They found each other in chat

From the convenor of a meeting in Northern CA:

The coolest thing happened at our meeting a couple of weeks ago. One Saturday morning two women who had never attemped recovery, who had never been in a chat room before both found the LifeRing website on Google and both went in the chat room on unhooked.com. They realized they both lived near [our meeting] and decided to come to the meeting and meet. That was day one for them. They have now been to three meetings and both have three weeks of sobriety and are great friends. It 's an inspiration to us all!

More Help from Professionals

This email came to the LifeRing Service Center a couple of days ago:

Hello LifeRing;

I am researching LifeRing and seriously considering getting a meeting started here in ______. ... I am looking for some guidance on how to become a convenor and start a meeting. ... I have 19 months sobriety this time around, almost exclusively without a 12 step program. I'm a participant at my CDRP at Kaiser Permanente. In fact, it is my therapist who suggested looking into starting a meeting.

I am very impressed with what I've discovered so far about LifeRing. I just finished listening to LifeRing 101 on my computer. I just ordered the workbook and "How's your week" from the website. ...

Any help you can give is greatly appreciated.

[Signature]

Note the line, "it is my therapist who suggested looking into starting a meeting." A very similar thing happened a few weeks ago in another city hundreds of miles away from the above: a counselor not only suggested that the client start a LifeRing meeting but set up the room and the time slot.

Another Professional Seeks LifeRing

Received yesterday at the LifeRing Service Center:

This is ___________ the owner of [Treatment Program]. I have space and would like to have an onsite LifeRing meeting on Friday evenings at our site. The ideal time frame for this meeting to start would be at 6pm and end at whatever the typical time frame is for meetings. We can however be flexible about the time if something else works better.

So, I need a facilitator and help getting it set up and listed. I will do anything you want me to do to help with this process. People being treated at our program would be encouraged to attend as well as it being open to the public. There would be no charge for the use of the space, we just want to offer the support group to our clients and the community.

Our only request would be that the room is cleaned up, materials put away, and that the building is locked up when finished.

Please let me know if this is doable and what are next steps. Thank you advance for considering us to provide this important service.

[Signed]

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.

LifeRing at CAADAC '07

My plan was to leave home at 6 a.m. and arrive at the conference hotel when the Exhibit Hall opened at 7:30, but I overslept my PDA’s alarm and didn’t arrive at the Marriott in Rancho Cordoba, a suburb of Sacramento, until 8:30. That turned out to be fine. The volunteer at the registration desk quickly found my name tag and I as quickly found the LifeRing table in the Exhibit Hall. The exhibit tables were crammed into the hall like sardines, and there was only room for two of our three pop-up displays. Setup took only a few minutes, and – there being no one in the Exhibit Hall but other exhibitors – I dropped in on the plenary opening session in the large ballroom next door.

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