Wednesday, November 7, 2007

Choice philosophy gets boost

The choice philosophy that LifeRing advocates, and that forms the core of the Recovery by Choice workbook, has received a major boost from two recent publications by well-known treatment professionals.

The first publication, the report of a 2005 recovery conference under the auspices of SAMHSA, the federal agency, contains a summary of recovery principles beginning with the important basic truth that there are many roads to recovery. An excerpt containing the entire summary is in my New Recovery blog here.

The second is a new monograph titled Recovery: Linking Addiction Treatment & Communities of Recovery: A Primer for Addiction Counselors and Recovery Coaches, by William White, MA and Ernest Kurtz, Ph.D. A PDF copy of the whole 80-page essay is here. It's published by the Addiction Technology Transfer Center, a SAMHSA project.

The Preface, by Charles Bishop and Michael Flaherty, summarizes the main point in these words:
This paper’s most important focus is on recovery and the suffering addict’s (client) needs and perspectives as the most important throughout the entire recovery process. This paper emphasizes how each person has both the responsibility for and a philosophy of choice in his/her recovery. Thus, the counselor and clinical treatment system staff become supporting partners along with a rainbow of community-based, non-professional mutual aid recovery fellowships, all working to help the addict. (emphasis added).
Anyone familiar with modern medicine may be tempted to yawn here, because the concept of patient choice and responsibility is by now entrenched and familiar there (source). But much of addiction recovery is still in the Middle Ages, so the notion that the patient has a choice in recovery -- and that this is to be recognized and supported -- is nothing less than revolutionary. What's even more significant is that this recognition comes from two heavyweight authors with solid-gold credentials in the 12-step universe. White is the author of the definitive history of addiction treatment in America, Slaying the Dragon, reviewed here; and Kurtz's Ph.D. thesis, Not God, is one of the classic texts in AA history.

The authors zero in on the subject of choice on p. 19. After a preface that takes note, without comment, of widespread allegations that the 12-step approach does not work for everyone -- a point that virtually every front-line treatment professional would readily concede -- the authors "recommend promoting a choice philosophy and monitoring each client’s ongoing responses to recovery support group participation."
The Choice Philosophy: A choice philosophy is based on the recognition of multiple pathways and styles of long-term recovery and the recognition of the right of each person to select a pathway and style of recovery that represents the individual’s personal and aspirational values. (emphasis added)
Here's what a choice philosophy would look like in the practice of a treatment center:

■ Professional counselors, recovery coaches and volunteers represent the diversity of pathways and styles of recovery.

■ Professional counselors and recovery coaches are knowledgeable about the full spectrum of religious, spiritual and secular recovery support groups and can fluently express the catalytic ideas used within each of these frameworks.

■ Professional counselors and recovery coaches are aware of patterns of co-attendance (concurrent or sequential participation in two or more recovery support structures, e.g., co-attendance at WFS and A.A. meetings, N.A. participation with later transitioning to A.A. as one’s primary recovery support structure).

■ Individuals and their families are educated about the variety of recovery experiences and the legitimacy of multiple pathways and styles of recovery.

■ Informational materials, lectures and structured exercises that people receive represent the scope of recovery support options, e.g., posting all local recovery support meeting schedules on the treatment agency website and facility bulletin boards, giving each client a wallet card with the central contact numbers of local recovery support groups, profiling local recovery support groups in agency/alumni newsletters.

■ Individual choice is respected; individuals receiving services are not demeaned or disrespected for the recovery support strategies they choose; clinical strategies involve motivational interviewing principles and techniques rather than coercion and confrontation.

■ Professional counselors and recovery coaches are encouraged to self-identify and bring to supervision negative feelings they may have about a particular pathway of recovery chosen by a client.

This is an excellent, useful list. Persons shopping for treatment programs might print it out and ask marketing reps to what extent their facility matches this picture. Patients currently enrolled in programs might use the list to advocate for reforms in the way programs are operated. Staff members could bring up points from the list at staff meetings to suggest improvements in patient services. Program administrators could circulate the list for discussion at staff retreats.

The authors go on to raise some of the central theoretical and practical issues in choice philosophy:

Choice and the Stages of Recovery: To implement a choice philosophy, addictions counselors and recovery coaches must reconcile the philosophical and therapeutic value of choice with the growing evidence of how neurological impairments can impair the choice-making abilities of individuals in active addiction and early recovery (Dackis & O’Brien, 2005). The challenge for the addictions counselor or recovery coach is distinguishing authentic choice from what A.A. calls “stinkin’ thinkin,’” what Rational Recovery calls the addictive voice or “Beast,” what Secular Organization for Sobriety refers to as the “lizard brain,” what LifeRing Secular Recovery calls the “addict self” (versus the “sober self”), and what Christian recovery groups refer to as the “voice of the Devil.” Given the dichotomy between the sober self and the addicted self, the question becomes “Who’s really choosing: Dr. Jekyll or Mr. Hyde?” Some would frame this as separating what each client wants/needs from what his or her disease wants/needs.

One way to partially reconcile this dilemma is to view recovery as a progressive rehabilitation of the will—the power to reclaim personal choice (Smith, 2005). At a practical level, this means that the first day of detox may not be the best time to rely exclusively on client choice. Without rehabilitation of the power to choose and an encouragement of choice, we get, not sustainable recovery, but superficial treatment compliance. To effectively apply a philosophy of choice will require discretion and skill where immaturity, acute psychiatric symptoms, drug impairment and impaired ability to read social cues severely limit choice generation, choice analysis and capacity to stick with any personal resolution. In such cases, we must carefully plot a path between complete autonomy (total choice and clinical abandonment) and paternalism (no choice). Scientific confirmation of this stance is found in a study in which people with severe alcohol problems, recognizing their impaired decision-making capacities, preferred therapist—set goals in treatment; whereas those with less severe problems preferred self-set goals (Sobell, Sobell, Bogardis, Leo & Skinner, 1992).

Creating Informed Consumers: A philosophy of choice is viable only with persons who have the neurological capacity for decision-making, who believe they have the right to make their own choices and who are aware of and can evaluate available service and support options. Creating informed, assertive consumers of addiction treatment and recovery support services can be enhanced by: 1) affirming the service consumer’s right to choose, 2) distributing and reviewing consumer guides on treatment and recovery support services published by recovery advocacy organizations, 3) teaching service consumers how to recognize quality services, 4) encouraging consumers to visit service options before making a decision (versus taking whatever is offered them), and 5) defining the criteria by which the client and service specialist will know if participation in a particular group is working or not working (Bev Haberle, personal communication). Similar considerations need to be extended to educate the family members of those needing or seeking recovery.

There's a lot here, more than will fit into one blog commentary. The authors clearly see the main issues. They have framed the topic in a way that can lead to useful discussion and to therapeutically important program reforms. LifeRing convenors, who have been facilitating the practice of choice philosophy in recovery for a considerable period of time, will have much experience to contribute to this discussion. It is gratifying to those of us who believe that recovery by choice is the wave of the future that these concepts are now being understood, formulated, and endorsed by respected and learned voices in the addiction treatment profession.


Anonymous said...


Anonymous said...

I find it interesting you refer to addiction as a disease. If it is a choice and a lifestyle, can one choose to not be diseased? If its a disease for life how can it then be "cured" by recovery?

Not sure I buy into the disease model, which seems to be a construct the benefits the insurance companies and treatment centers the most. If I did buy it, I don't think I would be sober and clean today. I can't think of any other disease you can set your mind, stand up and walk away from by choice.