Introspection can lead a person to look at the pluses and minuses of life. It will cause a person to look at things that have been done well and things that could have been done better. It can bring about growth through change. That is the spirit with which this is being written.
As addiction professionals, we have helped many people. Estimates are that we have helped up to 23.5 million people achieve long-term recovery. It’s hard to say exactly how many people with an active addictive disease are still out there.
In the life of an addiction professional and of a person in recovery, the topic of “shame” comes up frequently. It comes up in the treatment setting and in 12-step recovery meetings.
Often shame, or the stigma it creates, is talked about as something that is placed upon recovery by the world outside, a world or culture that we cannot control.
However, we also learn to focus on what we can control. We can control the shame that we create and we can make it go away.
We can control the shame that we create and we can make it go away.
Is it surprising that we may create shame? Maybe one reason that it happens is that we are all products of the culture that we accuse of causing the stigma. We grew up in it and have been influenced by it. So maybe we have accepted shame far too easily.
It may also be helpful to remember that the recovery movement has been heavily influenced by morality, e.g. the temperance movement, religion, the Oxford Group, etc. It has only been more recently impacted by Addictions Medicine.
So maybe we are on the brink of eliminating shame from addictions treatment and recovery? First we have to look at our role in creating it. Do we have the “courage to change the things we can?”
Shame: We Didn’t Intend to Create It
The first publication created by Behavioral Health of the Palm Beaches (BHOPB)’s Research Department was an outcome study published in 2006. At that time, the Research Department consisted of two people, myself and Dr. Donald Mullaney. Though making the phone calls was painstaking and tedious, it was at times very rewarding. As a result of those phone calls a few people got back into treatment and got back on track.
We did the best we could. We had to trust in people’s honesty. It was often hard to track people down. The result was that, our best efforts indicated that 63% of the people remained substance free one year after leaving residential care at BHOPB. We did an honest job. A 63% percent success rate seemed reasonable. We were pleased with ourselves.
We never really paid attention to the finding that 37% of the patients we contacted were labeled “failures.” You were either a “success” or a “failure.” There was nothing in between. After all, it was a study designed to determine our “success rate.”
Creating “treatment failure” led me to start thinking about and paying attention to other ways that we may have unintentionally created shame. Unfortunately, I found a few.
We’ve all heard patients say “I’ve been to treatment before.” Are they saying that they’ve failed before? It has to feel bad. It has to feel shameful. I wonder what it feels like to say “I’ve been to treatment three times before.”
It makes me feel worse when I think about how many times I’ve asked a patient: “How many times have you been in treatment?” What am I really asking? The implication is: “How many times have you failed?”
Shame or the expectation of judgment will keep a person from retuning for help if a relapse occurs. We may deny that this happens, but take a look at treatment plans for all patients who have returned to treatment multiple times. There’s always another First Step and the telling of a story. There’s the assumption that a person who has relapsed didn’t get the First Step. Where in the First Step does it say anything about not drinking?
A person who had established a period of recovery is not the same as a newbee. A person who has experienced recovery has learned a thing or two. It’s likely that a return to social drinking didn’t work. That could be a lesson the newbee has yet to learn. A person coming back likely knows something about 12-step recovery or maybe they know that trying to stay sober without support is really difficult. These are valuable lessons.
The Language of Shame
We tell our patients that they have a chronic disease but we use acute care models. Acute care language has become the language of shame.
We convey the message that you better get well fast and in the way we want you to do it or we don’t want anything to do with you. We have made statements like “come back when you’re ready” or “you need to do more research.”
I hate to admit that I have made similar statements to patients. What was I thinking? Would any one of us have made such a statement to a person with any other disorder?
Similarly, I’ve often heard the expression, ”I’m not going to work harder on your recovery than you are.”
On the other hand, we generally expect a patient to be in denial and ambivalent about recovery. So we expect a patient who is in denial of their disease and probably doesn’t really want to be in treatment in the first to work hard? We can’t have it both ways.
Traditionally, we’ve relied on one particular therapeutic skill to pull a patient out of their denial: confrontation. So if the patient is not shamed enough by this time we yell at them. That may be an overstatement, but not always.
How Do We Fix It?
Neither SAMHSA (2012) nor the American Society of Addiction Medicine (2013) includes abstinence from substance use as a measure of recovery. ASAM defines recovery as “A process of sustained action…in the direction of consistent pursuit of abstinence.” So, as long as a patient is still seeking abstinence they’re still in the game. Why wouldn’t they be? Diabetics with unstable blood sugar levels, but still in pursuit of stability, are never considered to be treatment failures. Only we do that!
If perfect blood sugar was the criteria for the successful treatment of diabetes, almost every diabetic being treated would be a” failure.” A similar argument could be made for the successful treatment of hypertension. Diabetics and people with hypertension are not considered to be “failures” as long as they’re treating their disease. Why not do the same for people with an addictive disease? It doesn’t have to be all or none; success or failure.
How Do We Measure Sustained Action… in the Direction of Consistent Pursuit of Abstinence?”
I think that the answer has to do with keeping people engaged in the process of getting well. We tell patients that we’re treating a chronic disease, but, traditionally, treatment has been heavily loaded on the front end.
We can learn something from how other chronic diseases are treated. Diabetics and people with hypertension will be monitored for their entire life. Can addicts have recovery check-ups with an addictionologist? Check-ups could be quarterly or semi-annual, but it would keep addicts engaged in treatment. There wouldn’t be failures.
There is something to be said for helping people in their “consistent pursuit of abstinence.”
The Term “Outcome” Is Inappropriate
If we’re treating a chronic disease, we’re not measuring an “outcome.” We’re measuring progress at a given point in time.
What a person has learned in the consistent pursuit of abstinence is important and needs to be taken into account when a patient with a history in recovery re-engages into a higher level of care (assuming that we consider that a patient has been engaged in a lifetime process).
It is true that within 12-step recovery a patient would be encouraged to pick up another white chip signifying that the recovery process has begun again. Even within 12-step circles picking up another white chip has been referred to as “the walk of shame.”
It is up to us to encourage a person to perceive it as a “welcome back” gesture.
We need to get better and take responsibility for motivating our patients. We don’t throw people away.
We need to get better and take responsibility for motivating our patients. We don’t throw people away.
Another way that we tell people that we don’t want anything to do with them and create shame is through statements like “come back when you’re ready” or “you need to do more research.” As professionals, motivating patients is our responsibility.
We can get better at motivating our patients and it is important that we do. We can learn to use Motivational Interviewing and Motivational Enhancement to help the people we work with.
What we would never consider doing with other disorders, we should not do with addictive diseases either.
The therapeutic skills of addiction Professionals have vastly improved from the days in which confrontation was the most frequently used counseling tool. Let’s remember that treatment for addicts began by one person helping another. The people providing care were well intentioned but untrained. Today therapists are mostly people with Master’s degrees and have been well trained in the use of therapeutic skills.
It is important to remember, shamed or not, a lot of addicts/alcoholics have gotten well because of devoted, well-intentioned people. We’re just trying to get better.
As a reader you may not agree with every point, but I think that it’s hard to disagree with them all.
It also seems possible to argue that developing a sense of humility is important in the process of recovery. The line between shame and humility seems pretty blurry. Concepts like “powerlessness,” “unmanageability,” and “sanity” may be close to that line. Care needs to be taken when they are introduced.
It Is Also Important to Remember that 12-step Recovery Is to be Respected
We may have to teach patients how to cope with aspects of 12-step recovery that may not be working for them, but there is no support out there that approaches what 12-step recovery can do and has done.
I believe that the major reason to turn away from 12-step recovery is arrogance. People who were never able to manage their addictive disease before treatment somehow think that they can do it now.
People can live with whatever they disagree with. I don’t know of any alcoholic who did a religious survey of bar patrons before drinking with them.
Being Respectful is Part of Recovery
I’ve tried introducing myself at 12-step meetings by saying “my name is Michael, I’m in recovery.” Much to my surprise no one blinked and eyelash and I was not the only one using that or a similar means of introduction.
I know that there are some people who find any change to 12-step recovery sacrilege. The fact is that 12-step recovery does change as culture changes. It would be silly not to and no one has ever accused 12-step recovery of being silly. Forty years ago no one heard “my name is…, I’m an alcoholic and addict.” Like it or not, it happens today.”
Change Happens When It Works
It’s going to take a while before addiction is uniformly treated as the chronic disease that it is. Treatment for addiction needs to become more similar to the treatment of other chronic diseases which recognizes that each disease has its individual characteristics. The intensity of care needs to match the intensity of the symptoms. There should never be a time when an addict is not getting at least periodic recovery check-ups.