional control over them), but public and professional meetings are not the appropriate venues to work out unresolved traumas of the past or present. When we drift across that line, it is time to take a break from this public service role.
Scope and Focus of Disclosure
People in addiction recovery have many stories they can share. There is the life preceding the onset of drug use, one’s addiction career, the turning point of recovery initiation, and the story of one’s personal and family life in and beyond recovery. All of these may be touched on in public recovery story sharing, but the emphasis of this story must be on the recovery story and the lessons drawn from it. Great care is required with the media to maintain this focus. There are dangers that others hijack a recovery story intended to lower stigma in a way that fuels stigma, social marginalization, and the criminalization of addiction. We best serve the advocacy movement and protect ourselves by maintaining a focus on the recovery side of our stories and how we escaped the chaos and drama of addiction.
Depth of Disclosure
There exists a continuum of intimacy defining the degree of risk in public recovery story sharing. There are experiences, feelings, and thoughts known only to ourselves that we have not shared with anyone else. There are experiences, feelings, and thoughts we have shared with only within our most trusted relationships. There are the communications we have expressed only within the context of professional counseling, within a sponsorship relationship, or recovery mutual aid meetings. And there are things about ourselves we have shared widely with those we encounter in our daily lives. Such communications range from high emotional risk to low emotional risk. The question is: Where does sharing our recovery story in professional or public meetings, in media interviews, or on social media fit in this continuum?
All recovery story sharing at a public level involves potential risks to ourselves and other parties, but those risks increase in tandem with the level of detail about our experiences contained within those stories. The category “people in recovery” includes highly armored people who are unable to trust others enough to share their real experiences, feelings, and thoughts. Others in this category enter recovery with no armor and no boundaries to facilitate the nuances of self-disclosure and self-protection in different settings and relationships. People existing on the extremes of this continuum from overly guarded to completely unguarded may need greater time in recovery prior to recovery story sharing at a public level. All people on this continuum need guidance and discipline to manage the depth of public recovery disclosure and the discipline to maintain this boundary over time.
Training and supervision related to public recovery disclosure can provide a safe setting in which we can address such questions as the following:
What is the level of risks (who could experience harm and to what degree?) in the following story sharing venues: a social media post; a radio, television or newspaper interview; speaking at a recovery celebration event; speaking to a professional audience; or speaking to a public audience; writing an article or memoir about our recovery experience?
What parts of my story are not appropriate to share publicly? (We want to break no-talk rules related to addiction/recovery, but we want to avoid disclosures that are so intimate in detail that they pose threats to our own emotional health or repel those who hear our story.)
What aspects of my past or present experience remain too emotionally intense to include in my public recovery story? (These are the boundaries we need to define BEFORE we stand before an audience or sit for an interview! Message training and peer supervision can assist this process.)
Have I avoided referencing other people’s stories who might experience harm or discomfort resulting from my disclosure? (It is best to get permission for inclusion of others within our stories, e.g., spouse, family members.)
Have I fully explored why I am sharing my story and sought feedback from other people who know me to understand the nuances and potential unintended consequences of disclosure?
Facing Criticism of Public Disclosure
As a final note, it is not unusual for individuals disclosing their recovery story at a public level to draw criticism for such activities from expected and unexpected quarters. You may be accused of “grandstanding,” “ripping off the program,” violating program traditions,” or be caught in the crossfires of various ideological debates. Some will comment on what you should have or shouldn’t have included in what you shared. Our advice is to have one or more people you are close to who can help you sort such feedback. And to positively use what you can and disregard the rest. Do know that such criticism is inevitable and can help us refine our message and its delivery—even when the criticism is unfounded and prompted by spurious motives.
Closing
We have tried in this series of blogs to explore the purpose, contexts, and risks of sharing our recovery stories at a public level and to explore some of the ethical issues involved in recovery story sharing. It is our hope that these discussions and suggested guidelines will serve as a catalyst for discussion and a tool for the training of recovery advocates who choose to join the vanguard of people who are putting a face and voice to the recovery experience.
Our stories have the power to achieve many things, but we must not embrace total responsibility for eliminating addiction/recovery-related stigma. Those individuals and institutions who spawned and perpetuated stigma and discrimination bear that responsibility. What we can do is offer our stories and our larger advocacy activities to offer hope to wounded individuals, families, and communities and do so in a way that protects our own health and safety.
Link to Blog Post HERE
Twinkling lights, delightful aromas, and joyous celebrations–it’s the most wonderful time of the year! Yet for some, it can be the most stressful time—especially if you’re in recovery. Not to mention, navigating the holiday season mid-pandemic has introduced new uncertainty and stressors to the season of cheer. Though challenging, this season can be made more bearable with a little planning, some support, and a lot of self-care. Here are some tips to stay on track with your recovery and get through the holidays this year with grace:
Make the time for meetings
The world has changed a lot in the past year, specifically the world of recovery. Meetings are available online 24/7 around the world and are only a call or zoom meeting away. If this time of year is typically stressful for you, block out time to attend extra meetings to get the support you need to continue to nurture your recovery. A helpful tip is to attend a meeting prior to your festivities/gathering (even if your family gatherings are virtual!)—many in recovery find this to be a great way to center yourself and calm your anxieties before speaking to family members and friends.
Keep in touch
It’s crucial that you stay as connected as possible with your recovery network during the holiday season. It may be easy to postpone a phone call because you’re busy or you may assume someone else is too busy to hear from you but that’s what they are there for—to support you in times of need. Pick up the phone and call your sponsor or a friend from your fellowship. Remember to reach out before things get hectic, and don’t try to do things alone.
Try to keep your routine
Routines are very important if you’re in recovery. Though gatherings may look different this year, the pressure of shopping, cooking, and giving gifts can still pull you away from your sense of normalcy. You should view the routines that you have as your sacred time, and treat them as such. Perhaps your morning routine involves your daily readings, meditating, or journaling. To the best of your ability, maintain consistency in these areas daily, regardless of travelling or events. Maintaining your “normal” motions can help avoid triggering feelings or stressors.
Remember, it is OK to say no
We say this in recovery often, but boundaries are important—and it is completely okay to say “no” to something that is going to jeopardize your sobriety. Whether the holiday gathering is in-person, or virtual, do an evaluation of who is attending and what type of activities are planned. Then, determine if going will threaten your recovery in any way. If so, don’t feel bad. Just politely thank the host and decline the invitation. People who are in your corner for recovery will understand.
Additional Resources
Investing time to prepare for self–care allows you to think of the holiday season in a different way and marks the start of a new tradition in your life of recovery. This year for many has been tough, and the holidays are no exception. Don’t succumb to feelings of stress, or even isolation. Here are some additional resources for those in recovery this holiday season:
For AA meetings near you, by state https://www.aa.org/pages/en_US/find-aa-resources
For NA meetings near you, by state https://www.na.org/meetingsearch/
Sober podcasts for long drives or to combat feelings of boredom
https://sobercast.com/
NA Speakers on Youtube https://www.youtube.com/results?search_query=na+speakers
AA Speakers on Youtube https://www.youtube.com/results?search_query=aa+speaker
There’s an urgent need to improve our response to Scotland’s drug problems. The focus has quite rightly been on harm reduction interventions, but some (including me) have also called for better access to residential rehab as part of the spectrum of approaches. While clearly not a panacea, could residential rehab make an impact on drug (and alcohol) deaths? It would be good to find out.
Following a survey of the field, the Residential Rehabilitation Working Group has just reported back to the Scottish Government with its findings and recommendations. I’m pleased to say these have been broadly welcomed – the Public Health Minister has pledged £90,000 to take some of this forward.
I’ve written already about what we found and the principles that should guide our work to make things better, but what did we actually recommend? The full recommendations can be found here. I’m going to paraphrase them over two blogs starting today.
- Access
We need to make sure that access to rehab is even and fair across Scotland and Alcohol and Drug Partnerships (ADPs) ought to ensure rehab is available to clients in all of Scotland. A list of providers should be created, we should capture all episodes of residential treatment, and barriers to rehab should be better understood through stakeholder consultation.
2. Capacity planning
Consideration should be given to setting up a needs assessment involving those with lived experience, families and practitioners and we need to measure current capacity understand the reasons for waits and monitor bed usage.
3. Best Value
Funding models need to be mapped and the relative advantages and disadvantages understood. Value for money should be explored.
4. Standardisation
The Scottish Government should consider the establishment of specific standards to support the commissioning of residential placements. This would include, but not be limited to; minimum time in treatment, mental health support including for complex trauma, relationship with communities of recovery, embedded harm reduction principles, housing, education and employability, outcome monitoring, aftercare etc.
5. Pathways
ADPs and the Scottish Government should work together to scope and compare current referral pathways focusing on vulnerable groups and those with the greatest need. Best practice should be developed on pathways into and from residential treatment. Explore diversion from the criminal justice system and in acute healthcare settings directly to residential rehabilitation.
Reflections on the place of rehab
As we’ve been doing this work, I’ve noticed an unhelpful tendency by some to set one type of intervention up against another. From this viewpoint it’s either harm reduction or abstinence or alternatively, it’s either medication assisted treatment or residential rehab.
We can multitask. We can have recovery as a hopeful principle in each harm reduction intervention and we can have harm reduction at the core of what we do in rehabilitation services.
We can have a spectrum of treatment approaches which are joined up and sensitive to the needs and goals of the individual (and their family) at each and every point on their journey. Journeys are rarely linear – people may have to use different sorts of services and interventions repeatedly to reach their destination.
But at the moment we generally don’t have that joined up system with real choice. We’ve found out that some people don’t have access to rehab. For those who do get there, they often report difficulty in accessing it and finding funding.
We need to improve this and my hope is that actioning these recommendations will take us closer to having that joined up system of care.
Picture credit: istockphoto: shpock (under license)
Find Gratitude
Whenever life feels tough, reflecting on reasons for gratitude can be uplifting and help put life into perspective. No matter how challenging life can be, there will always be something you can find to be grateful for. It doesn’t matter how small or seemingly insignificant that thing is, anything positive helps (even if it’s just ‘I’m breathing!’)
Let it go
No, I am not talking about singing that song from Frozen, although the words are rather magnificent! When we fall into rumination and negative thinking, it is really helpful to have a way to release that tension and overthinking. There are many ways to do this. Here are some of my favorite practices.
- Go for a walk.
- Write down how you feel and burn the paper.
- Put on your favorite music and dance.
- Talk to a friend (online or offline).
- This throwing out practice.
Self-care
Self-care is our best friend when it comes to beating stress, especially during the holidays. We get pulled in so many different directions this time of year, with so many people putting demands on our time. There is so much perceived obligation to do things for other people, it can be easy to forget that we need to take care of ourselves. In recovery, at this most triggering time of year, self-care is so important to help us stay well.
Help others
All spiritual traditions understand the importance of helping others. One way you can turn the tables on holiday anxiety, and make it truly memorable and meaningful, is to give to others. This help doesn’t necessarily have to be financial. There are plenty of ways we can help others that don’t cost a great deal of money. Look out for, and spend time with your elderly neighbors! Run errands for them, help them wrap Christmas gifts, or just make sure they are not alone. You could help out at a local homeless shelter, offer support to your local recovery community, or at your church. Look to see where in your community support is needed, and give what you can.
Just say no
Not in the Nancy Reagan sense (because we all know that didn’t work), but let’s remember we can say no to the demands and requests of others. This falls under self-care, but I think warrants its own section, because we are generally so bad at it!
You are perfectly within your right to do things the way you want to do them this holiday season. You don’t have to go to the boozy parties and visit the relatives that you actually can’t stand just because it is Christmas, Hanukkah, or Kwanza. You don’t have to put yourself in any situation that will trigger you.
Obviously, I am not advocating ignoring the needs of anyone else completely, but remember that your recovery is more important than ‘family traditions’ and colleagues’ hurt feelings. It is okay to take care of what you need for your wellbeing.
The holidays have become a massive millstone around people’s necks, and often brings anxiety rather than the joy it promises. Don’t buy into the hype, and make this holiday period one that soothes and nourishes your soul and your health rather than depletes it.
Please tell us how you manage holiday stress. Share in the comments what works best for you!
Esther is from Wales in the UK. She beat 20 years of alcoholism and drug abuse at the age of 41 when she trained to be a yoga teacher. She has been sober since Oct 12, 2014, and has written a book about her adventures (Bent Back into Shape, Beating Addiction Through Yoga).
Esther loves music, Yoga, her babies (three human sons and one dog daughter), walking in the hills and at the coast, and dancing like no one is watching (even when she is at the grocery store!). She is passionate about the power of Yoga to create health and happiness, and believes that through its transformational power, and particularly learning to breathe, we can create space, peace, healing and joy in our lives.
Considerations for the Study of Spiritual Recovery Communities
Alcoholics Anonymous (AA) is not without its critics. Some criticisms are quite valid; others are less so. Like all spiritual communities, be they the Freemasons or the Falun Gong, outsiders often attribute various ills and misunderstandings to AA.
The more valid criticisms, however, have little to do with any of these claims, and in fact, have little to with AA or the 12-Steps more broadly. The most pertinent criticisms involve the all-or-nothing approach of abstinence-based treatment programs, which long ago co-opted the 12-Steps as a for-profit treatment model. Another major issue involves the mandated attendance to AA through the criminal justice system that forcefully exports society’s substance-related legal issues onto a free community resource in order to avoid the cost and responsibility of the state to treat individuals with substance issues.
I should state upfront that researchers should be critical of both these issues. However, in doing so, they must also be wary of carrying on a long tradition of western science with a history of appropriation and the destruction of traditional spiritual communities. These non-professional mutual-aid communities exist outside of the scientific purview, and they exist in resistance to capitalist expropriation. Therefore, they are an ongoing target of the fee-for-service market and the scientific apparatus that legitimates and validates the commodities of medical and psychological services. This biomedical form of capitalism represents a real threat to free, egalitarian, community-based resources when scientific methods and discourses of “efficacy and evidence” are leveraged in ways that seek to disqualify and to dismiss the spiritual recovery of millions as mere “pseudoscience.”
Such attempts to disqualify these spiritual communities through “scientific and medical expertise” therefore raises a dark historical specter with roots in western colonial imperialism that disqualified traditional beliefs and practices of various Indigenous communities and local forms of knowledge throughout the world. Understanding this history is essential. Researchers entering the field of recovery science are part of the neoliberal knowledge production system, clinicians work in monetized arrangements, doctors provide a proprietary service for a fee. Remaining vigilant and cognizant of these facts are essential. The western capacity to damage traditional communities cannot be understated, even when their intentions are good. Researchers living in recovery, such as myself and a handful of others, have a responsibility to guide recovery research in ways that do not harm these communities nor invalidate the experiences we study.
Despite the research on the effects of the 12-Step process and ensuing outcomes, these communities are not treatment programs. The research on the efficacy of 12-steps generally comes from formal treatment models that use a manualized 12-Step facilitation. It is essential to consider the difference between the process of going through the 12-Steps (i.e., “working the steps”) and the community itself as it exists in social and material space. The psychosocial process of the 12-Steps, is separate, though related to the historical, cultural, and communal society of AA. They are self-selecting anonymous society for social support. They are the very definition of mutual aid; a community of voluntary reciprocal exchange, and mutually beneficial support. Meetings are free, open to anyone struggling with alcohol, and they are numerous. According to the General Services Office, worldwide, there are over 2 million members in 180 countries. Virtually every county in the United States has at least one group, and there are over 60,000 active groups in the US alone. It is the “largest club which no one planned to be a member.” For scale, AA is almost twice as large as Rotary International and Lion’s Club, and about 1/3 the size of the international body of Freemasons according to official statistics available from these organization. The 12-Step community in the US is about half the size of the Buddhist community.
Credit: L’arte Industriel. Artist: Boyen
Western Pathological Lenses
Defining what constitutes a pathology in a neoliberal capitalist society generally relies on the idea of a productive function as per market participation. Debilitations, particularly regarding “invisible” pathologies such as psychological depression, are defined by an inability or lack of desire to participate in work, home, and social life. The absent but implicit component of this definition is that one should want to participate, happily and productively. Thus, the lack of ability or lack of desire to participate in one’s work, home, or social life becomes evidence pathology.
Inherent in this formula is the individualization of pathology. Failure to meet the demands of the marketplace resides upon the individual to sort out. And sort it out they must, lest they become a drag of the forces of material production and surplus value extraction. To be unproductive is to risk economic insecurity. This fact is the absolute main driver of consideration and measurement of an individual’s ability to function in society.
Definitions
We must also define spiritual recovery and set this definition apart from the biopolitics of symptom management, death avoidance, and harm reduction measures through public health. Most importantly, we must set spiritual recovery apart from the restoration of productive function that biomedicine strives to achieve through medical or psychological management of troubling or debilitating symptoms.
The word “recovery” is broadly defined as an “individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness” (Ashford, et al., 2019). Furthermore, Recovery-informed Theory states that “Successful long-term recovery is self-evident and consists of a fundamentally emancipatory set of processes (Brown & Ashford, 2019). To synthesize the definition and theory of recovery– recovery is defined as a process that occurs over time, with no endpoint. Ergo it is not an outcome itself, but instead, a unique psychosocial process marked by intrapersonal, interpersonal, and ecological improvements to one’s life quality.
Recovery is considered “self-evident” in that the vast alterations in multiple life spheres when one moves from addiction to recovery are dramatic. The “evidence” of such a change is witnessed across nearly every life domain– from physical health to mutually respectful relationships, an improved outlook and mood, material changes to the quality of life, and ecological improvement in life circumstances such as stable housing, gainful employment, and educational attainment. Only then may we see how one reintegrates into society (functional participation) as but one self-evident benchmark of recovery.
Spiritual recovery, fits within these boundaries, and the pragmatic outcomes of spiritual recovery are both emancipatory, and noted by vast changes across life domains. Self-evident, in other words.
Accepting Spiritual Explanations
We should accept how people articulate their motive and conception. Those who freely seek recovery through the 12-Steps are seeking a specific kind of freedom. For many their drinking is the most expedient means to settle a seemingly innate existential disenchantment with everyday life. This is described on pg. 52 of the Big Book, as an inability to regulate one’s emotions, being uniquely sensitive to depression, feelings of uselessness and unreasonable fears. Conversely what they seek is contained in the so called “Promises” listed here:
“If we are painstaking about this phase of our development, we will be amazed before we are halfway through. We are going to know a new freedom and a new happiness. We will not regret the past nor wish to shut the door on it. We will comprehend the word serenity and we will know peace. No matter how far down the scale we have gone, we will see how our experience can benefit others. That feeling of uselessness and self-pity will disappear. We will lose interest in selfish things and gain interest in our fellows. Self-seeking will slip away. Our whole attitude and outlook upon life will change. Fear of people and of economic insecurity will leave us. We will intuitively know how to handle situations which used to baffle us. We will suddenly realize that God is doing for us what we could not do for ourselves” (Alcoholics Anonymous, 2014, pg. 83-84).
In the preface to the main text there is a letter from one of the leading doctor of the time who offers the view of the role that alcohol plays in the lives of the individual and why they are unable to live without it.
“Men and women drink essentially because they like the effects produced by alcohol. The sensation is so elusive that they cannot, after a time, differentiate the true from the false. To them, their alcoholic life seems the only normal one. They are restless, irritable, and discontented unless they can again, experience the sense of ease and comfort which comes at once from taking a few drinks” (Alcoholics Anonymous, 2001, The Doctors Opinion; Forward to the Second Edition, pg. xxvii-xxix).
And even Dr. Jung, while consulting with a man who would eventually come to be one of AA’s original members, stated, “Here and there, once in a while, alcoholics have had what are called vital spiritual experiences. To me, these occurrences are phenomena. They appear to be in the nature of huge emotional displacements and rearrangements. Ideas, emotions, and attitudes which were once the guiding forces of the lives of these men are suddenly cast it one side, and a completely new set of conceptions and motives begin to dominate them.” (Alcoholics, Anonymous, 2014, pg. 26-27)
If I find these explanations scientifically or intellectually unsatisfying that is no different than believing that I am somehow privy to some form of knowledge that is more important, better informed, and more useful than the very words, quotes, and concepts these communities use to define the nature of reality. Can you imagine walking in to some other spiritual community, listening to them describe their beliefs, practices, ideas, and then saying, “That’s nice and all, but what I believe is really going on here is X, Y, and Z.” Of course not. Thus, it is important that we take the right approach, consider our methods, and think about what forms of truth we are trying to capture.
This BBC story highlights research on dopamine’s role in wanting versus liking:
…wanting is more fundamental than liking. Ultimately, it doesn’t matter for the preservation of our genes whether we like sex, or like food. Far more important is whether we want to have sex, and whether we seek out food.
The single most important implication of the wanting-liking distinction is the insight it offers us into addiction – be it to drugs, alcohol, gambling, and perhaps even to food.
For the addict, wanting becomes detached from liking. The dopamine system learns that certain cues – such as the sight of a coffee machine – can bring rewards. Somehow, in ways that are not fully understood, the dopamine system for the addict becomes sensitised. The wanting never goes away, and is triggered by numerous cues. Drug addicts may find their urge to take drugs sparked by a syringe, a spoon, even a party, or being on a street corner.
But the wanting never ceases to go away – or not for a very long time. That makes drug addicts extremely vulnerable to relapse. They want to take the drugs again, even if the drugs give them little or no pleasure. For rats, the dopamine sensitisation can last half a lifetime. The task now for researchers is to find whether they can reverse this sensitisation – in rats, and then hopefully, in humans.
The science of addiction: Do you always like the things you want?
Does it matter?
Well, of course, better understandings of addiction can lead to better treatments.
I’m also a believer that better understandings of the complexity of addiction will lead to more compassion from providers and the public. Addiction is more than hedonism. It’s a disorder of learning, memory, wanting, liking, the will, decision-making, and more.
Sean Fogler, a doctor in recovery writing on Stat, explains how his dual roles – that of a physician and that of a person with experience of addiction and recovery – gave him a unique insight into attitudes to patients with substance use disorders and mental health problems in health care systems.
He gives evidence of negative attitudes held by professionals towards those suffering with addictions, including the belief that people with addictions are dangerous and should be denied certain rights. He powerfully contrasts this with attitudes held towards other conditions, like diabetes, whose sufferers are generally not discriminated against or shamed for their disease.
Fogler references a recent survey of emergency medicine doctors which found ‘that they had a lower regard for patients with substance use disorders than for patients with other conditions affecting behavioral health’.
People don’t die from overdoses. Though that cause may be listed on their death certificates, they die from trauma and pain, and they die from stigma and the isolation and self-harm that follows.
Sean Fogler
This reminded me of a research project undertaken by a group of medical students that I supervised a few years ago. The group decided they wanted to survey attitudes to people with alcohol use disorder across a variety of settings. They visited GP surgeries (offices), an Accident and Emergency department (ER), a detox clinic, a rehab, an AA meeting and also spoke with an ambulance crew.
What they found was pretty challenging, with evidence of stigmatising language, negative views and an unwelcoming attitude in a variety of settings. The places with the most positive attitudes were in AA, in the detox clinic and at the rehab.
The students were somewhat shocked, but the exercise helped them challenge their own views and we were able to broaden the learning to look at reasons that such attitudes might exist. Not least among those is the fact that the behaviours associated with substance use disorders can be very difficult to manage. But then so can the presentations of other conditions in health care systems which don’t attract stigma.
People who use drugs are marked and judged and confined to cages, cut off from each other, their families, and the connections that can help them heal.
Sean Fogler
Dr Fogler calls for harm reduction interventions to be widely available, and encourages us to embrace any step forward, but is realistic too: ‘More drug and alcohol treatment, medication-assisted therapy, and naloxone distribution are all steps in the right direction, but they will never be the solution to the addiction crisis.’
So what is the solution?
While he says damningly, ‘healthcare systems have weaponized stigma in many forms’, exemplified in the punishment of patients and healthcare professionals with addictions, he calls for a fundamental reform of policies and practice in healthcare to dismantle stigma and improve outcomes, including addressing the harm that comes from criminalisation.
He also calls for a change in the attitudes to professionals who struggle with addiction, saying they must be treated with the same care, compassion and science that everyone deserves. He makes the point that, if we as professionals can’t do this for colleagues, we won’t be able to do it for our patients.
Restoring and maintaining supportive human connections between people with addictions and those able to help them can lead to recovery
Sean Fogler
There’s a sharp edge to Dr Fogler’s analysis, and you can see why. It’s based on evidence of a system that’s not serving those with substance use disorders well, and indeed is harming them by preventing them coming forward or not offering healing. And all of this locked in place through policies that are not working. He’s not unrealistic. He knows the problems are complex.
As we look to next week’s publication of Scotland’s drug deaths figures with some dread, I think there is much in his thinking that might help us here.
Ethics involves the application of moral principles to promote good and prevent harm. Ethical decision-making within our service and advocacy activities is an assessment of the ratio of potential benefits to potential harms in any course of action—with a particular emphasis on “first do no harm.”
Such decision-making involves asking ourselves three questions. First, what parties could benefit or experience harm in this situation (and what is the degree and duration of such benefit or harm)? In our advocacy roles, it is helpful to assess such potential benefits and harms related to ourselves, our families, organizations with whom we are associated, the recovery advocacy movement, and the community.
Second, are there any laws, policies, or historical practices that offer guidance in this situation? This question illuminates the complexities between law and ethics: actions may be legal and ethical, unethical and illegal, legal but unethical, or illegal but ethical.
Third, what ethical values are most applicable to this situation and what course of action would these values suggest? Self-disclosure as an ethical issue has been explored in both professional and peer recovery support contexts (See HERE and HERE), but little attention has been focused on ethical concerns related to self-disclosure within the context of public recovery advocacy. Several traditional ethical values inform decisions related to disclosure of our personal recovery stories in public or professional settings.
Beneficence is the ethical command to help others and not exploit the service context. It invites us to share our story as a means of helping individuals and families suffering from addiction and commands us to focus that story on those in need rather than as an act of self-aggrandizement or a means of pursuing our own interests.
Nonmaleficence is the ethical command to do no harm. In the context of public recovery storytelling, it forces us to assess the timing and the intended and unintended consequences of our public disclosures on ourselves and other parties.
Honesty demands that the recovery story be a truthful representation of our experience. Honesty and candor challenge us as advocates to speak truth to power even when lacking confidence in the authority of our own voice.
Fidelity calls upon us to keep our promises. It asks us to remain faithful to pledges we have made to individuals and organizations. It asks us not to make promises that we cannot keep and to adhere to commitments made in the context of our story sharing.
Justice requires that we acknowledge disparities in recovery opportunities and resources and calls on us to seek equity in such opportunities and resources.
Discretion calls upon us to protect our own privacy, the privacy of our family, and the privacy of others in the presentation of our story. Public recovery storytelling is an act of public service; it is not public therapy or a platform for airing personal grievances.
Self-protection calls upon us in our service roles to avoid harm to self, family, and others. It is an acknowledgment of the legitimacy of tending to our own safety and health. It is a recognition that risks of harm to self and others exist within the public storytelling arena.
There are also values deeply imbedded within the history of communities of recovery that can inform recovery storytelling within public and professional arenas.
Humility reminds us of the dangers of ego-inflation and that we speak not for ourselves but for the experiences and needs of all people seeking and in recovery. (See earlier blog on distinction between recovery rock stars and recovery custodians)
Gratitude is a call to give credit where it is due and to express our thanks to individuals and organizations that made our story possible. We offer our own story in thanks for the meaning we drew from the stories of others at a time we were most desperate for the hope they offered.
Respect/Tolerance is a recognition of the spirituality of imperfection—that we are all wounded in some way, that through this shared brokenness and healing, we can experience profound connectedness. It is an extension of humility and empathy—seeing ourselves in the lives of others and respecting multiple pathways and styles of recovery.
Service is the call to carry a message of recovery to all those who continue to suffer from addiction and related problems. We do that as an act of altruism and as a perpetual step in our own self-healing.
There are many decisions involved in public recovery storytelling. Filtering these decisions through a model of ethical decision-making and core values of recovery can help minimize risk to self and other parties.
Coming Next: Guidelines for Public Recovery Storytelling
Bill White Post of Article link – HERE
There’s a bit of attention being given to residential rehabilitation in Scotland at the moment – something that’s good to see. A working group that I was part of has made recommendations to the Scottish Government which have been broadly welcomed. It’s good to hear that the Public Health Minister, Joe Fitzpatrick, has pledged £90,000 to support implementation.
So, what are the principles the working group developed as a result of the work we undertook? There are nine of them.
- There should be access to residential treatment on an equitable basis across Scotland.
- There should be a clear understanding of need, demand and capacity.
- Funding models for residential treatment need to ensure value for money.
- A standardised approach to support good practice should be developed.
- Referral pathways should be clear, consistent and easy to navigate.
- The approach to providing residential treatment should be underpinned by the evidence.
- The diversity of models needs to be understood.
- The work of improving access to residential treatment should support the work of the Drugs Deaths Task Force.
- Outcomes from residential treatment should be measured, published and monitored.
The reason for each of these statements relates to us either finding evidence of a problem or a gap in our knowledge. We did find much to celebrate too, but it’s developing the areas which need attention that will make things better.
Under each of these principles are specific recommendations which I’ll come back to. For now, it’s clear that we’ve got a bit of work to do, but I’m glad to say that there is a willingness to get it done. A bit of momentum is building which I hope will lead to a better understanding and acceptance of the value of residential rehabilitation and which will make it much more accessible to those who would benefit from it.
A summary of the report can be found here.