A community-based treatment initiative that just might work

Some of the comments following my last post asked the same question — and it needed to be asked: How might you apply this perspective? What kind of treatment program would embody these concepts? Let’s get concrete…how would it work?

I more or less ended that post with the following proclamation (copied here, in part, from that post):

waiting lineAny approach that meets addicts when and where they’re ready to quit is well positioned to help them move onward. Community-based settings can fill this role most easily, because…there is no line-up at the door… Nor, hopefully, are there rigid policies that preempt the addict’s personal incentive. When desire is ready to arc from the goal of immediate relief to the goal of a valued future, treatment can begin. Not by inducing desire—only frustration and suffering can do that—but by capturing and holding one’s vision of that future…[while the desire knob is turned up to max.]

Or, to put it in terms of the biology, “what will work best is whatever is available when the synaptic avenues of desire make contact with brain regions responsible for perspective change.”

But you often need other people — either one person or a group of people — to hold those elements in place, to help make it happen. Which is why treatment must be interpersonal if it’s to have any chance of working.

So, at the end of the book, and here in today’s post, I provide an example that captures the critical importance of striking while the iron is hot — when desire is turned up high and synched (for the moment) with the vision of a future self free of addiction. It’s a radical treatment initiative that birmingham up closeuses “other people” at the grass roots level, to hold the pieces together before the iron cools. And it’s been inspired and shaped by my friend Peter Sheath, a former addict and senior associate of a consulting group for service delivery in the U.K. Thank you, Peter, for inspiring me with your description of this exciting venture.

birminghamThe city of Birmingham (the second largest in England) is investing massively in this pilot program, designed to provide help for addicts at the very moment when their desire for change is ignited. Treatment nodes are distributed across the community, through sites that are most available to addicts in their day-to-day lives. Shopkeepers, including newsagents, shopbakers, butchers, and pharmacists, are trained in brief interventions. Participants’ shops display an ROR (“Reach Out Recovery”) sticker on the front window, so that addicts immediately see that they are “recovery-friendly” and ready to help. People come in off the street, perhaps buying a loaf of bread at the same time, and say “I’ve had enough! I’m ready to drunken manquit!” Then the shopkeeper tells them they’ve come to the right place, takes a quick inventory, and advises them on what to do next. “Hey, reduce your drinking a bit, and then pop by and talk with me this afternoon or tomorrow.” Or, in more severe cases, “I won’t be able to work with you but I know somebody who can.” People can be referred A community nurse making home visits in a rural area.to “peer mentors” who will show up the following day to help them with difficult issues such as detox and other medical matters. Even taxi drivers have been recruited, so that someone en route to score can throw up his hands and call it quits without that incentive getting lost in translation.

Obviously the community needs to be motivated to make this happen. But that’s a boon in itself, because it recasts the problem of addiction as everyone’s problem, not the burden of the individual alone. (Shades of Rat Park!) So the support is there, the immediacy is there, and the infrastructure is built and organized without any religious or medical axe to grind. And it’s free. The funding comes from the city, not from the addict’s already-stretched family.

I see this as a highly creative approach. Whether it will work as well as we hope remains to be seen. The project is inspired by intuitions about the mercurial nature of desire and the power it bestows on our most essential plans — an intuition that fits what we know of the neurophysiology of addiction. More generally, the project exemplifies the innovation and insight that can sprout when the disease model is retracted and a fresh perspective, free of orthodoxy and special interests, is allowed take in its place.

63 thoughts on “A community-based treatment initiative that just might work

  1. Shaun Shelly February 17, 2015 at 4:24 am #

    Oh wow! This is great…. I have for a long time been saying that successful treatment lies not in expensive rehabs, but in community out patient programs and by including problematic drug users in the community rather than excluding and criminalising them. Another thing I have always said is that 12-step programs would be great if it wasn’t for the steps. This seems to be a natural extension of both these ideas.

    I would really like to see how this develops. It looks like a fantastic initiative!

    • Robert February 17, 2015 at 9:36 am #

      I beg to differ. In my humble opinion, the 12-steps are nothing short of brilliant. By that, I mean the self evaluation process involved in the step process have helped many addicts sort out the source of their problems. While I agree the process is not for everyone, I has helped many people who have not been reached by traditional means. Much of what your community based solution entails closely resembles the 12-step method.
      I my personal journey, I discounted 12-step fellowships as being unsophisticated
      and unprofessional, but the self-discovery process I have experienced in the 12-steps along with peer-based sponsorship have been invaluable. I think 12-step fellowships(i.e N.A,AA) can play a bigger role in community based recovery programs.

      • Dougie Dudgeon February 23, 2015 at 3:45 pm #

        Why beg to differ? I had coffee with Shaun the other day, and we managed to agree that there is no “one way” into Recovery, there are multiple pathways all of which deserve mutual respect. The addiction/treatment/recovery field is done no favours with the combative, argumentative and sadly influential single issue merchants who had the influence to put too many addicts on methadone (although it works for some), championed tough love approaches (which worked for some) at the expense of other methods and even the mad men (and women) who pushed the war on drugs and Just Say No as the “right” approach. This issue is more complex than any one size fits all solution, although the politicians will pay anyone who claims to have that!

  2. Carolyn Kay February 17, 2015 at 6:39 am #

    Sounds similar to some of the interventions for high blood pressure and heart disease in Canada (http://www.ncbi.nlm.nih.gov/pubmed/23541658) and in the U.S.(http://www.nih.gov/researchmatters/march2011/03142011barbers.htm).

    One of the best benefits could be to make more people aware of the difficulties of overcoming addiction, and therefore more tolerant.

  3. Marc February 17, 2015 at 7:41 am #

    Hi Shaun. I figured that this would be right up your alley. And your slogan for revisiting 12-step philosophy is very inspiring. I never thought of it quite like this, but “steps” implies a lot of climbing before you actually get where you want to go. This approach piles much of the change process into the here-and-now — quite a different take on recovery!

    • Robert February 17, 2015 at 3:21 pm #

      Hi Marc

      I agree with the philosophy of “striking while the iron is hot”. 12-step programs refer to this state of mind as a “moment of clarity”. This fleeting state of mind is a break from the insanity of addiction. The 12-step process, based on my interpretation, is an acceptance of a few simple facts: drugs are not the solution,the addict needs a spiritual connection with the universe(not God), admitted you harmed yourself and others in your addicted state, make amends for your wrongs and forgive yourself and others. I feel all these concepts should be part of an addicts recovery process.

      • Marc February 18, 2015 at 8:49 am #

        Hi Robert. I’m not “anti-12-step” and I recognize that it has been invaluable for some and unhelpful for others. I think what Shaun meant about the steps was that it can seem like there is a lengthy and arduous set of accomplishments that you need to go through to really quit for good. For some, this may be the case. But others quit in one fell swoop.

        Whether that “moment of clarity” is the same as striking while the iron is hot? Not exactly, I think. The way meetings are organized, people start attending, whether they’re very inspired or not, and the hope is that the spark will catch them…and they’ll synch up with “the program” either sooner or later. I guess that “synching up” is the moment of clarity you refer to.

        On the other hand, 12-step fellowship groups have clearly been the most energetic and comprehensive community-based initiative ever. I don’t think many would dispute that. Still, as you say, more is possible.

        • Robert February 18, 2015 at 9:03 am #

          Hi Marc,

          Yes, I think ” more is possible”. The problem with the “12-step” community, to me, is adherence to principles that are based on methods established nearly a century ago. These communities view these traditions with the reverence of religious practices. The 12-step community is in desperate need of a “new age” overhaul, but these fellowships are unparalleled at meeting the most resistant addict where they are at. They still remain one of the few options for addicts that society has largely written off.

          • Marc February 18, 2015 at 9:10 am #

            I keep hearing exactly what you’re telling me. But I often hear about exceptions too — groups that are quite progressive and non-dogmatic. I guess the only absolute is that there is enormous variety in how these methods are practiced.

            By the way, that overhaul is already happening. More and more public attention is being drawn to the problems and pitfalls.

  4. William Abbott February 17, 2015 at 8:12 am #

    Marc

    This is truly a gasper !!! ( new word maybe lol) — and falls in line with whats happening in Portugal as well as those who subscribe to the Community Reinforcement Approach of Myers and Miller ( of MI fame) , a well documented method but vastly underutilized in the US at least.

    Here in the US at least there is now great attention ( finally) to Bruce Alexanders work- your well known favorite Rat park . So maybe there is hope that the light is finally shining thru– and your book , at least as I understand what its going to say, will definitel drive this in the right way .. the timing couldnt be better

    Bill

    • Marc February 18, 2015 at 8:53 am #

      Hi Bill. Yes, I think the wave is breaking in different ways and different places…and it’s happening pretty much now. Indeed, I hope my book catches and helps propel that wave.

      I’ll look into the Myers and Miller approach too.

  5. Cheryl February 17, 2015 at 1:34 pm #

    I certainly think it is key to help others envision the life they would love engaging in. I think it is equally important to reframe their past in a meaningful way rather than the defeatist way many see. One of the biggest meaning is in the power. If one has the power to create a mess beyond measure, one has the power to create the opposite. The 12 step groups lean to much on others so you are either aggrandized in their eyes or a failure (I am aware that this is not the goal but it is reality). The helping people to look for are the ones who are able to focus on the two things I mentioned above rather than people with personal agendas including “orthodoxy and special interests”.

    • Marc February 22, 2015 at 4:03 am #

      HI Cheryl. Looking carefully at the past, you see not only the mess you made but also the reasons you made it. That’s a key step toward self-forgiveness. And self-forgiveness…it’s so important. It almost gives you permission to create a kinder and happier future — for yourself. That way you’re tying past and future together to make a whole…a coherent narrative.

      AA encourages you to do this by “admitting” your flaws. That’s not quite the same as forgiving yourself for being human.

      • Cheryl February 23, 2015 at 6:54 pm #

        Yep, forgiveness is a beautiful, freeing thing. I think the process of focusing on one site you can really engage in helps to put some thing in perspective. This includes the knowing that you aren’t the loathsome creature you made yourself out to be, so the forgiveness process more easily comes in to play. As I remember from your last book, that is close to what it was that moved you forward.

  6. Robert February 17, 2015 at 2:30 pm #

    All things, not being equal. I must agree that 12-step programs are not perfect. In fact, peer based recovery models are woefully inconsistent, but they do tend to reach marginalized populations that can be a challenge to treat.
    The sponsorship model is designed to keep the recovering addict honest about his or her progress and provide guidance. In my experience, if the step process is followed in sequence, one gains considerable insight into personal flaws and shortcomings that may have lead to the addiction.
    12-step approaches are a great first step into the recovery process. I think one should advance to professional treatment to help fully realize recovery.

    • Adam Sledd February 24, 2015 at 12:03 pm #

      I think the great thing about the model described here is that it’s a lot easier for many reasons to walk into the local newstand and speak to a member of the community than to commit to rehab or subscribe to the dogma of the 12 steps. While it does work for many, there are also many who don’t hang around very long for various reasons. Rather than simply providing triage at the point of desperation, this model truly meets people where they are and allows for various levels of intervention. I have always agreed that the many benefits of the 12 step fellowhship can be found outside of that bubble and the community is the ultimate resource for these elements.

  7. Matt February 17, 2015 at 6:21 pm #

    “…it takes a village.” And anonymity and “disease” are poisoning the well.

    • Robert February 17, 2015 at 7:15 pm #

      Agreed, the “disease” concept embraced by the 12-step community needs to change. In addition, 12-step fellowships need to break antiquated guidelines that seriously restrict the audience they need to truly reach. Nonetheless, 12-step programs have their place. For resistant, difficult to reach addicts, they have been the only solution if any.

  8. Ania February 17, 2015 at 9:16 pm #

    Something I have noticed and observed in treatment programs (not saying all), and wouldn’t including this take us (addicts) even further? which is focusing on developing over all well-being and resilience? Trying to not focus on only “I’m an addict and I have an incurable “disease” and I need to focus on things to “help” me”.This was something that was always missing for me, which prevented me from not only staying clean but also working on the underlying problems effectively and actually achieving positive results and going further with them. Re-learning and learning a new lifestyle, transforming to be the best version of yourself and not just adding something in order to “help” but learning to understand and making it your life/lifestyle. Finding at least that one person that leads a truly happy, positive, and hard working but passionate towards life and of course one will then find many more people like this and being exposed to this once can learn so much. So since it is possible to change our thoughts, habits, ect through neuroplasticity why not focus on transforming our entire being this way? Just curious on other people’s thoughts.

    • Robert February 18, 2015 at 8:09 am #

      Ania

      I wholeheartedly agree. The way we label or refer to ourselves is a critical part of the transformation process. Members of 12-step fellowships often refer to themselves as “addicts” even after substantial recovery time. I think, at some point, you have to take responsibility for being a fully functional individual who has recovered from addiction. In addition, I also have reservations about the concept of total abstinence. While, I understand the importance of avoiding highly addictive narcotics, I think certain individuals can learn to drink moderately.

    • Marc February 22, 2015 at 4:08 am #

      That’s lovely, Shaun. Yes, it captures the switch point succinctly and accurately. I’ve added it to my stock. Thanks!

    • Cheryl February 22, 2015 at 8:01 am #

      I agree Shaun. Thanks for the link.

  9. Gary Goodwin February 18, 2015 at 7:26 am #

    I sincerely like and have always agreed that a community-based approach to treatment, or meeting the client where they are at, would be more effective with respect to treatment as well as sustained recovery. There is nothing wrong with anyone that isn’t human and to segregate addicts and/or alcoholics as being unique or different from the rest of “society” would be the first big mistake. One very important step, for me, in recovery was “discovering” that I was not much different than a lot of other people. Alcoholic’s anonymous was one very important example. However, it has been a few years since I have been to A.A.. The term “recovery’ hasn’t ever felt right to me because I felt “how can I recovery that which I never had”? I “discovered” that I was able to gain stability by utilizing reslience in a way that enhanced the qulaity of my life. In my opinion, resilence meant using drugs and alcohol in order to cope despite the consequences unitl I was able to adopt and/or adapt to a better way of living. In order to change my way of living I first had to adjust my thinking via imagining myself free from alcohol and drugs, acting upon my thoughts and taking the necessary steps by reaching out. Ultimately, I discovered that “I” was my own authority, not A.A., counselors, treatment programs etc…, and thus was responsible for the change I so desired!~ It was only with desire that I was able to change!~

    • Marc February 18, 2015 at 9:02 am #

      Gary, you sound like a poster child for the model I’m developing. Imagining a different future and synching it up with the desire to move on are exactly the key ingredients, whether looked at from inside the brain or inside the mind. I also really like your notion of resiliency. I don’t think I’ve ever considered it that way, but if I understand you, drug-taking itself can be an aspect or resiliency until that same resiliency takes you past it. That was surely the case for me. Drug-taking was a great way to cope…at first. The link between resiliency and impulsivity may also be worth exploring.

      I don’t like the term “recovery” either, for the same reasons as you. But we seem to be stuck with it for now.

      • Gary Goodwin February 18, 2015 at 9:38 am #

        Hi Marc,
        You’re absolutely correct! I did mean drug taking is in itself, at least in my opinion, a form of resiliency given a time period in my life and options available at my disposal. For me, I never ever wanted to die “but” nethier did I want to continue living the way I was living or perhaps existing. I believe beneath it all, at the core, was the nourishing of desire for a better way. The window of opportunity for change widens or diminishes or perhaps fluctuates from time to time and I think timing is everything. Instinctively, I’ve made decisions on impulse sometimes they were extremely helpful while other times they were not. I do sense there is a relationship between how I understand resiliency and impulsivity or fight or flight etc…

        Really enjoy this discussion and feel it helps me better understand the choices I have made. I strongly believe that everything always makes “sense” even what might be deemed “non-sense” once it is examined more closely!~

        • Marc February 22, 2015 at 4:12 am #

          Hmmm…..not sure everything makes sense, but this certainly does. Impulsivity is a kind of freedom. It helps you skip from one track to another. Then…compulsivity sets in. Check out Shaun’s link, above. It nicely captures the process of switching back out of addiction. You sort of remember that you do have that choice, that resiliency, after all.

          • Gary Goodwin February 23, 2015 at 7:12 am #

            Hi Marc…
            Without question, I am the author, the driver, the one who in fact gives “power” to the substance and addiction. It was always my “Belief” that became the “Thief”. As I may have mentioned in a prior post, the “Thought” of using alcohol and/or other drugs was, in many respects more powerful than the drug, in fact, it (my thoughts) was the vehicle and means of drug seeking.

            It was the very same “vehicle” (thinking) that also got me out of my own head and away from addiction. Once I understaood and it was clear to me that I gave all the power to my drinking, drug using and/or tobacco use I then took the power back into my own hands realizing that there was nothing outside of me controlling my behaviour.

            This was a moment of clearity which I believe translated into my ability to change. The term “spiritual awakening” in my opinion is the same thing as far as seeing myself and taking “full” responsibility without blaming anything outside myself. This was not only a humbling experience but necessariy in order to alter my thinking patterns.

            • Marc February 23, 2015 at 9:42 am #

              I think this is a very powerful way to frame addiction. I fully agree.

    • Ania February 19, 2015 at 10:39 pm #

      Absolutely agree with you, that’s interesting. One way I looked at it was when I was using in order to cope with depression and problems I always observed the difference in my mentality meaning that if drugs can make me feel this good, calm, focused, happy, and motivated then there just has to be a way I could make myself feel this way without mind altering substances. And if I can accomplish this then learning/living a new positive lifestyle while actually putting in the effort and work would not only be possible but at the same time feeding off those positive results will fuel me to even go further and further. And if I can only meet at least one person that lives this kind of lifestyle then I can have great examples to look up too and further learn instead of only being around people that are lost and unstable, which prevented me from moving further.
      Also Gary, you mention you haven’t been to a meeting in a long time and you realized that you are your own authority, that’s awesome. And when people are not their own authority and/or lost because they do not know who they are they are always looking to “belong” but when a person truly knows themselves they do not need to “belong” to a group. We also should be showing and teaching addicts on being intellectually independent, learning to understand so you are your own authority and not just going by the “rules”.

      • Marc February 22, 2015 at 4:14 am #

        Great synopsis, Ania. Thanks!

    • Cheryl February 22, 2015 at 8:04 am #

      I agree with this point. No one else can have authority of a volition that we alone own.

    • Cheryl February 23, 2015 at 7:06 pm #

      “I” was my own authority, not A.A., counselors, treatment programs etc…, and thus was responsible for the change I so desired!~ It was only with desire that I was able to change!~” I could not agree with this more, Gary! Marc I am so happy to see your response that you are creating a model based on this. Acting on resiliency takes a lot of volition and it is a powerful action. If we have the power to use it in one way we can certainly use it in another. To use it to better serve our interests and well being doesn’t take any more power or volition, just a change in perspective.

  10. Robert February 18, 2015 at 10:00 am #

    Hi Marc,

    One question. This may not be directly related to this topic, but I am curious how you manage to drink moderately despite your past struggle with addiction. I find myself in conflict with the concept of total abstinence. The 12-step community is anal about total abstinence from “all” mind or mood altering substances. Do you feel, one can “learn” to view alcohol in a different way. Thanks, once again for providing this forum.

    • Matt February 18, 2015 at 11:19 am #

      Hey Robert

      You’re reflections and reasoning on this topic are refreshing and insightful. I don’t think it’s really about drinking moderately, or heavily or being abstinent. It’s about having a drink. Having it be your choice. I am convinced now I could have a drink every now and then if I wanted, but I don’t want to. Any more than I would want to stay in an abusive family, even if I loved them. My “moment of clarity” was waking up one day knowing I didn’t have to do this anymore. And it was because my clinical endogenous depression had been lifted. Pharmacologically. I was myself again. Some people’s “moment of clarity” is when they go a few days and realize they hadn’t thought about drinking once. It’s about not having to change who you are to be in the world.

      • Robert February 18, 2015 at 2:00 pm #

        Hi Matt,

        Thanks for your insight. Your words truly resonate with me. After nearly 3 years of sobriety, I don’t feel the desire to drink. At this point, it,s give of novel to experience my emotions in “real time” without any kind of buffer. After 20 years of trying to escape “me”, it’s kind of wonderful to rediscover the world again.

    • Marc February 19, 2015 at 6:23 am #

      Hi Robert. I really don’t know if you can “learn” to view alcohol in a different way, but I suspect that you can, or at least that many former alcoholics can. That’s one interpretation of the research in any case. In one of the NESARC summaries, you find that about 30% of those who were classed “alcohol dependent” continued to drink while no longer “alcohol dependent” the following year. But roughly one-third of those were still classed as “at risk.” That’s just one statistic. Long-term stats show a higher proportion who quit but then returned to social drinking years later, but I don’t have those numbers at my finger-tips. If you want to start rummaging through the stats, you can start at the NESARC site: http://pubs.niaaa.nih.gov/publications/arh29-2/74-78.htm

      Of course it’s also clear that many alcoholics can’t ever drink moderately and they need to maintain total abstinence. Just like they tell you in AA. How would you know in advance which one you are? I’m not sure, but I think Matt’s post responds to that issue with clarity and wisdom.

      For me alcohol was never a problem. I liked it, but I never liked it so much that I became addicted to it. Opiates were my drug of choice. So my couple of drinks most evenings aren’t a problem. There is little temptation to keep drinking…in fact I quite dislike the feeling of being drunk.

      Total abstinence (from everything) is ideal for some.. It certainly is your best chance to feel clear and centered from day to day, especially if you meditate or use some other means to maintain mindfulness.. But for others, drinking nonaddictively is fine, even healthy. See Stanton Peele’s posts and writings for some of the benefits.

      From a neural perspective, I think it’s almost impossible to erase the meaning you built up about a substance you’ve been addicted to. But you CAN develop many alternative pathways to allow you to go on with your life free of addiction. I guess the question is really how strong and how accessible those pathways will be once you’ve had your first sip.

  11. Gary Goodwin February 19, 2015 at 7:16 am #

    Food for thought…

    If “Desire” is the fuel for change then perhaps imagination is the map which provides a sense of direction. I wonder if desire nourishes the imagination or does the imagination nourish the desire for movement toward change? If one lacks the “desire” but has an imagination, projecting in the minds eye for a better way of being, I believe there is a good chance for change. In my opinion, resiliency probably plays an important role where imagination is concerned providing possiblity, hope and/or options etc, … It’s not that the addict’s/alcoholic’s lack imagination but through prolonged use the mind and its ability to imagine gets diminished to such a degree that they tend to feel helpless and/or hopeless. Through a “re”-imagining perhaps via community-based treatment, meeting the client where they are at, entering thier map of the world together the spark of hope and desire can be nourished. Mindfulness also plays a vital role in helping a person to see, with some clarity, for themselves, not only the problem but also the resolution. Many of us are “the change” we want to see for others and that provides not only hope but perhaps an inherent humbling strength and beacon.

    • Matt February 21, 2015 at 9:45 am #

      Hi Gary

      You make a great point here. I couldn’t agree more that resiliency has a key role in all of this. But how do we get people to be more resilient, to learn resiliency? I think the classic longitudinal study done on the island of Kauai by developmental psychologist Emmy Werner points to some viable strategies. How we could effectively implement them remains to be seen. http://www.pathwaysrtc.pdx.edu/pdf/fpS0504.pdf

      • Cheryl February 22, 2015 at 8:46 am #

        Matt, thank you for this report. I truly feel that strategized resiliency can be taught to anyone at any age. If older, it will take intentional practice. Reaching those at a young age as a natural part of socialization is best because it becomes ingrained into ones life as a practice. Life constantly throws us curves and it is those with a natural resilience that are able to stay the course regardless. But there is a large population that resiliency is not natural so you get a large population that reacts rather than acts. A very vulnerable place to be. Creating a habit of addiction is an easy go to for people who are vulnerable. But even those who have gone down that rabbit hole can learn and practice it.

        • Matt February 22, 2015 at 11:47 am #

          Yes, absolutely!… and if they get out the other side in one piece…back through the looking glass, as it were… they can achieve an emboldened resilience and self-knowledge that people who haven’t experienced this may ever know. Not a recommended method for character building, but an added positive of successful recovery, nonetheless…

      • Gary Goodwin February 23, 2015 at 6:56 am #

        Hi Marc,
        First I want to thank you for sharing the study Emmy Werner(developmental psychologist), I found it quite interesting. I’m not exactly sure what the best approach would be to help people to acknowledge their own resilience. However, everyone who is here, alive today, has made it, and rather or not they feel resilient, I believe resiliency has been a factor at various degrees from person to person. First of all we may have to dwelve into the depth of resilience in order to gain perhaps a clearer understanding.

        Its great to know and/or acknowledge our strengths and feel they are attributes of resiliency but i also think acknowledging my weakness is as imperative because it too is a form of resilience.

        Perhaps many folks aren’t fully aware of their ability to adapt to circumstances, even sudden disruptions or ruptures of reality that create distress and/or trauma and how the mental as well as physiological aspects help to protect us during these times. I think by reframing people’s life stories, in such a way, that they are able to recoginze their own resilience could be one approach among many.

        Since people are complex entities we have a hard time keeping it simple and the more complex the story the belief might be the more complex the resolution. It just might be the complexity of simplicity. Change is an inside job!~

  12. Richard February 19, 2015 at 11:56 am #

    Hi Marc,

    I think that this is a brilliant and creative idea while simultaneously being a very basic and natural one. Peer and community support somehow dissolves the “mystery” and stigma of addiction. It returns it to being what it is – a fairly common and perfectly determinable challenge among our community and loved ones. Urgent or dramatic medical intervention is not necessarily required – and in many instances – can be an irritant/obstacle to those who struggle.

    My favorite part about this community out reach program is that it pokes holes in the notion that a specific program/recovery method is the only valid option – falsely implying that the solution lies within a “program” rather than within the individual. Regardless of what methods someone uses, the responsibility and ability to recover belongs to the individual – and so too does the credit and rewards for anyone’s success. The community is there to support and encourage someone’s inherent capabilities – NOT claim possession of “the answer”” or dictate a pre-determined, one-size-fits-all procedure or step-process – that is commonly dismissive of individual considerations, vital to ignite progress.

    When I was looking for answers, more often than not, those claiming to help were peddling a program or selling costly services, rather than trying to determine what would most encourage and inspire me personally toward recovery. At the very least, they were trying to validate their own recovery choices – as if alternative choices would somehow threaten their own sobriety. To make things worse, when I shared personal insights – and offered clues about who I am – the most valuable information available for someone who genuinely wishes to help another human being – I was often met by comments such as “Your best thinking got you here” or other dismissive statements about my “stinkin thinkin.” Or in those medical situations when the doctor or treatment professional implies he or she has the answers and is more vital to the recovery process than he who suffers – which of course is invalid – not to mention entirely illogical.

    Thankfully, I responded to the erroneous concepts espouses by treatment professionals with determination. Ultimately, I was supported by those who credited me for being capable and who were committed to nourish that which strengthened and empowered me – not by those who accused me of being fundamentally defective and requiring intervention or external management.

    There is so much about today’s recovery methods that is counter-productive and misleading. I also like the idea of people outside of recovery – who did NOT struggle themselves – being involved in helping those who suffer. It never made sense to me when someone who had not struggled with addiction was accused of being unqualified to offer help to a person who does struggle. I always viewed someone who didn’t use alcohol or drugs to cope with life – the way I did – as someone who I can learn something from. There remains a false and misleading distinction between addicts and non-addicts. Furthermore, while I do believe that each of us is unique, addiction isn’t what makes anyone unique – and certainly doesn’t set someone apart from the human species – which is oddly implied in some recovery arenas.

    Anyway, all that to offer my personal “stamp of approval”- for whatever that is worth – on the community out reach program. Hopefully I’ve offered a perspective that will contribute in some small way.

    Richard

  13. Gary Goodwin February 20, 2015 at 12:05 pm #

    In my own opinion:
    Regardless of one’s perspective in life I don’t believe it is helpful to be critical of programs, groups, professionals etc… in hopes to perhaps feel that you are “right’ in order to feed the Ego. True growth is to examine but without judgement which isn’t easy for the majority of us. Perhaps we can compare it to a landscape knowing that it just is whatever it is as we are passing along in the journey of life. Embracing the whole of life and allowing to be what is “change” within happens naturally. My judgements even “my opinions” can also be barriers. Just because I am able to conjure in my mind what “I” think to be true doesn’t mean that it is. Truth is elusive, like many aspects of life, and paradoxical. However, in recognizing that perhaps most of the problems I had suffered were due to my own Ego I had to only acknowledge this was the case and not try to stop or even change the Ego because if I did it was still the Ego operating on another level. Just total awareness of what is taking place presents not only clarity but also creates a sudden rupture of change simultaneously although we may not be consciously aware.

  14. jasmine February 21, 2015 at 5:16 am #

    At the risk of sounding like a voice of dissent, one with a glass half empty, I have many questions about this model. I glossed over some of the basic tenets, downloaded leaflets etc.

    So, if I understand correctly, the pilot project in Birmingham has local businesses/organizations – that agree to participate, and have been trained in brief intervention/s – place a “ROR” sticker at a visible/entry point, These stickers suggest anyone with substance ab/use issues can then go up to whomever, or pick up whatever information in hopes of providing support for healing/treatment.

    To take this further, the addict walking into whatever shop, either takes a pamphlet or approaches a staff member there to inquire. I’m sorry to say this, but how the heck could this not create a sense of stigma, othering and sense of hierarchy? So, the cashier at a pizza shop will be approached by an “addict” who says something like, “Oh, can you tell me about this program for addicts?” or something like that?? Am I missing something?

    This concept of “othering” is especially problematic for me – again, if I understand correctly. Does it not seem like a “them vs. us” sort of approach? As in, the community participating orgs and addicts, who are *ready/open/willing to disclose? As to the training, I won’t go there.

    Having also downloaded the pamphlets (if they are accurate from the main site), I found the language very un-user-friendly. So, the addicts who walk into the pharmacy (etc.) with the ROR sticker will pick up a pamphlet that offers “greater focus on recovery outcomes” and “a full range of integrated services” etc.,

    I could go on and on, and really hope I may have misunderstood. Though I appreciate an initiative that (finally) seems oriented toward those who can read/comprehend such pamphlets, I’m just not sure how those people would openly disclose such information, put it secretly in their pocket/purse etc., without worrying. And, for the less worried, I don’t really get how they can understand it??

    Maybe I just haven’t read enough, or something like that.

    Jasmine.

    • Robert February 21, 2015 at 11:29 am #

      Hi Jasmine,

      I agree with the purposed treatment model in theory, only. In the ” real world”, under real world conditions, most addicts are at a point of degradation that any treatment must meet them at a very fundamental level. The problem most people have about most traditional treatment models(i.e. 12-step program, N.A., A.A. etc.) is they assume the addict is a blank slate to which their particular ideology can be projected upon. Not everyone needs this approach, as many contributors to this blog have expounded. Most people need a safe, secure environment where that can compose, reflect and empower themselves towards new goals.
      I would argue that the percentage of active addicts that have the facility to use this approach without the added support offered by the traditional programs out there is relatively small. In reality, based on my experience, most addicts don’t have the wherewithal and personal initiative to benefit from such a “barebones” approach.
      In my opinion, the purposed initiative it targeted toward a more sophisticated audience that may not require such a heavy handed approach. In my personal journey, I have been through the 12-step fellowships, inpatient treatment and recovery house programs. Many of the addicts I encountered have additional issues such as mental illness, domestic abuse and illiteracy. Most of these individuals literally need to be humanized before we can even discuss addiction treatment. For addicts at this level, 12-step programs have been most successful.
      I guess if comes down to a question of what addict population are being targeted. The purposed outreach model may be more suited for those at a higher socioeconomic level.

      • jasmine February 22, 2015 at 1:16 am #

        Robert/others: thanks so much for your wonderful and enlightening responses 😉 I agree about some of the things you mentioned re: 12 step programs, treatment etc. The vast majority of my interactions in such realms/forums actually left me feeling far more functional; that these programs are not for people like me. However, from what you wrote/I read, this new approach has more potential to be – geared towards those considered higher functioning etc.

        My main challenge with that – and as I’ve encountered is the idea of being “outed.” That there is more to lose in being exposed. So, for example, someone in a similar situation would likely have more fear if they are seen grabbing a pamphlet, perhaps overhead speaking to a deemed “ROR” trained personnel member etc.

        I just also really struggle with the idea of proper training of these personnel, especially if the target “audience” is seemingly higher functioning. I could write more on that, and don’t mean to sound like I’m dissing the effort part. I just can’t help but think this could become kinda troublesome etc.

        Best Wishes to all,
        Jasmine

        • Marc February 22, 2015 at 4:38 am #

          HI Jasmine. Your concerns about stigmatizing, “othering”, and training have been responded do in detail by Peter himself — one of the organizers of the program. Please see his comments below. I think you’ll see that these issues are being dealt with in a way that is creative and compassionate…and rather clever — in fact if I wasn’t enthusiastic before, I sure am now.

          Note Peter’s comprehensive portrayal of the sort of community he’s dealing with. Clearly this program didn’t come out of nowhere; it evolved from currents in the community that were already present, and its goal is to systematize and improve the level of care already present in a very dynamic community — or set of communities.

          Anyway, just go to the horse’s mouth and see what you think.

        • Richard February 22, 2015 at 10:55 am #

          Hi Jasmine,

          I understand your concern for proper training. When developing any program which is intended to help those who suffer, it is natural to strive toward an effective, cohesive, and foolproof application. At the same time, I think that the brilliance behind a community outreach program – as opposed to a medical treatment program – is that the suffering is being re-introduced to its solution. From my perspective (and I know this could be easily debated) addiction is not a medical condition. It is a human condition. However inadvertently, in some instances, the reconciliation of undesired, painful, and even tragic human behavioral challenges , including addiction, is being held hostage by the medical community. We are far more inherently capable and recuperative than we realize. Medical intervention often points people away from inherent solutions rather than towards them.

          As much as I am personally incompatible with the philosophy of AA, I genuinely believe that prior to the treatment industry’s “take over”, AA had a certain wholesomeness and integrity that made it effective for so many. In my eyes, it wasn’t the 12 steps philosophy of AA that made it effective for so many. It was the sense of family and community that we all long for – addicts or otherwise. It was the “untrained” sharing of that which is so basic – kindness, decency, compassion, and good old-fashioned love. While I am certainly in favor of higher education, I think recklessness and tragedy comes about when the significance of academic pursuits is placed higher than the significance of love, compassion, and all forms of inherent human goodness. When it comes to “matters of the heart”, such as addiction, no amount of training can produce more powerful results than love.

          We have become so dependent on “formally trained/credentialed personnel,” that we dismiss our own wisdom and power. Sometimes the most brilliant (and healing) thing to do is wrap your arms around someone in pain. They don’t teach that in medical school. In fact, they discourage it. Perhaps a silly example, but my point is that we are intended to nurture ourselves and each other. We are designed that way and equipped with the resources to do so. We’ve lost sight of that, which has cost us dearly. Addiction is one of those human struggles that we are responsible for – individually and collectively. A community outreach program honors that truth and reclaims our abilities. Mistakes will be made – just as they are made within the medical treatment industry. However, returning the responsibility and ability to change back to where it belongs will realign the challenges with the solutions.

          I agree with you that any community outreach program intended to promote healing should have some basic guidelines and cohesiveness that may very well be best implemented through training. However, any training or procedural guidelines should be transcended by that which inherently guides us – compassion,, understanding, kindness, openness, flexibility, and all the miraculous consequences that come about when we make use of our most valuable asset – love. If the medical community and treatment industry were able to do that, perhaps they would not be so “powerless” to help addicts who they mistakenly view as being “powerless.”

          I feel compelled to conclude this by saying I may very well have converted your well-intentioned and valid point into a platform to vent my own frustration. My frustration with the treatment industry pre-existed this blog and should not be misconstrued as being directed at you at all. I genuinely enjoy hearing people’s perspectives and am grateful for your thoughts and insights.

  15. Peter Sheath February 21, 2015 at 2:34 pm #

    Hi Marc
    Sorry I’ve been away for so long, I have been checking in to see how this progressed and I’m pretty much overwhelmed by the positive messages and support. It’s taken some time to get to this point where we are about to take the quantum leap, in Birmingham, of helping people to begin to deal with the majority of addiction problems within their communities as a community. It’s pretty much along the lines of what has happened in Portugal, except for the decriminalization of drugs, and they are reporting dramatic reductions in almost everything negative associated with drugs. If it works, and many of us firmly believe it will, it will be a real game changer for the way in which we approach health care in general. It will help move us away from the deficits approach of needing an “expert” for just about every problem we encounter within our societies to a more co-productive community based expert by experience model where people can and do take responsibility for resolving their own problems.
    Jasmine makes some great points and we have thought long and hard about almost every one of them. The only one I don’t get is the, “I’m sorry to say this, but how the heck could this not create a sense of stigma, othering and sense of hierarchy?” point because much of the model is already happening in a very informal way all across Birmingham. The city is probably the most diverse city in the UK with lots of communities where English isn’t the first language with lots of cultures where they just wouldn’t dream of looking for outside help. Part of my role has been to find out what goes on, how they deal with addiction and if there’s anything we (ROR) can do to help. Most of the time all I’ve come across are very dedicated people doing it for themselves, who have developed some astonishing networks involving community elders, local businesses and resources. Far from stigmatizing addiction it has normalised it and, in many ways, made it the responsibility of the community.
    It should also be noted that we have not started yet, the start date is 02.03.15 and the leaflet that Jasmine is referring to is mainly for interested parties, professionals and commissioners to explain what we are trying to achieve. We want to consult with service users, which we can’t do properly until after the 2nd March, to develop a pamphlet as user friendly and contemporaneously accurate as possible.
    Most of the people we will be working with are engaging with all sorts of community resources on a daily basis, nearly 5000 are in receipt of opiate substitute prescribed medications which they pick up most days of the week from a community pharmacy store and around another 1000 are accessing the various needle exchanges delivered from community venues across the city. Most people with alcohol problems do go to either their General Practitioner or community pharmacist as a first point of contact anyway. Most of these, at present, have little or no support, supervision and/or training so simply refer to the alcohol team often meaning a delay in getting the help they need or maybe even actually creating a problem that could have been resolved at first point of contact.
    We have gone to great lengths to ensure that professional help, when needed, is easily accessible and readily available. Clinicians, keyworkers, structured group activities are never more than a short bus ride away and available within community centres, libraries, etc. The ROR outlets, pharmacies, retail premises, eventually taxi drivers and all sorts of other places, will know exactly where and at what time help is available. This will also be backed up with free availability to all sorts of on-line/telehealth support. We are hoping that, as the community develops and community champions come forward, professionals can begin to focus on people with complex issues and those who have maybe become stuck in and dependent on the treatment system for many years. Anyway, as you can no doubt imagine, I have work to do, please watch this space.

  16. Peter Sheath February 21, 2015 at 2:52 pm #

    Just one more thing, sorry Richard I’ve only just read your comment, thank you very much for your support and I agree with everything you’ve said and it really resonates with my experience both as a person who couldn’t deal with life without substances and a person who has dedicated his life to try to make things better. I believe the answer lies just where it always has, in the community. We, the treatment industry, have in many ways created a monster where we have persuaded people that they are sick and they need professional help to get better. Just as the great Bruce Alexander, Carl Hart and Marc have been saying addiction is what happens when people try to sooth away things like dislocation, marginalisation, poverty and dissatisfaction. Much of this comes about because of the systems or communities people come from, create an environment where communities can begin to heal themselves and, subsequently start to take responsibility for eachother then maybe change can happen. Focus on the individual, isolate them, treat them as sick, just like we are doing currently, and exactly what will happen then?

    • Matt February 22, 2015 at 1:31 am #

      …just as the facile AA nostrum bemoans, “If nothing changes, nothing changes.”

    • Marc February 22, 2015 at 4:25 am #

      Thanks so much, Peter. It is extremely helpful and refreshing to hear from the front lines. Obviously I didn’t know all the details, so it’s excellent that you’ve taken the time to respond to Jasmine’s queries. Now I can point to your summary and…wait a minute, wait a minute…I feel a thought coming. (I think I got that from the Three Stooges) How would it be if I take the text of your comments and turn it into next weeks post? Let’s have a little chat about that. You know where to reach me.

    • Marc February 22, 2015 at 8:54 am #

      In case anyone’s following this sub-dialogue, Peter has given my permission to make his comment into a post. So….at least I’ll try to contribute some nice pictures.

  17. Richard Hollett February 21, 2015 at 3:42 pm #

    Thank you, Peter. I am really excited to hear more about the twists and turns this program will take. Keep us posted.

    Richard

  18. Matt February 22, 2015 at 8:45 am #

    It is moving to hear so many thoughtful ideas about how to approach this, as well as the pointed concerns about potential pitfalls. Marc, you really seem to have assembled a remarkable brain trust of experience and expertise here motivated to effect the sea change needed to turn societal attitudes. And that can’t be done in the shadows, on the perphery or in dank church basements anymore.

    My wife once made an analogy about the difference between religion and spirituality. Imagine you are hungry, and you are looking around for a good restaurant. You visit several. One is spit polish with nice new silverware, a beautiful façade, great menu… Another looks rather pedestrian but has impeccable service and a delightful, congenial staff. And yet another is a crummy looking hole in the wall but has the most delicious food you’ve ever tasted. Obviously, religion is the restaurant, and spirituality is the food.

    We all have to find our own delicious food and where we want to eat it.

    Recovery comes in as many forms as there are variations in people’s addictive patterns and personalities. It’s a journey of negotiating change, not getting back to some desirable state you had before. Recovery may be a lot of things to a lot of people, but whatever it is, it depends on:

    1) the individual and the incredible variation in each of us;
    2) the context in which the individual exists;
    3) the ability to manipulate the interaction of 1 and 2 to optimally benefit everyone.

    And for something that seems consistent and regular to some, there is incredible variability caused by these factors. Recovery’s not determined by the program. That’s an illusion. It’s determined by the people.

    I can imagine any of myriad methods working. It all depends on the directed desperation of the individual (what Marc calls desire?). And for the individual getting exposed to the right opportunities at their most open, searching, educable and desperate moments– and by their compassionate, caring fellow humans.

    Peter, I applaud your foresight and “gumption” to see this possibility, put together a realization of it, and run with it. Of course you’re going to run into all kinds of barriers— but you can’t work the bugs out of something that doesn’t exist. Best of luck, and know we are all behind you in this!

  19. Peter Sheath February 22, 2015 at 12:23 pm #

    Wow I’m blown away with the positive and constructive comments. It’s such a great community that has been put together here and it’s so refreshing to see all the different ideologies being discussed. I’ve just started reading what looks like a fantastic book called, the brain’s way of healing: stories of remarkable recoveries and discoveries by Norman Doidge. I have only read a few chapters but it talks about the power of the brain and neuroplasticity in some of the miraculous recoveries we see people make from very serious conditions. It starts with a wonderful quote by the father of medicine Hippocrates written around 2500 years ago. He’s talking about recovery and says; “Life is short, and art is long: opportunity fleeting, experience misleading, and decision difficult. It is the duty of the physician not only to provide what he himself must do, but to enable the patient, the attendants and the external circumstances to do their part as well.”
    I guess that, in a nut shell is the environment we are attempting to create in Birmingham.

    • marc February 22, 2015 at 2:53 pm #

      Quoting from Hippocrates is pretty classy. But finding the quote that says exactly what needs saying is….over the top.

      So this is Norman Doidge’s second book. His first, The Brain that Changes Itself, was an important step in familiarizing the nonscientific world with neuroplasticity. Thanks, Peter, for bringing this to our attention.

  20. Gary Goodwin February 24, 2015 at 7:39 am #

    Just a thought!~
    Acknowledging as well as embracing the power within such as resiliency, adaptability, desire etc…, is kinda the premise, at least in my mind, of the self-help movement. In many respects, A.A. in “voiceless” and its the people that bring meaning as well as interpretation to it…not much different than our view and/or interpretation of life. I do believe the key, however, is knowing the process and that I see the world the way I am. Peoples’ view of the world changes with time, technology and perhaps through learning and/or inquiry. It is most helpful to quiet the mind long enough to feel and get a sense of our selves. This can be uncomfortable for many as they much prefer stimulation over quiet time or doing nothing.

    It is more difficult to access or even realize that you have inate abilities that can help bring about change that enhance your life if you constantly seek some form of stimulation. Perhaps our interpretation of desire distorts and clouds our minds to such a degree that we cannot see clearly. In my mind desire isn’t always about “doing” sometimes and perhaps more often, it ought to be about “being”.

    Most people are caught in the pattern of doing and kknow very little about being. Unless or until I can clear the debris from my mind and/or “clean the slate” how can I change? We have the ability to start over anytime we wish but if mine mind is cluttered this will cause distraction, stress and/or anxiety which is self defeating and back to the same old pattern.

    In order to move away from any given situation in my life I first have to acknowledge it and embrace it wholeheartedly. I believe the dilemma comes from trying to move away from difficulty without fully understanding it which moves me towards further difficulty, anxiety and stress etc.., Seeing, through the mind eye, helps to see in such a way that change in inevitable. Here is a quote of mine that helps me to comprehend: “In order to see we open our eyes, in order to understand we must close them” for me this helps to access the inner scope of life.

    • Marc March 9, 2015 at 5:03 am #

      Gary. This is very useful. A seasoned and sensible approach to mindfulness and how it interfaces with our stressed-out existences. When you have a sort of essay aching to get out, it’s better to contact me so we can consider it as a blog post. These comments, especially at the bottom of a long list, tend not to be read by most people.

  21. Janet February 25, 2015 at 9:00 am #

    Has anyone heard of San Patrignano in Italy? I was very interested in it but have never met anyone who has much knowledge of it. Thanks. Janet

  22. cath March 6, 2015 at 9:22 am #

    In the context I work in (resource starved South Africa) the challenge is not the moment of desire… our service beneficiaries express these freely, it is the lack of services to link them with in that moment. Its quite painful. After a fair amount of time working in privileged treatment settings which relied heavily on “confronting denial” it is sadly ironic that there are so many asking for services which do not yet exist.

    • Marc March 9, 2015 at 5:33 am #

      That is ironic — and sad. Check out the next post to see more details about how the Birmingham model came into being. There was apparently a lot of community activity already, and the powers that be realized it was cheaper to support that sort of grass-roots activity than to medicalize and institutionalize everyone with a problem. Also, you might check out Shaun Shelly’s newsletter/blog…I’ve put the link on the homepage of this site. Shaun lives/works in Capetown, he’s a frequent contributor here, and he’s a really great guy.

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