Monday, October 8, 2007
There, the keynote speaker, a Dr. Kevin McCauley, a former Navy surgeon now running a private addiction practice in Salt Lake City, was holding forth with a PowerPoint slide show on the disease model of addiction. CAADAC is the California Association of Alcoholism and Drug Abuse Counselors, and had chosen a speaker from Utah to kick off its annual event. Dr. McCauley’s talk impressed me with the positive attitude he showed toward addicted people. It was refreshing to hear a treatment professional speak of the good qualities of alcoholics and other addicts, not just of their character defects. He said, for example, that the heroin addicts he knew were “sweet, affectionate” persons, and that addicted persons generally shared character traits of great sensitivity and empathy – traits that they used addictive substances to mask and obliterate. Other aspects of Dr. McCauley’s talk impressed me less. His model of brain functions in addiction was so crude as to be a caricature. He worked the issue of sexuality for laughs like in a sit-com script for a teen audience. He delivered a number of opinions that may have been popular with many in the crowd but were blessed with little in the way of supporting evidence – for example, that author James Frey (A Million Little Pieces) was a “sociopath,” or that people who recovered without treatment were not really “alcoholics." I got the uncomfortable sensation that the doctor was catering to the lowest common denominator – an impression that was shared, it appears, by others with whom I spoke later in the conference. As a keynote presentation, to my mind, it set the bar low.
At the first coffee break I was back at the LifeRing exhibit table. The aisles between the tables were so narrow that traffic was discouraged, and if one person stopped to chat, the aisle was nearly blocked. Nevertheless, people came; and all of them were drug and alcohol counselors.
As I had done at the NAADAC and the APA conferences, I buttonholed people, saying “Let me tell you about LifeRing. LifeRing is an answer to the question, ‘What do I do with clients who are willing to give recovery a shot, but they tell you that 12-step is not their cup of tea.’ Do you have clients like that?”
Not a single person answered in the negative. Some said, “A few.” Many said, “I have a lot of those.” A few counselors said, “Practically all of them.”
“What you can do with those clients,” I continued, “is send them to LifeRing.” While listening for and responding to the customer’s questions, I gathered up a bundle of LifeRing literature and put it in their hands. The LifeRing “magazine” that we published last year was still new to nearly everyone with whom I spoke. The great majority of people who stopped at the table had not heard of LifeRing before, but it seemed to me that the minority who knew our name was a bit greater than at last years’ event in Burbank.
Very gratifying was to hear the number of enthusiastic responses to the presence of LifeRing. A program director from Bakersfield gave me her card and said her facility had available meeting rooms that we could use for a LifeRing meeting, for the asking. A Sacramento program director offered assistance in starting LifeRing meetings there. The owner of an inpatient facility on the coast near Monterey offered to host a LifeRing meeting on their site. Quite a few professionals from Southern California expressed interest in learning about future LifeRing meetings and activities in their area. Several members of the CAADAC board of directors and the organization’s Executive Director, Rhonda Messamore, stopped by the LifeRing table and spoke words of appreciation for our participation.
After the coffee break I had the good fortune to attend a workshop on “What is Recovery and How Do You Measure It” by B.J. Davis, Psy.D., Clinical Director of Strategies for Change, a large outpatient facility in Sacramento. Dr. Davis quoted extensively from published research on treatment outcomes, and supplemented the findings with research projects he had undertaken personally at his facility and in his prior academic positions. The most powerful factor in bringing about successful outcomes, he reported, was the counselor’s ability to forge a therapeutic alliance with the client. The specific counseling ideology, by contrast, was a very minor factor. Accordingly, Dr. Davis said, the counselor’s ability to empathize with and to work out a treatment plan collaboratively with the client was a key to success. The most effective treatment is that which the client is motivated to follow, whatever it may be. The use of positive reinforcement is highly effective, whereas negative reinforcement – punishment – usually fails. Dr. Davis criticized treatment strategies that rely on control. Too many counselors think that treatment is about imposing their program on the client, thus rendering the client even more powerless than before. Treatment should be about empowering the client and working collaboratively. Too many counselors are lazy; they have only one treatment plan for everyone: “get a sponsor, work the steps.” They know nothing else. What would we say to a doctor that handed out Prozac to every patient, regardless of their individual profile? We would consider it malpractice. Yet we do the same kind of thing all the time in drug abuse treatment. Counselors are well-intentioned but good intentions aren’t enough. In conclusion, Dr. Davis presented a number of instruments for measuring the Quality of Life in recovery – based on the profound truth that clients will have difficulty maintaining sobriety unless they achieve a subjectively satisfactory quality of life in their recovery.
Dr. Davis was not only a well-informed but also a powerful speaker, charismatic and humorous, who led his audience forward and upward, even if this meant entering a discomfort zone. The Association would have done well to have selected Dr. Davis as its plenary keynote speaker.
Lunch this day was a two-hour membership meeting, featuring reports by the various officers and committees. I have been a CAADAC member for several years and attended with voting rights, symbolized by a green plastic wristband. I learned among other things that CAADAC has 1,678 full members, plus about 1500 student members and about 1700 “recovery workers” (aides), and that CAADAC is one of nine competing organizations of addiction counselors in California. The highlight of the session was a report from a CAADAC-affiliated project at San Quentin prison, initiated by prisoners, designed to train the inmates as fully qualified addiction counselors on their release. Nine of the eleven inmates who took the test for CAADAC certification passed it. One of the recently released prisoners, Brian Smith, spoke briefly and received a standing ovation. When that was done, there was no time left over for membership Q and A or for floor debate on motions presented, and the session closed without anyone having the opportunity to use the green wristband symbolizing their voting rights.
I spent the afternoon in conversations with visitors at the LifeRing exhibit table and with other exhibitors. Among others, I chatted with the woman at the California Department of Alcohol and Drug Programs about the impact of the recent Ninth Circuit Court of Appeals decision affirming that AA/NA were religious. She was only vaguely aware of the decision. She did not believe that people were coerced into attending 12-step programs, or that they should have the right to sue if they were. She believed that secular alternatives existed everywhere, if the client asked for them. She did promise to take the LifeRing literature I gave her to her supervisor. I also ambled over and had a friendly chat with one of the fellows at the Narcotics Anonymous exhibit table. He told me that NA was able to use the 12-step program and other literature of AA free of charge, whereas all the other “Anonymous” organizations had to pay AA royalties. I explained LifeRing to him and he listened. We had a friendly chat. I cruised some of the exhibit tables representing inpatient treatment programs. One program had only four beds, yet turned a profit. Another did very well with ten beds, even at 80 per cent occupancy. Three of the larger programs occupied adjacent booths and I learned that they were owned by the same company, which owns more than 240 separate treatment facilities nationwide. I met a new hire whose sole job was marketing for one of these programs. I got the impression that there is some serious money being made in the private for-profit treatment industry, even in this difficult economy.
The next morning’s plenary presentation centered on workforce development in the addiction profession. The presenters discussed an ongoing survey of addiction workers, with considerable detail about the questions asked, but little in the way of results, as they had not yet evaluated the answers. Much of the ongoing survey dealt with addiction workers in the public sector (those working for counties, cities, and the criminal justice system). Fortunately there was time for questions. I raised my hand, was recognized, and asked what plans the Association had to help its members working in the public sector in the wake of the recent Ninth Circuit ruling that AA/NA are religious. A counselor in the public sector who gives a client only the choice of “get-a-sponsor-work-the-steps or go to jail” can be sued. What is being done to make secular treatment options and secular support group options more widely available?
After a few clarifying exchanges -- the speaker was not familiar with the decision – the reply was denial that people are coerced into 12-step programs. The speaker thought that secular treatment alternatives were available practically everywhere. He did, however, promise to give the topic further study.
I had unusually heavy traffic at the LifeRing table immediately afterward from people thanking me for asking that question and expressing their frustration at the speaker’s denial that 12-step coercion occurs. It occurs all the time. People shook my hand and smilingly called me a troublemaker, sh*t-stirrer, and similar compliments.
Minutes later the hairy beast was in full evidence. I attended a workshop on “Therapy in Conjunction with Adult Drug Court” – Drug Court being one of the main settings where clients risk being coerced into 12-step programs – and the presenter provided a five-page handout containing on its last page a copy of the 12 steps.
During an early question break, I asked: “I see from your handout that working the 12 steps is part of your Drug Court treatment program.” -- “Yes, that’s right.” -- “And if the client is not compliant with the treatment program, they go to jail, correct?” -- “Yes, that’s right.”
I then explained the Ninth Circuit decision in a few words. The speaker had apparently not heard of it, and manifested some trouble wrapping his mind around the concept of client choice, but with some prompting from others in the audience, he eventually got it. He then retreated into the same denial as I had seen earlier. “Oh well, if the client brings in some other program they want to do, if they’re not just playing games, the court evaluators will certainly look at it.” And, “the county has secular programs available.”
A woman behind me muttered something hostile about “judges legislating from the bench,” and the session showed signs of flying off the rails, but I backed off and the speaker resumed the droning exposition of his counseling approach. After a while I had to leave or risk falling off my chair with boredom. In retrospect I blame myself for not making a bigger fuss over the issue; it might have been a healthy thing, a spur to positive change, not to mention a relief from tedium, for this workshop to blow up in a floor fight over the First Amendment issue.
An excellent workshop followed lunch, titled “The Ethical Issues of Nicotine Use by Care Providers.” The presenter, Steve Sarian, is director of the U.S. Navy’s Drug and Alcohol Counselor School, an ordained Buddhist priest, and a hospice chaplain. He conducted the session in a highly interactive way, which made for a lively time. Sarian was eloquent in showing that nicotine is a mood-altering addictive drug, and that counselors in addiction treatment programs face ethical issues if they are nicotine users. He also cited research showing that alcoholic smokers are more successful in achieving durable abstinence from alcohol if they also quit smoking. Sarian used a light touch in outlining the issues surrounding nicotine use, an approach that was highly effective in stimulating participation and mental processing in the audience. I gave him very high marks.
After a final afternoon session at the LifeRing exhibit table, during which I sold the remainder of the workbooks I had brought, I packed up the displays, left a few brochures and magazines on the table for tomorrow’s session, and hit the road. The big awards dinner in the evening, if it was anything like last year’s, was eminently missable – a round of Good Ole Boys giving each other wall ornaments. The conference program had half a day to run on Sunday, but traffic at the exhibit tables typically would be very light, and several other exhibitors were also packing as I left.
In looking back over this experience, several thoughts occur to me.
(1) It was good to be able to combine the role of exhibitor with the role of meeting participant. Many of the other exhibitors merely sat in the cramped exhibit hall talking to one another or playing games on their PDAs between coffee breaks. Boring. By participating in the workshops I learned things, and I was able on a couple of occasions to ask questions and to raise issues that will in the long term help LifeRing to penetrate the secular market niche where we belong. Being an active participant was also a lot more fun.
(2) The CAADAC organization has a long way to go before it becomes an effective advocate for the addiction profession. Its main problem is that its wheels are stuck in the 12-step rut. Content-wise, the 12-step approach is dead. It cannot be developed further. One can only repeat it as an article of faith, over and over, like a Nepalese prayer wheel. Scientific progress on this basis is an oxymoron. Twelve-step doctrine may be a viable foundation for a lay priesthood, but not for a modern healing profession. So long as this religious doctrine remains the core teaching of the profession, parity with the medical healing professions, which CAADAC so fervently seeks, can never be achieved. Moreover, the constant influx of 12-step recruits possessed of nothing but their personal experience, and willing to work as counselors for the minimum wage or less, means that a general elevation of salaries and benefits, so crucial to professional workforce development, will remain a Sisyphean effort. In order to advance, the association must take a firm and clear stand that personal experience with the 12-step approach is insufficient qualification for a professional. The organization must actively learn, teach, own, and promote secular alternatives, or it will die a lingering death.
(3) The national organization, NAADAC, is probably no less an alter ego of AA than is CAADAC. In both organizations, in any session, if you say “Hi, I’m Joe, I’m an alcoholic,” most people in the room will reflexively respond, “Hi, Joe.” But the eyes are a bit more open and the brains have been working a bit harder in the national group. So, for example, in the national’s conference program in Nashville, the 12-step meetings at the start and/or end of the day were labeled “Optional.” The CAADAC program lists them without that qualifier. NAADAC’s headline speaker was Carlo DiClemente, speaking on Motivational Interviewing – a secular approach that has little in common with 12-step but much in the way of helpful insights for treating addictions. CAADAC’s choice of the doctor from Utah, McCauley, as keynoter, tended to massage the soft belly of the status quo instead of kicking its hind end forward, which is what needs to happen. The NAADAC conference program had only one workshop specifically devoted to a 12-step issue, and that one was canceled. The CAADAC program was larded with pablum for the faithful: “The Medicine Wheel and the 12 Steps,” “A Musical Journey Through the Twelve Steps,” “Spirituality in Recovery” (by Father John), and others; and even where the Step approach was not in the workshop title, it was frequently present in the content, as in the Drug Court program. On balance, therefore, my feeling is that CAADAC’s continued affiliation with NAADAC is probably a good thing to the extent that the more advanced thinking of the national group may be able to pull the local organization forward.
(4) Virtually all the people I met both in CAADAC and NAADAC are sincere, well intentioned, hard working, and approachable. When I first entered these halls a year ago in Burbank I felt apprehensive, as if in potentially hostile territory. I no longer feel that way. These are good people and they can be talked to. LifeRing should definitely continue to participate in these organizations. As more and more of our members become treatment professionals themselves, they should be active in these groups and, in an appropriate situation, play leadership roles. Although there are people in these groups who have tunnel vision, most participants subscribe to the philosophy “whatever works,” and if we can make our aims and methods clear to them, they will be powerfully helpful to us in giving their clients the option of attending LifeRing support groups if they so choose.
-- Marty N. 10/7/07
Saturday, October 6, 2007
A young man came from the Kaiser Chemical Dependency Recovery Program in
A not-so-young man came to the workbook study group, first time, and said that he had been busted for growing marijuana. His case fell under Prop. 36, the
The program director of a new inpatient treatment program in a nearby suburb telephoned the