A Call for Clinical Humility


Amends icetray

The history of addiction treatment includes a pervasive and cautionary thread: the potential to do great harm in the name of help. The technical term for such injury, iatrogenesis (physician-caused or treatment-caused illness), spans a broad range of professional actions that with the best of intentions resulted in harm to individuals and families seeking assistance. My recounting of such insults within the history of addiction treatment (see here, here, and here) also includes the observation that such harms are easy to identify retrospectively in earlier eras, but very difficult to see within one's own era, within one's own treatment program, and within one's own clinical practices.

The challenges for each of us who work in this special service ministry and for the specialized industry of addiction treatment include conducting a regular inventory of clinical and administrative policies and practices to identify areas of inadvertent harm, altering conditions linked to such harm, making amends for such injuries, and developing mechanisms to prevent such injuries in the future. In my own professional life, many of the projects in my later career were products of such an inventory and served as a form of amends for actions I took or failed to take in my early career due to lack of awareness or courage. (See here and here for two vivid examples.)

There have also been times I have taken the larger field to task for practices I deemed harmful. I have suggested at times that what were perceived as personal failures to achieve lasting recovery could be more aptly characterized as system failures (See here). I have suggested at times that the field was becoming addicted to professional power and money and that the field itself was in need of a recovery process that should include processes of rigorous self-inventory, public confession, and amends (See here).

The shift from acute care models of addiction treatment to models of sustained recovery management (RM) and recovery-oriented systems of care (ROSC) involves dramatic changes in clinical practices, including a shift in the basic relationship between the service provider and service recipient. The service relationship within the RM/ROSC models shifts from one dominated and controlled by the professional expert to a sustained recovery support partnership, with the provider serving primarily as a consultant to the service recipient's own recovery self-management efforts. Those who have made this relational shift inevitably look back on areas of potential harm that emerged from the expert relational model they once practiced. And then the question inevitably arises, "How does one make amends for past harm in the name of help within the context of addiction counseling?"

Chris Budnick, an addictions professional in North Carolina and founding Board Chair for Recovery Communities of North Carolina, Inc. (RCNC), recently responded to that question by preparing a formal letter of amends to the individuals, families, and communities he has served. Below is the text of that letter, which was presented at the North Carolina Recovery Advocacy Alliance Summit, February 24, 2016. (The link to the video is: https://www.youtube.com/watch?v=A5MYhZbnhfU)

My name is Chris Budnick and I am a Licensed Clinical Addiction Specialist. I first began working in the addiction treatment and recovery field in 1993.

There are many components involved in the broad issue of substance use disorders and recovery. Employers, first responders, the criminal justice system, policy makers, politicians, companies, advertisers, treatment providers, addiction professionals, the recovery community, families, and the individual with the substance use disorder. Of all these components, individuals with substance use disorders face the greatest scrutiny, stigma, discrimination and blame. For too long they have stood alone bearing the full brunt of this responsibility while systems of care and policies impacting housing, education, and employment have largely conspired to undermine any chance of sustaining recovery.

Last week I found myself approaching a police department to apologize for failing them. When they reached out to us in the middle of the night seeking services for a young woman we told themno. We can't help her tonight. She was killed within hours of this decision leaving behind a 2-year-old daughter. I told the officer that we pledge to do better.

This experience has nudged me to put to paper ideas that I?ve articulated and ideas I've only contemplated. I feel compelled as an addiction professional to make amends and pledge to do better.

While I have changed my attitudes and practices over the years, I have not spoken up to say I'm sorry. So here are the things I want to make amends for:

  • I'm sorry for all the barriers you confront when trying to access help.
  • I'm sorry for contradictory sobriety and active use requirements you encounter when trying to access services.
  • I'm sorry for the harm that has come to you, your family, your unborn children, and your community when you have not been provided services on demand.
  • I apologize for expecting that you will provide all the motivation to initiate recovery when I have assumed no responsibility for enhancing your readiness for recovery.
  • I am sorry for creating unrealistic expectations of you.
  • I'm sorry for provider success statistics that have misled you and your family.
  • I'm sorry that I have discharged you from treatment for becoming symptomatic. I'm even more sorry, though, for abandoning you at your time of greatest vulnerability. And I am sorry for how this failure has contributed to the heartbreak of your loved ones.
  • I am sorry for abandoning you when you have left treatment, either successfully or unsuccessfully.
  • I am sorry for the irritation in my voice when you have returned following a set-back because you didn't do everything that I told you to do.
  • I am sorry for my arrogance when I've assumed that I am the expert of your life.
  • I am sorry for privately finding satisfaction in your failure because it reinforces the fallacy that I know best and if you just do as I say, you?ll recover.
  • I am sorry for not celebrating as enthusiastically your successes when you have achieved them through a different pathway or style then me.
  • I am sorry for being a silent co-conspirator for the stigma that has resulted in systems of punishment and discriminatory policies and practices.
  • I'm sorry for turning you away from treatment because you?vebeen here too many times.
  • I'm sorry for not referring you to different services when you have not responded to the services I offer.
  • I am sorry for allowing you to take the blame when treatment did not work instead of defending you because you received an inadequate dose and duration of care.
  • I am sorry for reaping the benefits of recovery yet failing to do everything I can to make sure those benefits are available to anyone, regardless of privilege, socio-economic status, education, employability, and criminal history.
  • I'm sorry for being an addiction professional who has not provided you with the recovery supports needed to sustain recovery. More importantly, I apologize for conspiring through silence and inaction with a system that ill prepares you to achieve success.
  • I'm sorry for not calling to check on you when you don't show up for treatment. I'm sorry for not calling to support you after you leave treatment.
  • I'm sorry for letting society maintain the belief that you used again because you chose to.
  • I'm sorry for not fighting for adequate treatment and recovery support services. All persons with substance use disorders should be entitled to a minimum of five years of monitoring and recovery support services.
  • I'm sorry for not advocating for you to have opportunities to gain safe and supportive housing and non-exploitive employment.
  • I am sorry for being so self-centered that I only think about you in the context of treatment while failing to fully understand the environmental and social realities of your life and how they will impact your ability to initiate and sustain recovery.
  • I am deeply sorry to your loved ones who have been robbed of chances to have a healthy member of their family. I am deeply sorry to your community, who has been robbed of the gifts that your recovery could have brought them.
  • I'm sorry that systems of control and punishment has been the response to communities of color during drug epidemics.
  • I am sorry that through my silence and inaction that I have contributed to belief that persons with substance use disorders are criminals and should be punished.
  • I am sorry for not speaking as a Recovery Ally to families, friends, neighbors, colleagues, policy makers, and public officials about why I support recovery.
  • I'm sorry for all the things that I have left off this list because I?ve failed to regularly solicit your feedback about how effective I have been in supporting you in your recovery.

This sorrow is the foundation of my commitment to improve the accessibility, affordability, and quality of addiction treatment and recovery support services and to create the community space in which long-term personal and family recovery can flourish.

Chris Budnick

Licensed Clinical Addiction Specialist

This is a remarkable statement worthy of emulation. I look forward to the day when leaders prepare such a statement of amends to individuals, families, and communities on behalf of American addiction treatment institutions. I look forward to the day when clinical humility becomes a foundational ethic guiding the practice of addiction counseling.