Through my early tenure in the addictions field, the question of readiness for treatment and recovery was thought to be a pain quotient. We then believed that people didn't enter recovery until they had "hit bottom." If a person did not show evidence of such pain-induced readiness, they were often refused admission to treatment. Then we recognized that the reason it took people so long to "hit bottom" was that they were protected from the painful consequences of their alcohol and other drug use by people we called "enablers." We then set about teaching enablers to stop rescuing and protecting their beloved but addicted family members. Vern Johnson then came along and convinced us we could raise the bottom through a process he called intervention. Staging such interventions within families and the workplace was something of a revolution that brought large numbers of culturally empowered people into recovery, including a former First Lady. All of these early philosophies and technologies relied on pain as a catalyst of addiction recovery, and that was the view I brought to my work as an evaluator of an innovative network of women's treatment programs in the 1980s called Project SAFE.
Client engagement in Project SAFE relied on an extremely assertive approach to community outreach that often involved many home visits before a woman entered formal treatment services. When interviewing one of the outreach workers, I could tell she was becoming frustrated with my questions about how clients entered treatment and particularly my attempts to isolate the painful crisis that had propelled the decision to enter treatment. The outreach worker finally turned to me and said the following:
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!
As the evaluator of Project SAFE, I had the opportunity to interview woman many months and years after they had completed addiction treatment. More specifically, I had the opportunity to interview women in long-term recovery who at the point of initial contact with Project SAFE had a very poor prognosis for recovery. They presented with a massive number of severe and complex problems, involvement in very toxic intimate and family relationships, and innumerable personal and environmental obstacles to recovery. As I faced these amazingly resilient women, I asked each of them to tell me about the sparks that had ignited their recovery journey. Each of them talked about the role their outreach worker had played in their lives. The following comments were typical.
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.
(Describing the first day she went to treatment--after eight weeks of outreach contacts) 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 (for an assessment at the treatment center). 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 (recovery) a try.
And she kept sending me those mushy notes--you know the kind I'm talking about. (Actually, I had no idea what she was 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. She hung in with me through all the ups and downs of treatment and getting my kids back.
What I learned from these remarkable women was that, for the disempowered, the spark of recovery is a synergy of pain and hope experienced in the context of a catalytic relationship. Life and their addictions had delivered to these women more than enough pain; what was needed was an unrelenting source of hope delivered to them by a cadre of recovering women who lacked much by way of professional credentials and polish, but who brought an inextinguishable and contagious faith in the transformative power of recovery. These outreach workers knew recovery was possible. They were themselves the living proof of that proposition. And they spread the germ of recovery to women who initially caught it rather than chose it.
The assertive outreach that was the hallmark of Project SAFE continues today in cities like Philadelphia.
Our vision is to expand low threshold services that at the same time elevate peoples' sense of what is possible for them. We do this by exposing them to living proof that recovery is possible even under the most difficult of circumstances, confirming that there are people who will walk this path with them, and offering stage-appropriate services to support people in their journeys from addiction to recovery.--Dr. Arthur C. Evans, Jr.
As Dr. Evans suggests, we need to move beyond treating those who are ready for treatment to priming recovery motivation in those who are not yet ready. As the outreach worker so eloquently scolded me, "If we wait for them to hit bottom, they will die."