We must go where the pain and peril are greatest and the quest for real solutions is most desperate. Van Jones, Beyond the Messy Truth
Individuals re-entering the community from jail/prison or residential addiction treatment and those disengaging from medication-assisted treatment are at increased risks of addiction recurrence and drug-related death. Such risks lessen if individuals participate in recovery mutual aid meetings or other recovery support resources (e.g., recovery residences, recovery community centers, collegiate recovery programs, recovery ministries, etc.). The question is how best to link people in transition to such indigenous recovery support resources.
Research scientists have confirmed the ineffectiveness of passive approaches to recovery support linkage (provision of information on resources and encouragement to participate) and the superiority of assertive linkage procedures. The latter include in-depth orientation to recovery support options, respect for personal choice, identifying and resolving obstacles to participation, personal introductions recovery support representatives, and personal guidance into recovery support activities via a recovery coach/guide/navigator. Repeated studies have also confirmed the value of ongoing recovery checkups and, when need, assertive re-linkage to recovery support resources.
A recent study by Jennifer Johnson and colleagues offers insight into the challenges faced in linking individuals to ongoing recovery support resources. Johnson and colleagues evaluated a "warm handoff" intervention that sought to link women with an alcohol use disorder to community-based twelve-step meetings who were leaving jail. The linkage design involved a volunteer from a local AA group meeting each woman in jail, calling her after her release from jail, and joining her in attending her first local AA meetings. The key findings of the project were as follows:
- Twelve-step volunteers initially resisted making the first post-release call to the women participating in the project.
- The source of resistance was their understanding of AA's Tradition Eleven, which calls for a stance of attraction rather than promotion of the AA program.
- Women leaving jail resisted making the first call to the volunteer and viewed the volunteer making the call to them as a test of the volunteer's compassion and care.
- Of the 169 women followed for six-months post-release, more than a third were not aware of any effort of their assigned volunteer to contact them, only 38% completed an initial call from their volunteer, and only four attended an AA meeting with their volunteer following their release from jail.
Johnson and her colleagues drew the following conclusions from this study:
A twelve-step volunteer led warm handoff for women leaving jail did not have a significant effect on post-release twelve-step attendance or drinking, likely because the post-release part of the handoff did not occur. The twelve-step tradition of Attraction may inhibit the active outreach required to connect women to services after jail release.
While interpretation of Tradition Eleven varies across localities and particular twelve-step groups, the Johnson study does raise questions related to the training and supervision of recovery coaches who may themselves participate in a twelve-step program. There have been related discussions on the differences between a twelve-step sponsor and a recovery coach (See HERE and HERE for my own takes on this distinction). Distinctions between these roles include who initiates the recovery partnership and the degree of assertiveness involved in the initial engagement process.
Linkage to recovery support resources, particularly for those with histories of ingrained passivity, helplessness, and hopelessness may take a far more assertive approach to recovery engagement than is common in most treatment settings and recovery mutual aid groups. Both have historically relied on addiction-related pain to heighten recovery readiness and motivation for change.
Outreach workers in Project SAFE, a women's recovery project that exemplified an extremely assertive approach to recovery engagement, explained such necessity when I interviewed them in my role as evaluator of this innovative project.
Bill, you're not getting it! My clients don't hit bottom; my clients live on the bottom. Their capacities for physical and emotional pain are beyond your comprehension. If we wait for them to hit bottom, they will die! The issue of engaging them is not an absence of pain, it is an absence of HOPE!
You must be there when they hit bottom. You must build a relationship so that in crisis they reach for you and not the drug. Hitting bottom doesn't necessarily mean change. When she hits bottom alone, she reaches for the drug and addiction continues. When she hits bottom and I'm there, change is possible.
When I interviewed women involved in successful recovery from Project SAFE about how they began their recovery process, they explained:
I couldn't get rid of that women! She came and just kept coming back--even tried talking to me through the locked door of a crack house. She wore me down. She followed me into Hell and brought me back.
It was like a thousand other days. My babies had been taken and I was out there in the life. I'd stopped by my place to pick up some clothes and there was a knock on the door. And here was this crazy lady one more time, looking like she was happy to see me. I looked at her and said, "Don't say a word; let's go" . She saw something in me that I didn't see in myself, so I finally just took her word for it and gave this thing a try.
And she kept sending me those mushy notes--you know the kind I'm talking about. You know, the kind that say, "Hope you're having a good day, I'm thinking about you, hope you are doing well" and all that stuff. I treated her pretty bad the first time she came, but she hung in there and wouldn't give up on me. I can't imagine where I would be today if she hadn't kept coming back.
Brooke Feldman, in a most insightful blog on the distinction between attraction and promotion in twelve-step programs (and its oft-distorted interpretations), suggests the following:
What we know about addiction and recovery is that assertive outreach is effective, that motivational interviewing works, that exposure to recovery can be contagious and that being offered hope can be transformative. What we know is that recovery can and ought to be promoted, that getting out there and engaging people yields positive results. What we know is that when we fail to promote recovery, when we wait until a person wants it bad enough or is ready, we miss opportunities and we lose human beings. And when people die, families suffer immeasurably, communities are impacted drastically and the world is robbed forever of that irreplaceable treasure called untapped potential.
All I can say in response is: Amen!
People in recovery involved in the delivery of recovery support services outside the arena of recovery mutual aid groups require reorientation to the degree of assertiveness required for engaging those with the least recovery capital and the most severe, complex, and prolonged substance use disorders.
Feldman, B. (2017). "Attraction Rather Than Promotion" - Let's Clear Up the Mix Up. Accessed November 11, 2021 at https://www.huffpost.com/entry/attraction-rather-than-promotion-lets-clear-up_b_59013c91e4b00acb75f1849f
Johnson, J. E., Schonbrun, Y. C., Anderson, B., Timko, C., and Stein, M. D. (2021). Randomized controlled trial of twelve-step volunteer linkage for women with alcohol use disorder leaving jail. Drug and Alcohol Dependence, 227, 109014.
Scott, C. K., Dennis, M. L., Willis, B., & Nicholson, L., (2013). A decade of research on recovery management checkups. In Interventions for addiction: Comprehensive addictive behaviors and disorders (pp. 267-273). San Diego: Elsevier, Inc., Academic Press.
White, W., Woll, P. & Godley, S. (2003) The delivery and supervision of outreach services: Project SAFE. Chicago, IL: Illinois Department of Human Services, Office of Alcoholism and Substance Abuse.
White, W., Woll, P and Webber, R. (2003) Project SAFE: Best practices resource manual. Chicago, IL: Illinois Department of Human Service, Office of Alcoholism and Substance Abuse.