Family gatherings, year-end celebrations, seasonal stress: there are lots of opportunities and reasons to drink—and drink heavily —over the holidays. Yet, with a little planning, you can deal with these triggers and urges from a place of personal power.  Consider these five helpful tips to successfully deal with urges and stay sober this holiday season.  1. Identify Your Triggers […]

The first time I guzzled alcohol, I was seven years old. My mom left me with her glass of sauvignon blanc when she went to use the restroom. I sucked down a giant gulp, like I couldn’t get it in fast enough. When she returned, I didn’t say anything, just handed her the plastic cup and went on my way. I don’t think she, in her muddled mind, even noticed. Who would suspect their seven-year-old of stealing their booze?

But that was just the culture, and isn’t it still? Parents drink to forget they’re parents, at least for a little while. At least, mine did.

After that incident with the sauvignon blanc, I drank nothing more than childhood sips of my dad’s beer and half glasses of wine at Christmas. My dad was (is) an alcoholic too.

Then came college. Ironically, my parents had been extremely overprotective of me, so once I got away, I lost myself. I blacked out, my eyes rolling up until only the whites showed. I screamed obscenities, drank and drove, ended up in random guys’ beds, stole liquor, drank at work, almost went off the side of a cliff, slept on the street. At one point a chair got thrown out a window. I don’t know who did it, but I know I was involved. I’d like to blame it all on the alcohol, but it was more than that. It was me. It was my lack of self-esteem and self-respect.

This went on for eight years until I met my husband. After one drunken night where I screamed at him over nothing, I ended up in a tearful ball on the living room couch. My roommate spoke the words that turned it all around: “If you don’t get it together, you’re going to lose him.”

He was worth it.

I moderated my drinking and I did it well. I did it for eight years, even after a debilitating postpartum mood disorder when my daughter was a baby. I drank in a healthy way, and I was happy, well-adjusted, stable.

I was lucky. I was able to moderate when not all can. I was able to make a choice rather than alcohol choosing for me.

After my son was born in 2016, I went off the deep end. Mania, depression, mixed mania, hearing voices, intrusive thoughts about something bad happening to my children that shook me to my core. The medication wasn’t working. Nothing was working. I was sure I could continue to practice moderation, but the alcohol made the symptoms worse. I became sure I would act on the intrusive thoughts.

One fateful night when the cravings got to be too much, the voice of reason too muddled and I gave way. I can’t talk about it. It’s too painful. But the next day I cleaned myself up, stood up tall, and made a decision. I told myself I’d give up drinking for a year.

In a perfect world, all of my problems would have been solved with this commitment to sobriety, but in reality, I was still mentally ill, and I was still incorrectly medicated. It took another nine months to get the medication cocktail right, and a lot of therapy to work through the trauma that haunted me.

But I stayed sober. And after a year of sobriety, even though I’d been mentally stable for six months, I decided that drinking had to be a thing in my past. No more beers with my brother, no more wine tastings with my friends. No more. I had to choose what was more important.

Sobriety with a mental illness is a tenuous thing. One false step could send me into a rage or on a bender.

I have to stop thinking of how things used to be and focus on how they are and how they can be. I have to be better than those who parented me, and I have to stay strong and stay dedicated. I won’t drink to forget I’m a parent—I’ll live to forget I drank.

I see so many amazing warrior moms letting out their battle cry of, “I won’t be like my parents before me! I will give my children unconditional love, free of the confines of the alcohol prison!” Now I add my voice to the fight—because it is a fight. It’s a fight I will win—because my babies are worth it. My husband is worth it. And because I’m worth it too.

This post was submitted by Rachel Nolan.

A Sober Mommies Contributor is most often a non-professional – in and out of recovery – with reality-based experience to share about motherhood & active addiction, the multiple pathways to recovery, or a family member’s perspective.

For a significant number of people in recovery, rehab has been part of their journey, yet the truth is that we know very little about residential rehabilitation in Scotland. 

In the summer of 2020, the Scottish Government public health minister, Joe Fitzpatrick, set up a working group to explore the subject. I was asked to chair the group. We were tasked to take a look at provision; location of rehabs; bed numbers; programme types and duration; referral criteria and support; waiting times; staffing; costs; involvement of families; regulatory frameworks; outcomes; relationship to mutual aid and community recovery resources and finally, admissions and discharges.

How did we do it?

1. We explored the evidence
2. We developed a mapping tool
3. We surveyed the field
4. We reviewed Alcohol & Drug Partnership reports
5. We discussed the findings
6. Finally we made recommendations

What did we find?

We found 18 treatment centres with 365 beds across the country. We estimated that just under 5% of total treatment starts in Scotland in 2019-20 were for residential treatment. This compares to an average (in a 2014 EMCDDA report) of 11% of all treatment in Europe, and 2% of treatment episodes in England.

Across these facilities, around half (48%) of the beds/places were provided by third sector organisations, around a third (33%) by private companies, and a small minority (6%) by statutory providers.

It is estimated that a total of around 1340 individuals started a residential rehabilitation placement 2019-20, with around 830 of these individuals estimated to have been resident in Scotland prior to their placement. There are some caveats around this which we detail in the report.

Access and treatment elements

We found that access across Scotland is not even. The group heard evidence of areas where there was little or no access in practice, with the only option locally being self-funding.

Seventy percent of providers said they used the therapeutic community approach – an evidence-based treatment model. The majority of services offer cognitive behavioural therapy and motivational interviewing. All provided aftercare and assertive linkage to mutual aid. There were high levels of linkage to community recovery resources. 

Two thirds of those responding said they offered family support and many reported integrated peer support. All reported measuring short-term outcomes. Completion rates varied, but were generally good.

Pathways and funding

From our analysis of the thirteen services for which data were available. Alcohol and Drug Partnerships fund only a small proportion of treatment places with the bulk being self-funded or funded through health insurance, benefits or charity.

We also found that pathways to rehab are confusing with a variety of potential barriers in the way and wide geographical variations in referral rates. It’s apparent for many seeking recovery that routes to rehab are not easy to navigate. Indeed it became clear to us that there were lots of unanswered questions. Part of the reason for this is the dire lack of research on rehab (and recovery) in Scotland.

It did seem to us that although we found much to celebrate, we also found that there is work we need to do. That work forms the basis of our recommendations to the Scottish Government. I’ll come back to that in a further blog post. 

Joe Fitzpatrick, the minister for public health, said:

I welcome the findings of the group. This research will help us to improve the provision and quality of residential rehabilitation services

Meantime you can find the published report on the Scottish Government website.

I’d like to thank the members of the working group and everyone else who contributed. Thanks also to Nick, Ruth, David and Anniek from SG for their support, advice and hard work.

Stacey McKeever is a librarian in southern California.  Her lifelong struggle with food addiction has led her to use SMART Recovery as one pathway to maintaining balance in her life.  In this podcast, Stacey talks about: How she was a librarian even before she earned her degree Being put on diet pills at eight years […]

Public Health England (PHE) recently published their summary of what’s going on in substance use disorder treatment in England over 2019-20. Despite the shared culture and proximity of Scotland and England, there’s been a significant divergence in drug and alcohol policy and treatment delivery over the years.

We’ve not been good as we might have been in Scotland at capturing the detail and outcomes of treatment episodes across both drug and alcohol interventions, though that’s about to improve with the introduction of a new monitoring system here.

We still have a strong network of addiction specialists working in the NHS in Scotland while this seems to have been eroded in England and many commentators have highlighted reduced funding south of the border. Having said that, comparisons are difficult and of course we have a much higher drug-related death rate in Scotland.

So, what’s going on in England? The numbers entering treatment are pretty steady compared to last year, at over 132,000, more than half for opiate use disorder. There was evidence over time of a stabilisation of the numbers of people entering treatment after past falls. Sadly, there was a 6% increase in deaths of opiate users in treatment since the previous year. Overall, the number of people in treatment totalled over 270,000.

After opioids, the next biggest group was those seeking help for alcohol use disorder (28%). People seeking help for cocaine (powder and crack) was up, which continues a trend, with crack problem presentations increasing much faster than powder cocaine. Problematic ketamine use seems to be up too, increasing 19% in a year, though the numbers are still small.

Something positive

Of the 118,000 people who left treatment, it is reported that almost half left ‘having successfully completed their treatment, free from dependence’. That suggests that a lot of people met their treatment goals and is encouraging.

Something interesting

Here’s something interesting – 58% of those starting treatment were smokers. That’s much lower than I expected, though still about three to four times the rate in the general population. Sadly, given that 50% of smokers will die of causes relating to that addiction, only 3% were offered interventions to quit.

Something disappointing

According to the European Monitoring Centre for Drugs and Drug Addiction’s 2014 report on Residential Treatment, 11% of total treatment episodes on average across 20 European countries are for residential treatment. In Scotland in 2019-20, we estimate it was roughly 4-5% percent. In England, according to PHE it is 2%. This is down 41% over five years. 

Something alarming

Of those clients/patients leaving treatment, a third of patients left without completing.  For those in the opiate group who left, almost three quarters left without successful completion, which is alarming given the risks around relapse.

For comparison, 59% of the alcohol-only group successfully completed. It would be good to understand what factors are influencing the high drop out rate and what we need to do to get better at holding on to people in the treatment system.

Something missing

On page 37 of the UK Government’s 2017 Drug Strategy there is a commitment: 

We will support local partners to measure outcomes from key processes which promote recovery, including: the proportion of clients facilitated to access mutual aid or peer support. 

UK Government

This is great, as is the PHE toolkit on mutual aid. Connecting to mutual aid is consistently associated with improved outcomes. I’d love to see a similar commitment in Scotland.

I was looking to see how many of the new treatment episodes captured this statistic – the proportion of clients who got plugged in to mutual aid. I couldn’t find a single mention of mutual aid or peer support in the report. That’s something missing which could also be used as a proxy measure of quality for services.

Something reflective

As I’ve been writing I’ve challenged myself on my own practice in each of these areas and I’ve thought about what these statistics might have to teach us in Scotland. I’d like us to do better here too with retention in treatment, smoking cessation, connection to mutual aid/peer support and better access to residential rehab.

I hope you’ll agree, there’s not too much to argue with there.

Photo credit: istockphoto.com/Zmaj88 (under license)

December 3, 2020

A central goal of public recovery self-disclosure is to challenge myths and misconceptions about addiction and recovery through the elements of our personal stories. Recovery advocates must avoid contributing to false narratives by having selective parts of our stories appropriated while ignoring the central recovery message.

Addiction/treatment/recovery-related social stigma and its untoward consequences rests on old and new misconceptions regarding the sources and solutions to alcohol and other drug problems. Such key pillars of belief about the nature of addiction, addiction treatment, and addiction recovery constitute the structural supports of addiction-related social stigma. Below are examples of such pillars (in the stigmatized language in which they have been historically conveyed) and how our stories can be hijacked to support these false narratives

Addiction is a product of moral turpitude (badness) that is best prevented and discouraged by public shaming and other forms of punishment. Acts flowing from this premise began with American colonies forcing those convicted of public intoxication to wear the letter D (for “Drunkard”) on their clothing or to be set in stock in the town square under a sign reading “Drunkard.” The moral turpitude pillar continues to feed social shunning, serves as grounds for divorce, and provides a rationale for political disenfranchisement and discrimination in housing, employment, education, and medical benefits. Overemphasizing or exaggerating the “bad people” we were in the addiction portion of our stories inadvertently feeds this view.

Addicts pass on their degeneracy (“bad seed”) to their children. This pillar of belief has resulted in the inclusion of addicted people in mandatory sterilization laws, surgical sterilization without consent during institutionalization, and loss of parental custody and related legal rights. It also feeds false narratives that paint the children of addicted parents with the same brush, e.g., false narratives of “crack babies” as a “biological underclass.”

The addict is an infectious agent who must be closely surveilled and isolated from the community. This pillar of belief provided the rationale for inebriate penal colonies, prolonged institutionalization in psychiatric asylums, prolonged surveillance (addict registries, prolonged probation/parole), and fed the modern era of mass incarceration.

Addicts pose the greatest threat to the community when they associate with each other. This belief undergirded laws banning addict fraternization and probation or parole violations for associating with other addicts. “Loitering addict” laws provided for the arrest of known addicts for simply being in the presence of other individuals identified as addicts. Policies that dissuade recovery networking and the inclusion of recovery voices in matters that affect us may well be rooted in earlier biases against addicts being with each other.

Addiction does not discriminate. Actually, it does! It was with the purest of intentions that the tagline of “addiction does not discriminate” became one of the public education mantras in the wake of the “opioid epidemic.” It was a way of saying, “See…it could happen to anyone… and now you should care.” This narrative sought to normalize (AKA Whiten) addiction by projecting the image of “innocent,” (AKA White), middle-class children and their parents deserving of public resources to support their care. Such care was advocated as an alternative to arrest and incarceration for the “deserving” (AKA White people of means), while addiction in communities of color continued to be stigmatized, de-medicalized, and criminalized.

Stating that alcohol and other drug problems cross boundaries of race and class in the United States obscures the inordinate toll addiction and drug policies have long taken and continues to take on communities of color and other historically marginalized populations. The addiction vulnerability of these communities stems from historical trauma; social, economic, and political marginalization; and related disparities in access to prevention, harm reduction, early intervention, treatment, and recovery support services. An ethical framework of public messaging and education would call for equity of policy application and resource allocation across all affected communities. Ideally, recovery storytelling would include the stories of people from diverse backgrounds and living circumstances. It is important that through our stories we convey the reality of recovery, the varieties of recovery experience, and the challenges of recovery across cultural contexts.

Addiction is untreatable (“Once a junkie, always a junkie.”) This pillar of belief feeds personal, public, and professional pessimism about addiction and provides the rational for prolonged institutionalization /incarceration as well as justification for harmful and potentially lethal treatment experiments. In the U.S., the latter have included brain surgeries, indiscriminate use of chemo- and electroconvulsive therapies, toxic drug withdrawal procedures, and other harmful treatment methods. Portraying the role treatment played within our recovery stories and the nature and positive effects of modern treatment challenges this misconception.

Treatment Works! is a counter misconception in that it suggests the presence of a uniform protocol of addiction treatment in the U.S. that achieves consistently positive clinical outcomes. It also ignores widespread addiction treatments that lack empirical evidence of their effectiveness as well as the presence of treatments more focused on financial profit than long-term recovery outcomes. This central marketing slogan of the treatment industry misrepresents the highly variable outcomes of addiction treatment, which span minimal, moderate, and optimal effects, as well as harmful effects. Addiction is a treatable condition, but recovery outcomes depend upon numerous personal, clinical, and environmental factors. Great care must be taken in how our stories are used by the addiction treatment industry. What we are offering as advocates is living proof of long-term recovery, not an advertisement for a particular proprietary approach to addiction treatment. (See HERE for full critique of this slogan.)

Recovery is not possible until an addicted individual “hits bottom.” Actually, most people recover from addiction long before “hitting bottom” (losing everything). Addiction-related loss and pain in the absence of hope is an invitation for continued self-destruction. Recovery initiation is the fruit of addiction-related consequences interacting with sources of hope for a healthier and more meaningful life. The “hit bottom” premise suggests that recovery responsibility rests solely with the individual—that there is little family or community can do until that point of individual awakening arrives. This constitutes an invitation for family and community abandonment of those suffering from addiction. This premise is untrue, is not applied to other medical conditions, and should be forever discarded within the addictions arena. We must not let our story be twisted to support this supposition even if we were one of those who did hit bottom and lost everything.

Addiction recovery is the exception to the rule. Actually, recovery is the norm; individuals who do not achieve sustainable recovery are the exceptions. Those who struggle with recovery stability are distinguished by higher problem severity, co-occurring problems that make recovery initiation and recovery more difficult, and fewer natural recovery supports in the community. Even people with the most severe addiction problems can and do recover with more intense and prolonged recovery support resources. We must repel any effort to cast our recovery as the heroic “exception to the rule” and convey the consistent message that no one need die of addiction. Recovery is far more than possible; it is the probable long-term outcome for those who experience alcohol- and other drug-related problems.

Addiction recovery is a brief episode that allows one to then get on with their life. For people with mild to moderate levels of addiction severity who possess substantial recovery capital, recovery may be just that. However, for those escaping addictions marked by severity, complexity, and chronicity, recovery is a prolonged process comparable to the assertive and sustained management needed for other chronic medical conditions. It is important in our stories to acknowledge variability of addiction severity and recovery support resources. Our recovery story is just that—our personal story; it is not the whole addiction/recovery story.

Media channels frequently tell the story of addiction recovery only as a personal story rather than a larger story of the role of family and community in addiction and recovery. The prevalence and severity of addiction are profoundly influenced by social, economic, and political contexts. The recovery tipping point has as much to do with family and community resources and capacity for resource mobilization as it does what is going on inside the addicted person. We serve best when we present our journey from addiction to recovery within these larger contexts and extoll the role of family and community in the recovery process.

Addiction recovery is only achieved through a particular type of professional treatment, lifelong affiliation with a recovery mutual aid society, and lifelong abstinence from alcohol and illicit drugs. Actually, people recover from substance use disorders with, and without, treatment, and through diverse approaches to treatment and recovery support. People achieve recovery with and without involvement in recovery mutual aid groups. Professional- and peer-supported pathways of recovery constitute particular styles of recovery, not the only pathways to recovery. Those involved in treatment and recovery mutual aid represent more severe and prolonged patterns of addiction. There are secular, spiritual, and religious pathways to alcohol and other drug (AOD) problem resolution, and AOD problems can be resolved through styles of sustained abstinence or through decelerated patterns of drug use (the latter most viable for individuals with less severe AOD problems and greater social supports). Our personal story illustrates one within many pathways and styles through which people resolve AOD problems. We preface our stories with “In my experience…” and “What I have observed is…” We are sharing our experiential knowledge, not universal truths that have stood the tests of science or application across diverse cultural contexts.

The above pillars of belief (and the degrading caricatures that often accompany them) serve the interests of multiple parties. They aim to socially stigmatize and discourage drug use. They disparage groups with whom the drug is, correctly or incorrectly, associated. They justify surveillance and over-policing of marginalized communities. And they feed institutional profit. Collectively, these pillars define us as a people as outsiders–outcasts for whom doors of entry into the human community should remain closed.

Our goals run counter to these interests. Our intent is to elicit what Isabel Wilkerson has christened “radical empathy”—the ability of listeners to emotionally project themselves into our experience to the point that they move beyond tolerance and compassion to actions that include us within the human community. This requires framing our stories to elicit conscious awareness that addiction is only one of many forms of woundedness that can and do touch all of our lives, and that recovery mirrors the promise of healing that can follow. The challenge we face is to assure that our recovery stories serve this higher purpose and not feed false narratives that are part of the problem.

Link to Post on Bill White page HERE

Recovery is not only possible, it is common.

Eddie et al, 2020

If you are looking for reasons to be cheerful in these testing times, read on. I’ve been taking a look at a piece of research (1), about to be published, from the Recovery Research Institute in Massachusetts, which examined questionnaire responses from over 25,000 people who identified as having a past alcohol or drug problem which was now no longer problematic. The researchers say that while most alcohol and other drug disorders remit, little is known about the details of people’s achievements on the way. They wanted to shine a light on this. The findings are encouraging and cheered me up.

What’s the point?

The researchers were looking to quantify the achievements gained by people as recovery takes hold. Much addiction research measures the lowering or abolition of negatives (less drug use, less crime, less mental illness, fewer viral infections), but David Eddie and his colleagues had recovery in mind. They cite past research that shows people who overcome alcohol and other drug use disorders often go on to reach many of their goals, get on better with their families and become active again in society. Because of that they become happier, more confident and have improved psychological health.

Why bother?

So why do this research at all? Eddie and colleagues lay out that much of the existing research is on patients in addiction treatment programmes or in mutual aid groups. They wanted a much more representative sample including people who got better without formal treatment. They also wanted to look at the detail. How many saw achievements accruing? When did they occur? What factors were influencing the improvement? So they asked a lot of people a lot of questions to find out.

How did they do it?

The questions were across four themes:

1. Self improvement
2. Family engagement
3. Civic participation
4. Economic participation

More specifically, they asked questions around substance use; mental health diagnosis; treatment; mutual aid; psychological distress; self-esteem/happiness; quality of life; recovery capital and achievements. Achievements included things like volunteering, getting a new job or a promotion, helping others, getting into education, completing education, financially supporting one’s family or regaining child custody, voting, giving to charity, buying a home and/or a car etc.

What did they find?

More than 80% had attained at least one achievement on the researchers’ list and more than 60% had achieved two or more, with achievements growing the longer recovery continued. Black and Hispanic individuals did better than white individuals, possibly mediated by greater family engagement. Those in education seemed to gain more achievements overall compared to those not in education, suggesting education helps multiple trajectories.

Being in a 12-step mutual aid group was also associated with a greater number of achievements overall, driven by greater civic participation – probably related to the 12-step emphasis on helping others. Although the numbers were smaller for non-12-step mutual aid, there were grounds to be optimistic that this benefit may also be true of other mutual aid groups too.

The authors acknowledge that the methods used in the study had limitations and that ‘effect sizes were… generally fairly small’, but that given the complexity and multiple variable studied this was to be expected.

Push and Pull

They also point out that factors that move people towards recovery can be ‘push’ or ‘pull’. Push factors are things like hitting rock bottom or other negative consequences, but pull factors are the positives that come into lives (e.g. achievements) as recovery progresses and these seem to be important for the journey. Indeed, getting better from a substance problem ‘is far more than the removal of alcohol and drugs from an otherwise unchanged life’. It involves the gains, achievements and rewards that are at the heart of the process of recovery.

In my experience, when people report improvements as recovery takes hold, they don’t say ‘I’m grateful I have fewer drinking days’ or ‘So happy I reduced my blood borne virus risk’, they talk about hope, happiness, connection with others and feeling good about themselves again. These are the things that matter most.

Take home message

“Most recovering individuals accomplish several achievements associated with self-improvement, family engagement, and civic and economic participation. Further, these achievements are independently associated with measures of well-being including greater self-esteem, happiness, quality of life, and recovery capital.”

Now, isn’t that something to be cheerful about?

(1) Eddie, David & White, William & Vilsaint, Corrie & Bergman, Brandon & Kelly, John. (2020). Reasons to be cheerful: Personal, civic, and economic achievements after resolving an alcohol or drug problem in the United States population. Psychology of Addictive Behaviors. In press.

A copy of the paper can be requested via ResearchGate. Thanks to Davie Eddie and Bill White for correspondence on the research.

We are pleased to announce the release of our newest Tips & Tools for Recovery that Works! video Overcoming Holiday Triggers.

The holidays can be challenging for those in recovery. The latest video offers ways to help overcome triggers during the holidays.

Click to watch this on our YouTube channel.

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This clip of Hunter Biden has garnered a lot of attention in recovery advocacy circles.

I have mixed feelings.

Her characterization of him being “in and out of treatment 7, 8 times” frames his relapses as a personal failure in a way she wouldn’t frame relapses in other chronic illnesses, even where behavioral strategies are considered important for recovery.

The first part of his response, “say it nicer to me”, made me uncomfortable. It’s possible I’d feel differently if the interviewer was a man, but it felt a little too close to telling her to smile.

Personally, I’m more inclined to tell people the impact of their messages and set a boundary than to tell them what to say and how to say it. (Though I also might get a little prickly during a lengthy interview that was nearly entirely focused on the bad things people say about my personal and professional life.)

What I liked a lot more was his reframing it for her, “sought treatment, for an issue, like most people.” He also told her it came across as insensitive.

One of the things that interesting here is that Robach’s characterization didn’t violate any language do’s and don’ts. Rather, she conveyed a lack of respect and seemed to frame his relapses as failures of character.

Language is important AND people can use all the right words while still conveying and perpetuating disrespect, judgement, and contempt. Further, people can use the wrong words while speaking from a place of respect, compassion, and equality.

Certain words can insert negative valences and embed assumptions into sentences and thoughts. Those words add bias. Discouraging use of these words makes a lot of sense to me.

Other words may not have an innate negative valence or embed assumptions, but can evoke bias held by listeners. Here, I’m not so sure that prescribing language makes sense–the bias is in the person rather than the language. Changing the language here might avoid evoking their bias, but the bias is still there. The bias emanates from the person, not the words.

(That said, avoiding these words might make sense in some contexts. For example, for public educators and people sharing their stories for the purpose of bias and stigma reduction. They would want to avoid evoking bias when trying to convey bias-reducing messages and information.)

We all want to reduce the bias, but how best to do that?

I don’t pretend to be an expert on bias reduction and I don’t presume there is one correct approach.

Undoubtedly, personal contact with people affected by addiction is a critical strategy. (However, even that is fraught. What may help reduce bias for one population, may increase bias for another. For example, while it’s sometimes disputed, education about addiction as an illness and the possibility of recovery may reduce bias toward people with addiction, that same strategy could inadvertently reinforce bias against people continue to use ATOD.)

In the case of language that adds bias, we can educate people about the bias it adds, the consequences of that bias, discourage its use, and provide alternative language.

Where the issue is bias in the person, rather than in their language, this seems more challenging. I wonder what treatment critics can teach us here.

Harm reductionists and treatment critics often criticize treatment as too directive and too confrontive. Motivational Interviewing is frequently pointed to as a better way.

In 2007, Bill White and Bill Miller published an article about confrontation that distinguished between confrontation as a goal vs. confrontation as a style:

In its etymology, the word “confront” literally means “to come face to face.” In this sense, confronting is a therapeutic goal rather than a counseling style: to help clients come face to face with their present situation; reflect on it; and decide what to do about it. Once confronting is understood as a goal, then the question becomes how best to achieve it. Getting in a person’s face is rarely the best way to help them open up to new perspectives. There is, as Hazelden observed in its 1985 recanting of aggressive confrontation, “a better way.” People are most able and likely to re-evaluate reality within safe, empathic, supportive and nonjudgmental interpersonal relationships that do not necessitate defensiveness.

MI asserts that resistance (or discord, or defensiveness) is a product of the relationship. If our goal is for them to come face to face with the the ways their attitudes and behaviors harm others and doesn’t align with their values or self-perception, MI believes that’s best accomplished in the context of a safe and nonjudgmental relationship. It’s in that context that we might be able to find, explore, and develop discrepancy. A confrontive style will interfere with achievement of our goal.

In the past week, there have been a couple of NYT stories that provoked a reaction from recovery advocates. One, about Diego Maradona, celebrated his legacy but click bait teasers said that his addiction “marred” his legacy. The other, about digital 12 step meetings and treatment, used the term “substance abuse” in the headline. I was also involved in a similar issue with a professional association publication where a piece had “substance abuse” in the title.

I detected no disrespect or contempt in the latter two articles, just use of discouraged words. The Maradona coverage seems more loaded with judgement and potentially stigmatizing language (even though it’s not clear to me that it didn’t align with his own framing of his SUD).

If I had to choose between prioritizing changing people’s words or changing their hearts in relation to ATOD problems, I’m much more interested in changing hearts. If we were to change their hearts, their words wouldn’t matter all that much. And, I guess all of this makes me wonder if all the attention on managing what comes out of their mouths, pens, and keyboards distracts us from changing hearts.

I’d also add that there are a lot of groups who are passionate about their particular cause and are trying to change language around their cause. For example, last night I listened to an interview with the founder of PETA who discourages the use of the words “pet” and “owner.” My point here is that members of the media and the public have a lot language direction coming at them, it’s enough that it’s difficult to keep up and enough to evoke some resistance that may have have much more to do with this context than SUDs in particular.

The text below is a post from a while back. It is about the Surgeon General’s attempt to tweet a destigmatizing message that addiction is a disease rather than a moral failing and it happens in good families, including his own. However, he used the word addict, which set off criticism of him for using stigmatizing language. I scrolled through the responses and, fortunately, the nastier responses appear to have been deleted.

Something is amiss in recovery advocacy.

Earlier this week, the Surgeon General’s office tweeted the following paraphrase of a speech given by the Surgeon General. (Later clarified to be incorrectly transcribed.)

Addiction is not a moral failing and that it affects “good” families. Nice message, right? We need more influencers to say the same kind of thing, right? Not so fast.

Recovery advocates corrected him for using the word “addict” (some corrections were pretty generous, others were more scolding) and he responded with the following:

People with addiction have called themselves addicts for decades and I’m not aware of any in-group vs out-group differences in use.

John Kelly (2010) was the first person I recall focusing on the associations people have with various words related to people with addiction. That work has been extended by White, Wakeman, Ashford, and Brown.

This work started with words that have innate negative valences, like “abuse” and “dirty.” It’s since extended into all sorts of other words, like addict, relapse, and involves calls for “person-first language” (which emerged in the late 1980s for other populations).

My memory of the emergence of all of this attention to language was at the level of advocacy with storytelling. As a strategic matter, recovery advocates were encouraged to tell their stories with certain language that was found to be less likely to arouse bias and stigma.

On the one hand, this made pragmatic sense to me for advocacy efforts. On the other hand, this also felt backwards. Abandoning objectively neutral words because some people (usually people who hold a negative bias toward people with addiction) have attached negative associations to them seems like a recipe for tail-chasing. What happens when the new words acquire a negative association? Do we just keep changing terms as people with biases learn them and contaminate the new words with their bias? (Also, who does this put in control of our language?)

We’ve already seen this happen. Opioid Replacement Therapy and Opioid Substitution Therapy were replaced by Medication Assisted Treatment, which is now on the do-not-use list. This creates significant descriptive problems for the sake of stigma reduction–an early recovery advocacy goal was to distinguish treatment from recovery. The new preferred term, Medication Assisted Recovery, conflates treatment and recovery, undercutting a key message of methadone patient advocacy efforts.

From Walter Ginter, medication-assisted recovery advocate:

The problem with the methadone community is we have too many people who think methadone is a magic bullet for that disease—that recovery involves nothing more than taking methadone.

This view is reinforced by people who, with the best of intentions, proclaim, “Methadone is recovery.” Methadone is not recovery. Recovery is recovery. Methadone is a pathway, a road, a tool. Recovery is a life and a particular way of living your life. Saying that methadone is recovery let’s people think that, “Hey, you go up to the counter there, and you drink a cup of medication, and that’s it. You’re in recovery.” And of course, that’s nonsense. Too many people in the methadone field learn that opiate dependence is a brain disorder, and they think that that’s all there is to it. But just like any other chronic medical condition, it has a behavioral component that involves how you live your life and the daily decisions you make.

White, W. (2009). Advocacy for medication-assisted recovery: An interview with Walter Ginter.

So . . . I get the pragmatic and strategic reasons to encourage advocates to adopt certain language but question the wisdom of it. However, this has evolved from a strategy to be used by recovery advocates to a requirement of anyone making public statements on the topic, with call-outs for shaming and being an agent of stigma.

I also don’t understand whose wishes this represents. How many people with addiction object to or feel harmed by the term addict? Hasn’t our message been that we’re resilient and resourceful people who only want the same opportunities as everyone else–the elimination of discriminatory barriers to treatment, employment, school, etc?

I’ve also previously expressed anxiety before about treatment and recovery being drawn into culture war battles. (And, culture wars have only heated up over the last several years.) Of course, this isn’t a culture war hotzone, but the enforcement and call-outs give it a similar feel–that there are sides, and one side is righteous and fighting for justice, while the other side are agents of stigma, injustice, and discrimination.

• At what point do some of these efforts to reduce stigma alienate potential allies? IDK.
• How well do recovery advocates represent to the beliefs, preferences, and priorities of people with addiction? IDK. However, it’s difficult for me to believe that these reactions to this tweet are representative of the views of significant numbers of people with addiction outside of advocacy circles.

I have been thinking lately of the generational shifts in the recovery movement and what it means for our collective future. Young people in recovery face an uncertain future. Less opportunity, less optimism about the future and strained social networks have made things been particularly hard for them. They have been devastated by deaths of despair. They tried to navigate an acute and fragmented SUD care system nearly impossible to use even as their friends and family died from addiction. They have lived through false promises of change that comes with every new funding initiative that never reaches the ground and experienced a myriad of scams associated with patient brokering, urine testing schemes and the business end of the treatment industry. Why would they place trust in us or the SUD care system we have developed over the last five decades? They want change now. Can we blame them for losing faith in us, and the flawed care system we have today? Should they not expect more?

Yet, those of you who are in these generations, I ask you to withhold harsh judgement on us. And I hear back “OK Boomer (although I am a generation Xer), I do appreciate the work done by the generation of recovery advocates that came before me and helped where I could along the way. They gave us what we have today. Consider what they did and not just what they failed to do. Before then we pretty much had nothing. It is important to remember that in 1970, there was no funding for drug and alcohol treatment, just jails, mental institutions, frontal lobotomies and electroshock therapy. Those recovery advocate boomers created our care system.

What they accomplished is certainly less than half a pie, but every sliver took a full court, unified effort with a whole lot of blood sweat and tears. As soon as they achieved that small slice, forces starting whittling away at it. Many of those things stem from the implicit biases that exists against anyone with addiction, persons in recovery and to some degree everyone who is involved in trying to help us. I would point out that in my state (Pennsylvania) reimbursement rates for outpatient treatment were higher in adjusted dollars when I walked into treatment in 1986 than they are now, with roughly a tenth of the administrative burdens. Members of our workforce qualify for welfare, and when people gain experience, far too often they migrate away from this work. Our peer services are moving out of the hands of our recovery community and are being over professionalized. We are repeating pitfalls of the past and failing to heed the lessons of history, yet again. Not much pie left on this fork and every reason to expect change.

I can tell you that there have been a lot of unintended consequences of our “old guard” advocacy efforts. The ones I see without exception are a result of consistently underestimating the degree of stigma and implicit bias against persons with addiction and the recovery community. We advocated for a greater voice in polices and to some degree only accomplished elevating the stigma. We advocated for more resources and when they came, they never reached us and instead went to academic groups and beltway bandits that show up when the grass is green and roll out of town as soon as the resources go away. When they are in town, they dismiss our lived experience, patronize us or shut us out when we raise inconvenient truths. We are patronized by the very systems and services we advocated for.

Yet, the only way through this is always together. History shows us that. You rightly want change now. Experience lends me to be cautious and at times to consider unintended consequences. That may look too cautious to you. A truism is that if you change too quickly or the wrong things in haste, the outcome may not be the one you want.  The gains are typically realized by those who can exert the most influence. It is never us unless we are united.

It is also vitally importance to understanding our own history. People like Bill White who has documented our history are invaluable for understanding the pitfalls and opportunities we face moving forward. The word of caution I would express is to suggest that you not move forward with a mindset that we failed you and the work we did needs to be burned down to the ground, a sentiment I am hearing. If that occurs forces outside our recovery community would use it as an opportunity for further colonization and cooptation. These same lessons are also contained in our own history.

So the question, is as always, what can we build together so that more people can get into and stay in recovery than have in the past?  We are only strong enough to achieve anything when we are all playing the same tune. After spending a whole lot of time listening to our community my sense of that objective is the five-year recovery paradigm.  In this model, we keep people alive through harm reduction efforts, use individualized treatment and a variety of long term, low threshold recovery community support strategies to get people to five years of recovery, the point at which they have an 85% chance of staying in recovery for the rest of their lives

Does this make sense to you my millennial and zoomer brothers and sisters in recovery? If yes or no – lets keep talking and find where consensus lies. Without consensus we will have no pie to carry forward, of that much I am certain.