The profession of addiction counseling is historically rooted in the lived experience of recovery, but the degree of recovery orientation in addiction counseling has ebbed and flowed over the course of the field’s history. Four overlapping eras illustrate the evolution in the field’s recovery orientation—recovery orientation here defined as respect for recovery-based experiential knowledge, a focus on the facilitation of long-term personal/family recovery, adherence to recovery-linked and scientifically-grounded service practices, and emphasis on the role of community recovery capital in the initiation and maintenance of personal/family recovery.
Recovery Roots of Addiction Counseling
The birth of a specialized helping role to facilitate the resolution of alcohol and other drug problems can be traced to the first persons recovering from such problems who committed their lives to helping others similarly affected. In the United States, such roles included the leaders of 18th and 19th century Native American abstinence-based religious and cultural revitalization movements and the “reformed” temperance missionaries within the Washingtonian Temperance Society (1840s), recovery-focused fraternal temperance societies (1840s-1870s), the Ribbon Reform Clubs (1870s), and such local recovery mutual aid groups as the Drunkards Club in New York City (Coyhis & White, 2006; White, 2000a).
Collectively, these individuals shared their recovery stories in public and private meetings, penned recovery-focused pamphlets and autobiographies, conducted private consultations with individuals and families experiencing addiction-related problems, helped organize local recovery support groups, and maintained prolonged and prolific correspondence with those seeking recovery (White, 1998). The employment of such charismatic recovering figures within the rising network of mid-19th century inebriate homes, inebriate asylums, and private addiction cure institutes marked one of the first controversies and professional splits in the field of addiction treatment. Inebriate homes were often founded and directed by persons in recovery, maintained close links to local recovery mutual aid societies and emphasized the importance of public commitment (signing the abstinence pledge), sober fellowship, service to others, and the value of short voluntary stays to prime the recovery process. In contrast, inebriate asylums were physician-directed and emphasized physical methods of prolonged, legally mandated institutional treatment emphasizing medical treatments aimed at curing. Inebriate asylum directors attacked the hiring of “reformed men” on the grounds that:
Physicians and others who, after being cured, enter upon the work of curing others in asylums and homes, are found to be incompetent by reason of organic deficits of the higher mentality….The strain of treating persons who are afflicted with the same malady from which they formerly suffered is invariably followed by relapse, if they continue in the work any length of time (Crothers, 1897).
The tensions between the inebriate homes, asylums and institutes, experiential knowledge versus professional knowledge, and recovery support versus medical cure were lost in the larger collapse of addiction treatment and recovery mutual aid groups in the opening decades of the 20th century.
The Addiction Counselor as a Paraprofessional Recovery Specialist
The collapse of 19th century addiction treatment in the U.S. left those with the most severe alcohol and drug problems abandoned to inebriate penal colonies, the back wards of aging state psychiatric asylums, or the “foul cells” of large public hospitals. Those conditions spawned new recovery support efforts, including clinics that trained people in recovery as “lay therapists.” Courtenay Baylor, Francis Bishop and Richard Peabody were among the earliest and most distinguished of such lay therapists and might well be called the first addiction counselors in the United States. This lay therapy tradition was carried forward by Ray McCarthy and others within the Yale alcoholism clinics of the mid-20th century and the extension of Alcoholics Anonymous sponsors into what were first called “AA counselors.” It was further extended with the hiring of “ex-addicts” in the growing network of therapeutic communities, methadone maintenance programs, and outpatient counseling clinics in the 1960s and early 1970s. This emerging “paraprofessional” counselor role incorporated multiple dimensions—the tradition of recovery storytelling (self-disclosure), mutual recovery support, counseling (new skills incorporated from the fields of psychiatry, psychology, and social work), and community recovery resource development and linkage (White, 1998, 1999). The paraprofessional era was marked by high recovery representation within the addiction treatment workforce, close linkages between treatment and local recovery communities (particularly AA), and an emphasis on experiential versus professional/scientific knowledge. The primary and sometimes exclusive credentials the paraprofessional addiction counselor brought to his or her role were personal recovery and a passion to help others recover (White, 1998, 2009b).
Professionalization of Addiction Counseling
The professionalization of addiction counseling unfolded within the emergence of a specialized, revitalized field of addiction treatment—the growth of local treatment programs; formally designated state and federal agencies responsible for planning, funding and evaluating treatment programs; the extension of insurance coverage for the treatment of alcoholism and other addictions; the rise of hospital-based and private addiction treatment programs; and the emergence of addiction treatment program licensure and accreditation standards. To achieve public and professional credibility, this rebirthed field required an expanded and credentialed addiction counseling workforce.
Two milestones significantly shaped the addiction counselor role. First, addiction treatment migrated toward an acute care intervention (modeling itself on the hospital via early accreditation standards) rather than on the models of more extended recovery support that prevailed during the paraprofessional era. Second, the role of addiction counselor was modeled on clinical functions performed by psychiatrists, psychologists and social workers. Notably, key functions were lost in this transition, such as assertive outreach, community-based recovery resource development and linkage to indigenous recovery supports in the community. The core functions of the addiction counselor narrowed (screen, assess, diagnose, treat/counsel, document, discharge), and substantial state and federal resources were invested in skill development related to these core functions. The professionalization of addiction counseling was also marked by the rise of national and state associations for addiction counselors, the development of certification and licensing standards for addiction professionals (with increased educational requirements), the proliferation of preparatory addictions studies programs in colleges and universities, new resources for continuing education, and improved salaries and benefits for addiction counselors.
The 1970s and 1980s marked the transition of the addiction counselor from the status of paraprofessional to that of a clinical professional on par with other recognized helping roles. Rarely noticed during this period of explosive growth was the decline in recovery representation in the addiction treatment workforce and among executive leadership and governing boards, the erosion of once strong volunteer and alumni programs, weakened connections to local communities of recovery, and a shift in orientation from long-term recovery to ever-briefer periods of treatment. Cyclical episodes of biopsychosocial stabilization became the norm with a growing portion of persons entering treatment with multiple prior admissions. Throughout the 1990s there was a sense of great pride in how far the field of addiction treatment had come in a few short decades, but there was also underlying unease that things of great value had been lost in the professionalization, industrialization, and commercialization of addiction treatment (White, 2000b).
The recovery advocates of the 1940s-1960s spent much of their lives advocating for the federal legislation that in the early 1970s established the foundation of modern addiction treatment. They did so in the belief that specialized addiction treatment could provide a portal of entry into recovery for people who could not otherwise initiate or sustain recovery. By the mid-1990s, there was a growing sense among a new generation of recovery advocates and many long-tenured addiction counselors that the multibillion dollar addiction treatment industry had become disconnected from the larger and more enduring process of addiction recovery and from the grassroots communities whose efforts had had birthed the field (Else, 1999; Morgan, 1995; White, 2002, 2004).
Several contextual conditions set the stage for calls to renew long-term recovery as the central mission of addiction treatment and addiction counseling: the growth and diversification of recovery mutual aid organizations, a new recovery advocacy movement that both supported addiction treatment and challenged its diminished recovery orientation, the emergence of new recovery support institutions as adjuncts and alternatives to addiction treatment, a growing body of research findings on the limitations of the acute care model of addiction treatment, the reconceptualization of addiction as a chronic disorder, and increasing calls to shift treatment of the most severe and complex AOD problems toward a model of sustained recovery management (Dennis & Scott, 2007; Kelly & White, 2011; McLellan, Lewis, O’Brien, & Kleber, 2000; White, 2005, 2008a,b,d; White, Kelly, & Roth, in press; White & McLellan, 2008). It was perhaps inevitable in the face of such changes that the field’s organizing center began to slowly shift from its historical focus on addiction pathology and the mechanics of treatment to rising interest in the prevalence, pathways, and processes of long-term personal and family recovery.
Fulfilling the vision of recovery-focused addiction treatment and addiction counseling will require substantial changes in the field’s infrastructure (McLellan, Carise, & Kleber, 2003), service practices (White, 2008c), and evaluation methodologies (McLellan, 2002):
Efforts to increase the recovery orientation of addiction treatment/counseling are underway across the United States under the conceptual rubrics of recovery management and recovery-oriented systems of care. The success or failure of these efforts will exert a powerful influence on the future of addiction recovery in America and the fate of specialty-sector addiction treatment as a cultural institution.
Research for this article was supported by NAADAC under the Recovery to Practice initiative of the Substance Abuse and Mental Health Services Administration (SAMHSA). The opinions expressed here are those of the author and do not necessarily reflect the policies of NAADAC or SAMHSA.
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