Continuity of Recovery Support vs. Replication of Abandonment (Bill White and Jason Schwartz)
Many people enter addiction treatment in the United States with abuse, abandonment, and loss as central thematic threads within their lives. Such experiences distort one’s self-perceptions (e.g., “I am not worthy of love and respect”), diminish one’s capacity to trust (e.g., “Everyone I love will either abuse or abandon me”) and impede one’s ability to initiate and sustain healthy relationships. The clinical antidote to such wounds has long been posited as a “corrective emotional experience” in which the person, through a helping relationship marked by safety and trust, is able to redefine themselves and their view of the world. In reality, the helping relationship can either achieve such redefinition or reconfirm this self-limiting view of self and the world. So what does all this mean for the provision of addiction treatment and recovery support services? Here are five beginning reflections on this question.
Effectively treating people with histories of abandonment and loss requires a time-involved process of testing and engagement. Arbitrarily brief treatment and abrupt relationship terminations (driven by considerations of cost over quality of clinical care) inadvertently confirm self-limiting views of self and the world by replicating the experience of abandonment and loss within the context of professional care at a time the embryo of trust is often just forming. Acute care models of addiction treatment can unwittingly replicate earlier trauma, with each episode of treatment decreasing one’s future capacity to enter into a transformative helping relationship. Continued replications of abandonment within these acute interventions often breed self-defeating styles of relating to those in professional and peer helping roles. In contrast, models of sustained recovery management offer some hope for continuity of support by affording time to work through this testing and relationship building process.
Effectively treating people with histories of abandonment and loss may require continuity of relationship support spanning multiple levels of care and episodes of care. This proposition challenges what have been standard practices in many addiction treatment programs, e.g., refusing to readmit people who resumed alcohol and other drug (AOD) use following one or more earlier treatments, assigning a new primary counselor each time a patient is readmitted, or discharging individuals for behaviors that test the helping relationship.
Also of concern is how people with histories of abandonment and loss can be effectively treated within a system whose workforce is constantly turning over. Such workforce transience is not conducive to quality of clinical care and makes continuity of support impossible for those with the most severe, complex, and chronic substance use disorders. If sustained relational engagement is an essential ingredient in successful addiction treatment, then we as a system of care are failing to meet that challenge. At present, of nearly 1.5 million people annually admitted to addiction treatment in the U.S., only 43% successfully complete treatment. (More than 380,000 leave against staff advice and more than 106,000 are administratively discharged—most for confirming their diagnosis via continued or resumed AOD use.)
Transitions in relationship support of people with histories of abandonment and loss risk rapid clinical deterioration, resumption of excessive drug use, and increased risk of death. Multiple studies (see here for review) confirm that the period of highest risk for post-treatment resumption of drug use is immediately following discharge from a level of care, with most addiction recurrence beginning in the days and weeks following loss of the clinical support relationship. Such abrupt transitions are inherent as an endpoint in the dominant brief models of acute care, but they are also common within these models. The person entering addiction treatment is too often rapidly transitioned from person to person without a single point of relational continuity. Screeners and intake workers give way to a primary counselor and a host of allied roles that can change mid-treatment and with every movement from one level of care to the next. Every passing of the service torch is, in actuality, one more replication of abandonment and loss. Current efforts to integrate recovery coaches within acute models of addiction treatment are, in part, an effort to assure some degree of continuity in what is otherwise experienced as a relay race—conveying the feeling that one is being processed on a fast-moving assembly line.
A just published study by Bogdanowicz and colleagues underscores the high stakes involved in such relationship transitions. Their study examined the risk of death for patients in medication-assisted treatment during their transfer from one program setting to another. Bagdanowicz and colleagues found that patients in medication-assisted treatment transferred to another treatment provider experience increased overdose mortality risks, particularly within the days immediately following the transfer. Earlier studies of all forms of treatment found increased rates of drug use and death following treatment dropout and immediately following planned discharge from treatment, but no earlier study has so definitely focused on the risks of transition within the process of continued treatment. All relationship transitions within the early stages of addiction recovery constitute zones of risk for recovery destabilization. Such transitions must be minimized and assertively managed via increased monitoring and support.
People with histories of abandonment and loss may find it easier entering into relationship with a community of shared experience than the more emotionally risky relationship with a single professional helper. But such communities require great care in their creation and maintenance, particularly when nested within formal service organizations that can drift towards cold hospitality. As Christine Pohl suggests: There is a kind of hospitality that keeps people needy strangers while fostering the illusion of relationships and connection. It both disempowers and domesticates guests while it reinforces the hosts’ power, control, and sense of generosity. It is profoundly destructive to the people it welcomes. In the field of psychiatry, this has come to be christened “sanctuary harm.” When we seemingly do all the right things with a spirit that emphasizes our virtue and the pathology and neediness of those we serve, we inflate ourselves as we deflate those who seek our help. In making them feel small and incapable, we feed hopelessness in the name of hope.
In contrast, The Book of Life describes how. . . the warmly polite person is always deeply aware that the stranger is (irrespective of their status or outward dignity) a highly needy, fragile, confused, appetitive and susceptible creature. And they know this about the stranger, because they never forget this about themselves. Such warmth and empathic identification are built upon our own prior experiences of pain, fear, anguish, hopelessness, confusion, vulnerability, and loss. The former is a noisy hospitality that focuses on the value of the host; the latter quietly focuses on the hidden assets masked by the immediate vulnerability and needs of the guest.
Riane Eisler, in The Chalice and the Blade, has characterized the former style of helping as a dominator relationship model and the latter a partnership relationship model. Achieving the latter requires that traditionally-trained professionals step out of their more detached comfort zone to embrace the value of mutuality and rethink professional boundaries of self-disclosure and personal vulnerability. It also requires a deep understanding of the role of community in recovery.
Effectively treating and supporting people with histories of abandonment and loss requires the creation of what Sandra Bloom has christened healing sanctuaries or what Don Coyhis has depicted as a healing forest. Ernie Kurtz and Katherine Ketcham have described such healing environments and the experience of finally “being-at-home.”
Some places are more conducive to this experience than others. But wherever and whenever we do attain the sense of “being-at-home,” we experience a falling away of tension, a degree of balance between the pushing and pulling forces of our lives. In such a place, we can cease fighting—most important, we can cease fighting with ourselves….Home, then, is the place that is like our pelt, our skin, our hide, in that it is that which covers us less in a concealing than in a protective way….It is the place where I can be naked, which is to say vulnerable—undefended against being wounded because of confidence that I will not be wounded. Or that if I am wounded, that I will also be healed. (Kurtz & Ketcham, 1992, p. 237).
Treating and supporting addiction recovery among people with histories of abuse, abandonment and loss requires, time, safety, systems stability, continuity of support, and community—a place to “be-at-home.” Assuring these ingredients will require moving from a focus on brief clinical micro-interventions to forging healing communities within and beyond the walls of addiction treatment and recovery mutual aid societies.