Addiction Counseling as Community Organization

A few recent posts have put Bill White’s paper on Addiction Counseling as Community Organization on my mind.

First, was a post where I wondered if we were at risk for recovery capital becoming a proxy for class. I worried that this could lower expectations for people with lower socioeconomic status and be used as a justification for different standards of care.

Then, a study on the power of access to transportation as a factor in exiting poverty. This got my gears turning about the impact of these kinds of external factors on addiction treatment outcomes.

Next was a post with a rather heated exchange in the comments that discussed socioeconomic class differences in responses to treatment and what to do about them.

And then, a friend shared this study on racial disparities in treatment outcomes:

More than one-third of the approximately two million people entering publicly funded substance abuse treatment in the United States do not complete treatment. Additionally, racial and ethnic minorities with addiction disorders, who constitute approximately 40 percent of the admissions in publicly funded substance abuse treatment programs, may be particularly at risk for poor outcomes. Using national data, we found that blacks and Hispanics were 3.5–8.1 percentage points less likely than whites to complete treatment for alcohol and drugs, and Native Americans were 4.7 percentage points less likely to complete alcohol treatment. Only Asian Americans fared better than whites for both types of treatment. Completion disparities for blacks and Hispanics were largely explained by differences in socioeconomic status and, in particular, greater unemployment and housing instability.

And, of course, addiction treatment isn’t the only aspect of health that’s affected by class. Just today, The Atlantic posted the following:

Brookings economist Barry Bosworth crunches the data on income and lifespans for the Wall Street Journal, and the numbers tell three clear stories.<

Rich people live longer.

Richer people’s lifespans are growing at a faster rate.

The problem is worse for women than for men.

What do we do about this? Do we lower our hopes and expectations for people with lower socioeconomic status?

The Health Affairs article on disparities calls for more services:

States could also offer providers incentives to address barriers to completion of outpatient treatment. For example, homelessness and low education are particularly prevalent among blacks and Hispanics and are contributors to lower completion rates in these groups. Future research might explore whether broadened access to resources such as supported housing and vocational training are cost-effective strategies for improving outcomes and reducing disparities. Efforts to improve the tracking of individual patients could increase retention and improve outcomes, particularly for homeless populations.

Bill’s emphasis is a little different. He calls on us to raise our expectations of ourselves and the system while focusing on recovery and the community as the locus of healing. (Rather than emphasizing treatment at the expense of wellness and glorifying ourselves.) [emphasis mine]

Addiction treatment must always adapt to the evolving context in which it finds itself. Such redefinition may push treatment toward the experience of retreat and sanctuary in one period and toward the experience of deep involvement in the community in another. I would suggest that the focus of addiction counseling today should not be on addiction recovery-that process occurs for most people through maturation, an accumulation of consequences, developmental windows of opportunity for transformative or evolutionary change, and through involvement with other recovering people within the larger community. The focus of addiction counseling today should instead be on eliminating the barriers that keep people from being able to utilize these natural experiences and resources. Our interventions need to shift from an almost exclusive focus on intervening in the addict’s cells, thoughts and feelings to surrounding and involving the addict in a recovering community.

Someone (I can’t recall who) identified 4 tasks of treatment and recovery:

Recovery from the other genetic, biochemical, social, psychological, or familial influences which initially contributed to the development and trajectory substance problems
Recovery from the adverse psychosocial consequences of the substance use
Recovery from the pharmacologic effects of the substances themselves
Recovery from an addictive culture

When I saw this list for the first time, I was struck by the intuitive truth it organized and articulated. I was also struck by how it illuminated the scope of the treatment and early recovery—”social, psychological, familial . . . psychosocial consequences . . . addictive culture”.

That paper on Addiction Counseling as Community Organization was really an early step in the development of his concept of Recovery Management, which is explained more fully here. In this paper, Bill shifts the language to “community renewal.”

A major focus of RM (Recovery Management) is to create the physical, psychological, and social space within local communities in which recovery can ﬂourish. The ultimate goal is not to create larger treatment organizations, but to expand each community’s natural recovery support resources. The RM focus on the community and the relationship between the individual and the community are illustrated by such activities as:

initiating or expanding local community recovery resources, e.g., working with A.A./N.A. Intergroup and service structures (Hospital and Institution Committees) to expand meetings and other service activities; African American churches “adopting” recovering inmates returning from prison and creating community outreach teams; educating contemporary recovery support communities about the history of such structures within their own cultures, e.g., Native American recovery “Circles,” the Danshukai in Japan;

introducing individuals and families to local communities of recovery;

resolving environmental obstacles to recovery;

conducting recovery-focused family and community education;

advocating pro-recovery social policies at local, state, and national levels;

seeding local communities with visible recovery role models;

recognizing and utilizing cultural frameworks of recovery, e.g., the Southeast Asian community in Chicago training and utilizing monks to provide post-treatment recovery support services; and

advocating for recovery community representation within AOD-related policy and planning venues.

It can be overwhelming. But, the alternative is despair.