By AM Brown
While working on a publication, I wrote a paragraph about recovery culture that brought forth a couple key ideas I think are important to consider. William White wrote this about recovery culture:
“In an era that continues to be dominated by acute care models of addiction treatment, treatment that focuses almost exclusively on neurobiological stabilization (e.g., short-term detoxification, medication with minimal if any sustained psychosocial support), and treatment that views recovery as a primarily physical and psychological process, it is helpful to again remind ourselves of the role of culture in the processes of addiction and recovery. If recovery is for many a journey between two worlds, then there is a need for a fully developed culture of recovery available across geographical and cultural contexts.”
One aspect of recovery that we know for sure is that it largely takes place well outside of the clinical or professional space. It is often said that “treatment is not the gatekeeper of recovery.” I think this is a very important point. All too often the discourse of treatment professionals, scientists, and medical professionals are limited purely to the brief moment in time they work around recovery. A time that, in total, will have little to do with the overall recovery journey of the client. I think scale is important here. Allow me to illustrate with my own personal experiences.
A Question of Scale
From the age of 16 to the age of 30, I spent total of 4 times in acute care rehabilitation. Within that, I met with a professional 2-3 times a week, between group and individual therapy. Less formal group sessions, skill building, meditation, and psychoeducation composed the bulk of treatment hours. That is an average of 16 weeks of acute care, over four treatment episodes consiting of 4 weeks each. Of that, 8-12 total hours per treatment episode were spent in direct clinical interventions. This means that all told, I have spent somewhere between 32-48 direct life-time hours in clinical sessions directly dealing with my psychological needs around substance use disorders. 32-48 total lifetime hours of direct clinical interventions aimed at my chronic addiction issues. That’s a paltry sum.
In comparison, I have spent 87,600 lifetime hours in coninuous recovery. This is not accounting for the other times where I managed to piece together between 6-24 months of recovery. It is highly unlikely that a mere 32-48 clinical hours of intervention were sufficient to initiate and support 87,600 hours of recovery. So where does the actual support for recovery come from?
In my third stay in treatment I had a particularly hard-nosed counselor, herself a recovered crack addict, who had lived a previous life as a prostitute. I do not recall the particulars of the discussion, however, I do recall it was the very first time I was able to grasp the truth around my substance use. I vaguely remember her telling me I was “full of shit” and then she proceeded to explain to me why. A light went on, I staggered out of her office, and sat on the curb outside in the parking lot. It wasn’t enough, but it was something. It was the very first time I had experienced a profound paradigm shift. Was it possible that I was wrong? Was I really out of control? What would happen if I just did what they suggested? Would there be even more truth revealed to me? Greater and more profound realizations? That shift alone was enough to get me to commit to recovery, at least for a while. It is, to this day, the only true awakening I ever had that was spurred by a professional counselor. It opened a door, just a crack. I didn’t stay sober that time, but I did try for the first time.
So while clinical interventions are not meaningless, or pointless, at least for myself, they provided very little in total. And it took a person with significant lived experience (who happened to hold a clinical license), and who had the credibility (lived experience) to forcefully call me out. This brought me (however briefly) to a point of truth about my life. Her truth-telling had less to do with her clinical training, than with her own recovery experience. Her credibility, in my eyes, had almost nothing to do with the license she held, and had everything to do with her ability to transcend her past. A past that her and I happened to share.
So where did the majority of the momentum for my recovery come from if not through professional channels? Quite simply it came from exposure to the lived experience, values, norms, and beliefs of other who had recovered. In other words, it came from exposure to recovery culture, and the shared sense of identity and meaning that I derived from my association with said culture.
Granted this is my own limited experience. However, if we take the broad scientific view of recovery we see that my experience is common. Most recovery occurs through social relationships that have nothing to do with clinical tecnique, and everything to do with building trust through shared experience and identity. This means that recovery is largely a non-professional affair. This is why treatment is not the gatekeeper to recovery. And it is why treatment and medications, in their current forms, really play a minor role in the overall recovery community. This is very important for recovery professionals and researchers to remember. Clinical accounts of recovery are a very small, and exceedingly brief cross-sectional slice of any recovery journey. It is important not to overestimate our importance.
More importantly however, is that it is essential for us to understand, support, and study the cultural aspect of recovery, since, in all likelihood, that is where most of the recovery occurs for the individuals we seek to help. Downplaying such things, while overestimating our own role as clinicians and medical professionals, is the pinnacle of egoism. The most effective professionals are those that humbly understand their roles and seek to prepare the individual for a lifetime of cultural and community involvement that supports recovery. This starts by reminding ourselves that we don’t actually hold the answers, but that we can point people in the right direction and prepare them for engagement.
Between Two Worlds
If we take note of what White says, we see that the clinical space is but a brief rest stop on a long journey, with limited tools, and limited impact. Even if treatment were longer, it would still involve limited clinical work. More important is for our clients to learn to live in recovery. This happens outside the confines of our offices and clinics. Our clients come to us in a state between two worlds. A culture of addiction, and a culture of recovery. In our limited interactions, we must consider what function we truly serve, how limited our role really is, and how best to serve as a signpost for transition. This starts by being knowledgable, and honest. We best serve our clients with the understanding that our role is not only limited, but for many, it isn’t even neccesary. People get well without our help all the time. In comparison to the benefits of recovery culture, our clinical roles are very small, often, but not always, insignificant. That’s a tiny range of influence for some of the authority I see slung around by professionals. We are not the experts. And some of us have quite a bit more credibility than others. This means that for any single professional, their impact is very, very small.
Acknowledging Recovery Culture to Support Recovery
I remember watching an interview with a rural doctor who was providing pharmacotherapy to his clients. He said (and I paraphrase),
“I’ve given him something for his physical dependency. That’s it. He now needs to finish school, find meaningful work, develop healthy relationships, find people with whom he can develop love and trust with, people he can depend on. That’s the real work. What I’ve done is nothing in comparison.”
I think about this comment all the time because it illustrates how much of the work requires that which we simply cannot offer. The best we can do is provide guidance to the recovery world, perhaps confront some of the grosser malfunctions that would absolutely prevent our clients from connecting with others and developing a community that can support them. I believe that when we overstep our boundaries, either as scientists, advocates, or clinicians, we risk a nearsightedness that can at best render us ineffectual, and at worst promote dependency and possibly even death.
When we fail to confess to our clients that the majority of the work will occur through communities and relationships well outside of our office, when we downplay traditional communities, when we over insist that medication is all that is needed, when we take only limited measures of brief moments in recovery – We risk everything. Not only for ourselves but for our clients.
We are merely a helpful guide at a reststop between the world of darkness and the world of light. All we can (and should) do, is point the way, orient our clients to a new world, and send them on their way. The best we can do is to give them the tools to access a recovery culture. That is our best intervention and the best shot they have a life of freedom.
In closing I would say this: The most valuable skill for all of us who work around recovery is to be culturally competent about the recovery community, and to help provide the tools to partake in recovery culture.