The Crooked Road Of Recovery: Rethinking Relapses And Success In Addiction Treatment And Research

By Dr. Sergio Rizzo Fontanesi and Harriet Rossetto, MSW

It’s Friday night in West Los Angeles. As Angelenos flock with their entourages to trendy restaurants and night clubs, an eclectic group of recovering addicts attend Shabbat services at Beit T’Shuvah – a synagogue and residential recovery community. Here, current and former residents, ranging from neophytes celebrating their first sober year, to veterans celebrating several sober decades, stand before the congregation to share their story, sing a collective rendition of “Happy Birthday, Keep Coming Back Sober!”, and indulge in defrosted chocolate cakes. The speeches elicit an assortment of responses: laughter, tears, gasps, nodding heads, and empathetic grunts. The men and women celebrating are the ones that have managed to get and stay sober, and in the process, demonstrate that Beit T’Shuvah’s treatment program is successful.

This view of success, however, is incomplete. It corners us into equating recovery with the sobriety clock – the amount of time that one is abstinent from abusing substances – rather than conceptualizing recovery as multidimensional. From sobriety apps downloaded on smart phones, to sobriety chips distributed at 12-step meetings, counting time eclipses the purpose of recovery as a holistic journey that involves much more than abstinence. It is as if the addiction of using has been replaced with an addiction of counting, returning us to the rigid cognitive schemas that engulf addictive behaviors in the first place.

Consider the case: “Sara” recently celebrated her first sober birthday and landed her first post-rehab job. A few weeks into her position, however, she went on a drug run. Typically, Sara would be asked to complete thirty days at an outpatient program or she might lose her privileges altogether, including employment, and be recommended to return as a resident along with the other newbies starting at Level 1. While well-intentioned, these practices can be counterproductive. People often relapse at the point of new transitions. Relieving them of their commitments so that they can return to the rehab-womb might reinforce future relapse behavior when the going gets tough and they seek to avoid responsibility. As a result of her relapse, Sara’s sobriety clock was also reset, and along with it, a loss of respect and sponsees ensued. The insights that she garnered were overshadowed by the newcomer chip that she received at her longstanding AA meeting. So, her one slip, placed Sara in front of her AA group, introducing herself, once again, as a “newcomer.”

The loss of sober time can be accompanied by the misguided judgment that the person has failed at recovery. Our overt focus on sobriety breeds the misperceptions that relapses are inherently devastating and that the growth and change that precede the relapse are figuratively thrown out along with the bathwater. In fact, the opposite is true. Recovery trajectories are complex and nonlinear, with potholes, detours, and dead-ends along the way. The proverbial road is crooked. In Sara’s case, success was evidenced not just by he achievement of 365 sober days, but also by her continued commitment to recovery despite her relapse. In Jewish spirituality, this is known as teshuvah, and according to the ancient tradition, not even the most righteous can stand where the repentant person does. While Sara’s sobriety appeals to a naïve one-dimensional view of treatment success, her relapse also challenges us to consider that this view is fragile. Those who are sober today might not be sober tomorrow and vice versa. Addiction is considered, after all, a chronic relapsing condition. Ultimately, Sara was not asked to return as a resident nor was she fired. Instead, she was told to return to work and received supportive services during the transition period. A novel idea for someone who had already completed one year of residential treatment and was struggling to overcome a littered track record of inconsistent employment.

In the current era of evidence-based practice, how researchers conceptualize outcomes have profound implications for the program’s continued existence. The funding landscape is competitive and sparse, and those programs with quantifiable results and digestible definitions of success are the ones most likely to receive funding. In the field of addiction research, using sobriety as the metric of success is appealing because it is simple – using (failure) or not using (success). But this overemphasis on sobriety propagates a bifurcated view of human transformation. This dichotomy is foolish considering the complexity and nuance of human behavior and eludes the idea of recovery as a lifelong trajectory, with many necessary successes and failures along the way.

Consider yet another case: “Avi”, a recent Beit T’Shuvah resident, agreed to treatment at the bequest of his family for his abuse of alcohol. Six months after completing the program, a follow-up call was made. Avi disclosed that since finishing treatment he continued to struggle with abstinence, though rarely drank to the point of intoxication. Moreover, he was meeting regularly with his sponsor, working again, and in the process rekindling his relationship with his family. During the call, Avi also revealed that his time at BeitT’Shuvah set him on a path of “living well.”

Is Avi evidence of treatment success or failure? If success, as with many effectiveness studies, is measured by whether abstinence is achieved, Avi falls squarely into the latter category. But, if a more expansive definition of success is used, Avi unquestionably belongs in the former classification. Perhaps Avi is both. He has succeeded in certain domains and has not succeeded in others – at least for now.

Let’s be clear. We are not discounting the paramount importance of sobriety on the journey of recovery, nor are we minimizing sober birthdays as laudable moments to celebrate the hard-won achievements of those once in the throes of addiction. Moreover, it’s unlikely that someone with a history of addiction can “use just a little bit” without it indicating deeper problems, and certainly, if you can’t stop using, you will need a drying out period before
reassuming your responsibilities. We must also be cautious not to minimize relapses to the point of justifying using. Sobriety, however, cannot be the sole indicator of success in addiction practice and research. When it is, misperceptions are bred about recovery, treatment success, and about the internal work that still must be undertaken. In this way, both the individual who has fallen off the wagon and the one who has remained on the wagon are at risk: the former mistakenly believes their efforts have been in vain, but more disturbingly, the latter does not see beyond their motivation to acquire yet another chip or celebrate another year. Ultimately, using the sobriety clock as the metric of success in recovery ignores the multitude of other markers that slowly – and inconsistently – reveal how individuals courageously emerge from shadows of addiction.

https://www.youtube.com/watch?v=4BqnickstVc&t=8s
Dr. Sergio Rizzo Fontanesi completed a joint MSW and PhD in Social Welfare at the UCLA Luskin School of Public Affairs. While at UCLA, his areas of study and research were  Nonprofit evaluation, faith-based social services, and the broad intersections between culture, spirituality, and mental health care. After earning his doctorate, he joined the faculty at the USC Suzanne Dworak-Peck School of Social Work, where he continues to teach graduate courses. He also worked for four years at the UCLA Luskin Social Justice Research Partnership. While in this position, he served as Project Director of a two-year program evaluation of Beit T’Shuvah (BTS); the start of his deep love for, and commitment to, the organization. It was during this time that he learned a transformative lesson: “step out of your role and into your soul”, and in the process, he discovered a place of belonging, passion, and purpose. www.beittshuvah.org

Harriet Rossetto started Beit T’Shuvah over 30 years ago with a tremendous humanizing task: to help broken souls and change a broken system. Harriet’s belief that addiction is a malady of the soul requiring spiritual healing inspired her to create a thriving community that supports addicts of all kinds, wherever they are in life. Her greatest reward is witnessing and participating in the miracle of transformation. Her view that everyone is capable of redemption is at the core of why she empowers the residents of Beit T’Shuvah with employment, hiring ninety percent of her staff from within. Today they are the lifeblood of the organization.

Today, Harriet is a sought-after speaker in synagogues and community groups worldwide. She received her Master of Social Work degree from the University of Minnesota, and is now a trainer for the National Association of Social Workers, teaching classes about the treatment and philosophy of the “dis-ease” of addiction. Harriet is also an author of the book Sacred Housekeeping: A Spiritual Memoir. www.beittshuvah.org