A few months into my new job working the overnight shift at the in-patient treatment center, the facility experienced its first ever on-campus death from overdose. It occurred while my shift was just getting started. A patient had snuck in some drugs and they killed him. It happened in the wing I supposed to be working in that night, and I arrived on campus shortly after the patient was found, so the on-site nursing staff was still tending to him, attempting to revive the man while awaiting the ambulance. I ended up aiding the medical staff and patients, who were understandably shaken up, but the whole night ended up being sort of a blur. The event was a tragedy, to say the least—an increasingly common end-point of the opioid “epidemic,” resulting from the surge or drugs laced with the incredibly potent synthetics fentanyl (which is roughly 100 times stronger than morphine) and carfentanil (10,000 times more potent than morphine). While unrelated, so as to sync up the timeline, it was around this time where I began retreating from 12-step. Having general insight into the non-organized organizational aspect of A.A. and an increasing level of awareness of the overlap between the recovery community and treatment industry, the lines started to become blurry for me, and I really struggled to maintain a clear perspective. I worked alongside other “wounded healers,” no different than myself, but began to develop a distrust of the system as a whole based on the problematic nature of the overlap between the two worlds, and the tendency for the advice given to those seeking help to be of a clashing—if not outright contradicting—nature based on the source prescribing it.
On the anniversary of an A.A. member’s sober date, they’re encouraged to pick up a commemorative coin, often referred to as a “chip,” to celebrate the achievement. Chips are usually handed out at the end of A.A. meetings by a volunteer member of the group, and it’s encouraged for those who have achieved a particular threshold of sobriety to accept a chip commemorating the achievement, even if only to show “newcomers” that it can be done. These coins are issued for those looking to commemorate 24 hours of continuous sobriety, as well as 30, 60, and 90 days of sobriety, with monthly markers also available up to the year point. After the first year, chips are issued for anniversaries. The four year chip was the final I picked up in the fall of 2019, and by that time I had already largely stopped attending meetings. A contributing factor to this came from an unpredictable source, as a few months after the death at the treatment center, and a few months before my anniversary, I transitioned to a different role at the treatment center, working in the field of peer support.
In Tennessee, where I was living, the state offers a Certified Peer Recovery Specialist program, which aligns with the job I moved into. Per the state, “A Certified Peer Recovery Specialist (CPRS) is someone who has self-identified as being in recovery from mental illness, substance abuse, or co-occurring disorders of both mental illness and substance use disorder. To become certified, a CPRS has completed specialized training recognized by the Tennessee Department of Mental Health and Substance Abuse Services on how to provide peer recovery services based on the principles of recovery and resiliency.” I’ll add to it that the minimum qualifications also include having a GED and two years of self-reported sobriety, so by the time I landed in the position I was well on my way to certification. To sum up the role, my job involved immersing myself in the patient population at the treatment center, sometimes attending group therapy alongside patients, sometimes eating meals with them, always in an effort to share my own experience and build rapport—just what the title suggests: peer support—while also following up with phone calls and text messages once individuals had discharged from the facility to offer support throughout early recovery. Details of the job—and my frustrations with its at-times resemblance to telemarketing—aside, it helped transition me into a paraprofessional role, which I thought would provide helpful experience. As a huge plus, it also served to get me out of the graveyard shift. The job wasn’t without its own problems, however.
Prior to discharge, patients were made aware that someone from the peer support team would be keeping up with them at regular intervals. Ideally that would be someone in my role, who they had met and interacted with before leaving treatment. That wasn’t always the case, however. And if individuals stopped responding to communications, we were encouraged to reach out to any family or friends who had releases of information on file to check in on that person’s well-being. Aside from the problematic aspect of cold-calling strangers who had their own tangled history with the patient we were trying to contact, we would also walk into calls sometimes where we learned that the person we were originally trying to reach had died. Sometimes it would be a patient who went silent for weeks or months, sometimes it would be someone we’d just talked to. I knew several men who died during the six months I was in that role. It was not uncommon.
There’s a cottage industry which has been built around supporting roles to assist those struggling with addiction, including such titles as interventionist, sober transports, and sober companions. Within this complementary bubble which surrounds the treatment industry is where the role of peer support also exists. There’s nothing clinical about the position, per se, as it’s instead based upon a principle established by Carl Jung suggesting that “only the wounded doctor can heal.” This is where the term “wounded healer” comes from. A decade ago I was far more critical of this concept than I am now, though not only because of my own experience moving through the professional side of treatment, but through a gained understanding of the broader mental health field and those working within it. Besides the previously mentioned study addressing “wounded healers” within the social worker field, at the clinics I did my masters-level internships at, it wasn’t just commonplace for counselors or therapists to have personal experience with their area of therapeutic expertise—whether that be addiction, ADHD, OCD, etc.—it was the norm.
In terms of peer support, from an outside perspective, one might wonder what the benefit of such a role might offer compared to readily available support from peer support groups like A.A. At the time I went through the training, the state of Tennessee accounted for over 1,000 individuals who had become accredited as Certified Peer Recovery Specialists. Besides having lived experience from which to draw upon in the support of newly sober individuals, the training focuses on a variety of areas including Motivational Interviewing techniques, role mentoring, and guidelines for ethical care. The CPRS handbook calls out some of the differences which are meant to separate peer support and peer support groups, but the lines delineating the two are blurry in practice. In the opaque space between my professional role and personal recovery, where I was talking about recovery all day every day with people at work, then expected to maintain 12-step group participation on my own time, I found myself increasingly drained. “It’s strange,” I wrote in a December 2019 journal entry, “I haven’t had a drink of alcohol in over four years but I talk about it every day.”
Unintentionally coinciding with the kick-off of the pandemic, I transitioned into a peer support role at a healthcare start-up in March of 2020. Part of my duties there included resource gathering in support of aligning clients with local support networks. While all in-person peer support groups began to shut down around this time, many transitioned online, where virtual groups attempted to fill the need. To be transparent, I can’t speak for how well any of these groups have rebounded after things began to open back up, but even prior to that point in time, non-A.A. groups such as SMART Recovery and Recovery Dharma were only ever scattered in my area. For comparison’s sake, in the spring of 2020 there were over 300 A.A. groups across middle Tennessee offering in person meetings, while SMART Recovery offered seven, with no presence in outlying towns outside of Nashville (where I was living); in person Women for Sobriety meetings are even more scant, Moderation Management groups have transitioned almost exclusively online, and in Believed to Be Seen I regularly mentioned groups like Rational Recovery, but their website doesn’t even resolve anymore. My hunch is this sort of representation isn’t exclusive to the area I was living in.
The reason for bringing all this up is because it paints the landscape for which peer recovery and peer support both exist. There are resources available, though they are primarily based around 12-step methodology. (Aside from A.A., the second most prevalent group for those seeking help with an alcohol addiction where I was living was Celebrate Recovery, which is a Christ-centered 12-step peer support group.) From a perspective of someone seeking help, it is possible to find that help outside of A.A. Possible, yes, but without a doubt more difficult. From the side of someone who’s providing peer support in a professional capacity, a different challenge arises when attempting to offer a person-centered approach, matching an individual with a group that would best suit them… If nothing exists in someone’s area besides A.A., that limits the scope of assistance that can be offered. And if a professional peer’s lived experience is rooted in a recovery methodology like A.A., as mine was, there was no way not to become an inadvertent spokesperson for A.A., as would occasionally happen for me and others I knew who were in that role. I, or any of my colleagues, could only provide information within our lane based off of our individual experience, but when meeting someone who knows nothing of Alcoholics Anonymous, or recovery for that matter, that peer’s individual experience—for good or bad—contributed to an educational foundation. This, as a reminder, is slightly perpendicular with A.A. tradition, and brings me back around to the problematic nature of conflicting recovery methodologies.
I might be making a bigger deal out of this than I should be, but the peer support role did have a significant influence on a sense of internal conflict surrounding how to best help both myself and others in need. In A.A. groups, my lived experience was helpful in connecting with people, to show those still struggling how someone else has been through it, and communicate that there’s hope for better times ahead. Without the outreached hand of a similar person before me, my world would be drastically different now. In the peer support world, however, a conflict began to eat away at me based around a sense that my story was merely becoming professional currency. Whether true or merely a misguided thought that had arisen in my own mind, I believed the foundation of my qualifications in the peer roles I’d adopted was primarily based on whether I had gotten sober or not, and whether I had been able to continue to refrain from drinking alcohol or not. That was it. Along with the aforementioned concerns outlined around safety within the fellowship, I was becoming less and less invested with group’s methodology, and the perfect storm of it all signaled the end of my personal/professional relationship with A.A. Save for a few scattered online meetings I attended in the first months of the pandemic, I haven’t returned.
As I’ve tried to outline with everything to this point, it should be understandable as to why and how it’s so easy to still consider Alcoholics Anonymous as the best option for those seeking immediate, free support for their addiction. But another factor for what was skewing my perspective was the difficulty I was having in promoting A.A.’s abstinence-only model to others. This might be a misguided way of looking at it, but what first started to influence my perspective about this was my own ongoing problematic relationship with eating. In July of 2016, not even a year into my sobriety from alcohol, I wrote in my journal, “I feel like I can’t survive without over-eating right now.” And I can’t begin to count the number of times I’ve felt that since. But when I raised the idea of struggling in that area within my men’s group, as part of the broader discussion around using external sources to escape my internal feelings, I was practically mocked. I vividly remember another group member saying, “Let me put it this way, no one’s ever been pulled over for driving under the influence of ice cream.”
A minority of those with a drinking problem seek help, and only a fraction of those who do end up in Alcoholics Anonymous. Once in A.A., problem drinkers are told to follow an abstinence only model. But when I was looking at myself as objectively as possible, at no point in my recovery have I had a prolonged period of abstinence related to a more abstract notion of emotional sobriety. Don’t get me wrong, I haven’t had a drink of alcohol since October 20, 2015, but so often I’ve used food as a placeholder. If I’m relating my broader experience to A.A.’s first step, which states “We admitted that we were powerless over alcohol—that our lives had become unmanageable,” there are definitely times in the past several years which I have felt truly “powerless” over my desire to eat, and that consistently maintaining a healthy weight certainly fits the bill of being “unmanageable” in my life. I’d be lying if I said anything less.
It’s worth noting that there is significant value in the all or nothing approach as it relates to alcohol, for me. I don’t have any misgivings about that, and recognize that any feeling telling me I could somehow return to a healthy level of drinking is an extreme red flag. To say that I could drink again in a healthy or normal manner would be to welcome denial back into my life in a way that I understand can only have one singular resulting outcome: Death. But, projecting that same ideal onto others going through their own problems is tricky business, particularly when starting to look outside of the problem of alcohol and at the broader landscape of addiction.
No doubt if you’re here reading or listening to this, you’ve heard of the opioid “epidemic” in America. This is criminal in its oversimplification of what’s happened, but an increasing trend surrounding questionable practices of prescribing opioids (and subsequently anti-anxiety meds like Xanax) have influenced surging rates of those reliant on (largely) legally prescribed prescription drugs. Because of relaxed prescribing policies, too many drugs were issued without enough caution, and due to the highly addictive nature of those drugs more people began to develop a dependency on them. Unforeseen consequence of this came in part due to the ongoing expense of those prescription drugs, pricing individuals out of maintaining their prescriptions once a physical reliance upon them had developed. Another angle came through having the prescriptions run out once the physical dependency has taken hold, which has also led many people to securing those drugs through alternative sources. Additionally, aligned with addiction is tolerance, and because of that, the same volume and frequency of use that soothed one’s pain yesterday—or provided a good feeling—doesn’t work as well today and tends lead to increased used over time. Again, this is a vastly oversimplified picture of how someone makes a leap from an Oxycontin prescription to heroin use, though it’s a far less uncommon leap than you might imagine. And because street drugs are becoming increasingly likely to include a potent synthetic like fentanyl, users are more likely to overdose from them, which has led to the increased spike in drug-related deaths. There’s the “epidemic.”
The point here isn’t to debate what addiction is or what’s at the heart of the opioid epidemic, but rather to question the abstinence only treatment model within the context of today’s treatment landscape. Within this discussion come something like Suboxone, for example, which is a broadly utilized medication in the treatment of opioid addiction. Suboxone works as a “partial antagonist,” which means that it can help with a physical dependency to opiates by curbing significant withdrawal symptoms without providing a “high.” Here’s the thing though, Suboxone isn’t something that a user can just stop taking overnight if they decide they no longer want to be on it, as that would provoke the same wave of withdrawal symptoms that it’s being used to stave off in the first place. In a perfect world, Suboxone use would be closely monitored by a physician as part of a more robust aftercare plan, which might also include therapy or a lower level of care for addiction treatment, and the dosage would be slowly and carefully be tapered off. The duration by which a Suboxone prescription is tapered off from is based on prior levels of opioid usage, however, and this is further complicated by the level of chemical dependency reported by that particular individual and the perceived risk of relapse they might have without the assistance of the drug. That could mean that they’re on it for months or years, if not indefinitely. I’ve heard 12 Step group members (whether it be Alcoholics Anonymous or Narcotics Anonymous) refer to Suboxone as watered down whiskey because of this… framing it as a less legitimate form of recovery because of the nature of having to maintain the prescription to curb active opiate use. With the men in mind that I knew while working in peer support who died, or when thinking of the individual who overdosed and died on campus at the treatment center I worked at, I’ll ask: Could this have helped save their lives if it was offered as an option? We’ll never know. At the time, the rehab I worked at aligned their therapeutic methodology with A.A.’s model of abstinence, and didn’t offer Suboxone. Now, even just a few years later, it does.
The subject of what a “drinking goal” should be is a complicated topic, even for those who generally have a solid foundation beneath them when deciding to get sober. A.A. takes autonomy away in this regard, making that decision on the behalf of its members, but that doesn’t make sense for all situations and certainly doesn’t work for everyone. In the 12-step community “half measures,” such as attempting to moderate one’s use, are generally frowned upon, with jokes made when people stray from its guidelines and instead use something like “the marijuana maintenance program.” In such a recovery landscape, any alcohol or drug use (which in some groups includes painkillers or antidepressants, which are regarded as crutches that shouldn’t even be taken as prescribed by medical professionals) is seen as a sign of relapse or personal failing on behalf of the participant. But if a less destructive “crutch”—be it an antidepressant or Suboxone—helps someone along the way, is that as bad as them not trying to improve their lives at all? I hear echoes of that ice cream joke even as I write this, but is the only thing that separates the two in the eyes of A.A. the chemical response to the usage? If my intention of using food is the same intention I had when I was drinking, at what point do the lines become blurred regarding an honest sense of what it means to be sober? Replace food with anything else you can be addicted to, from sex to gambling, and the broader question of what “recovery” is absolutely begins to change.
“Rarely have we seen a person fail who has thoroughly followed our path,” recalls A.A.’s Big Book. Speaking to this, Charles Bufe writes in Alcoholics Anonymous: Cult or Cure that, “In attempting to gauge the effectiveness of A.A., it’s very difficult to tell if you’re gauging results due to the A.A. program or results due to the characteristics of A.A.’s membership. There are several factors predictive of a positive outcome to alcoholism treatment: Motivation, middle class status, marital stability, employment, relatively mild and short term problems with alcohol, and absence of serious mental illness being probably the most important.” He’s spot on in recognizing that there are other factors that influence a person’s well-being and recovery than just their primary addiction, and that person’s whole situation needs to be accounted for when approaching something like recovery from addiction. It’s natural to fall into black and white thinking when it comes to discussing “success” or “failure” around recovery of addiction, but when looking at the broader picture of someone’s life, it becomes increasingly difficult to conclude when and if either has been achieved. If, say, abstinence is the lone measure for whether or not treatment has succeeded, does some form of “relapse” imply that treatment has failed? And when looking at the individual, their individual situation, their individual addiction, and their individual circumstances, what it means to be “in recovery” becomes an increasingly individualized concept.
The subject of success rates (or even clinical outcomes, for that matter) is complicated, and only made more so when incorporating an understanding of polysubstance use, secondary psychiatric issues, the influence of trauma, and pharmaceutical interactions, compiled by individual social determinants of health including housing, transportation, other medical care, employment, and even child services. When painting a more holistic understanding of a person’s needs when trying to break the cycle of addiction all of this needs to be taken into consideration. When I worked at that first treatment center, for example, the clientele were generally financially stable, with many of those lower level needs such as safe and affordable housing and adequate access to food taken care of. When moving to the healthcare startup to continue working in peer support, we worked exclusively with people on Tennessee’s Medicaid program, and for many of those we assisted, these lower level needs went unsatisfied. How do you measure impact or define “success,” from an organizational or even personal perspective, when sobriety is the marker of impact, but the majority of time spent with someone is working to establish a broader foundation of security based on pressing individual needs like getting food to eat or a safe place to sleep? Likewise, how do you measure success from the perspective of someone in recovery, trying to fit one’s unique life experience and social situation into 12 Step’s binary mold of sobriety? The answer to this, I believe, is found in addressing the difference between what recovery is, and what sobriety is.
While it follows an abstinence only ideology, one approach I appreciate can be found in the book Staying Sober: A Guide for Relapse Prevention by Terence Gorski and Merlene Miller, where they write, “Recovery is not abstinence from alcohol and drug use. Abstinence is only a prerequisite for recovery. The actual recovery process involves completing a series of tasks daily that allow management of acute and post acute withdrawal and the correction of the bio-psycho-social damage caused by the addiction.” They continue, “Sobriety is abstinence from addictive drugs plus abstinence from compulsive behaviors plus improvements in bio-psycho-social-health. Sobriety includes all three things.” This reconciles somewhat with A.A.’s Big Book, so long as you have a very loose definition of what the word “spiritual” can mean, where it notes, “What we really have is a daily reprieve contingent on the maintenance of our spiritual condition.” The value for each of these resides for me in their approach to being proactive about taking action in support of continued well being. Recovery isn’t defined by making a decision to combat addiction, but in the action that follows. And that is where any discussion surrounding an individual’s success in recovery actually begins to bear value for me.
Likewise, as is written in the book Refuge Recovery, “Renunciation alone is not recovery… It is only the beginning. Those who maintain abstinence but fail to examine the underlying causes and conditions are not on a path to recovery. They are simply stopping the surface manifestations of addiction, which will inevitably resurface in other ways.” Recovery is reducing or eliminating use in support of finding and living a satisfying and meaningful life, however someone might define that for themselves. Recovery is an ongoing process of changing one’s attitudes, examining beliefs, defining goals, and reclaiming a positive sense of self. Recovery is a restoration of health and not merely the absence of harm.
What happens when you change as a person? When you grow, or even outgrow a process, system, group or organization? What happens when the body of that group changes, or when you realize that your values no longer seem to align with that of the group? A few years ago I found myself asking these questions of myself, and clichéd as it might seem, out of those questions I continue to find solace and direction from the words of two unsuspecting sources: the Dalai Lama and Bruce Lee.
“I have often said that if science proves facts that conflict with Buddhist understanding, Buddhism must change accordingly. We should always adopt a view that accords with the facts. If upon investigation we find that there is reason and proof for a point, then we should accept it. However, a clear distinction should be made between what is not found by science and what is found to be nonexistent by science. What science finds to be nonexistent we should all accept as nonexistent, but what science merely does not find is a completely different matter. An example is consciousness itself. Although sentient beings, including humans, have experienced consciousness for centuries, we still do not know what consciousness actually is: its complete nature and how it functions.” –The Dalai Lama
“Each man belongs to a style which claims to possess truth to the exclusion of all other styles. These styles become institutes with their explanations of the ‘way,’ dissecting and isolating the harmony of firmness and gentleness, establishing rhythmic forms as the particular state of their techniques. […] Jeet Kun Do favors the formless so that it can assume all forms.” –Bruce Lee, Tao of Jeet Kune Do
There’s a cross-section between these two thoughts, which to me communicates a couple points. One is a welcoming of recognition that we don’t truly have a definitive grasp on much of what we claim to recognize as gospel. Another point is that by aligning oneself purely with a singular philosophical or ideological perspective, the rigidness inherent to all singular perspectives can lead to self-imposed limitations on personal growth. If I’m an Alcoholics Anonymous member, for instance, and A.A. is the methodology by which I achieved sobriety, is it likely or unlikely that I’m going to profess its merits and dismiss criticisms that might otherwise question the methodology behind why and how A.A. worked for me, personally? And the deeper one becomes aligned with that position, the stronger it grows into their identity, creating more rigid defenses of ideas that stand in contrast to it. Eventually, no matter what the evidence might be, this is where a belief becomes impenetrable regardless of the facts.
As Charles Bufe adds, “That A.A. relies on its Twelve Steps as the only means of sobriety is troublesome. It’s interesting to consider if this is done out of self-validation, wanting to assure themselves that they’re doing the right thing.” For many, in terms of recovery from alcohol, Alcoholics Anonymous absolutely is the right thing. But for no one should it be the only thing. There is no sacred information bestowed within the Big Book, just as there are no uniquely spectacular treatment protocols at expensive, upscale rehabs. A.A. promotes meditation and prayer, but I personally get much more practical value out of exercise and healthy eating. By recognizing this for myself, I’m not abandoning everything I’ve learned from my several years of conversations, groups, step work, and sponsorship. On the contrary, I feel it means that I’m actually adopting a broader view of recovery that incorporates what I’ve been through, without locking myself into the mindset of a past version of myself. In a way, that’s what this entire project is based on. “In my working of Step 12,” writes Russell Brand, in his commentary on A.A. and the 12 Steps in his book titled Recovery, “is the understanding that I will always default to self-centeredness; if I don’t work on my mental and spiritual state I automatically become selfish and indifferent to the suffering of others.” I can find personal value in a statement like this today because I don’t feel a necessity to fit myself within the construct of how either A.A. or someone like Russell defines recovery, instead striving to carry forward the helpful aspects of that statement and dismiss of the rest. For me, recovery isn’t writing all this as some grand declaration that everyone do the same, so much as it’s an ongoing trial and error process of figuring out what I genuinely need to stay on track, and that I do my best to remain honest with myself and others when that’s not working. That means recognizing and admitting when I’m wrong about what works just as much as it means maintaining accountability for doing the things that I need to be doing day in and day out. To me, that’s recovery.
[The track opening and closing the episode is called “styles.”]