Recovery from Addiction: Maintaining our Focus on Basic Human Needs

The addictions treatment field counts as one of its primary cornerstones the ability and responsibility to help people suffering from the disease of addiction maintain their employment. Active addiction to any number of drugs, including alcohol, has derailed the careers of many people, and regaining that occupational and/or educational mojo is often a critical component of early recovery. Indeed, the founders of Alcoholics Anonymous were both great examples of careers detoured by alcoholism: Bill Wilson as an investment advisor, and Dr. Bob Smith as a colorectal surgeon (with the shakes….yikes!).

For many years, one of the most reliable and effective means to convince people to get help for a problem with addiction has been the leverage associated with fear of losing their job. In the 1980’s and 1990’s, many companies in America had active employee assistance programs designed, in part, to assist employees with personal problems that affected their work performance. The subtle message was often clear: “If you don’t address the personal problems that are impacting your performance, you probably can’t expect to continue to work here.” This fear of job loss was a very powerful weapon that was partially responsible for many people starting (and staying) on the road to recovery. As an aside, this is one of the reasons that programs for impaired professionals (often, but not always, health care, legal, or transportation professionals) have grown and been successful in America: the loss of a job as a physician, registered nurse, airline pilot, or attorney is a real threat to both self-esteem and financial well being, and professional sanctioning bodies have become very adept at using that leverage to require a reasonable amount of compliance with treatment, including urine drug screening protocols often more vigorous than most.

Today, many treatment programs see increasing unemployment rates among their patients, in spite of a labor market approaching full employment. I have personally done “back of the napkin” calculations to ascertain the unemployment rate at a treatment center I managed, and found the rate among adult patients to be as high as 70%. Why this change? The broadened capacity of Medicaid to fund addiction treatment is one answer, along with many others, including the rapid growth of opiate addiction as a percentage of the admitting diagnoses at many treatment centers, often accounting for the great majority of the patients. It’s simply almost impossible to maintain gainful employment and financial health as an opiate addict, which becomes a full time job in and of itself.

So, we’ve gone from a philosophical framework in treatment settings of “we want to help you get clean and sober in order for you to save your career,” to one where employment often wasn’t in the picture prior to treatment at all, and unless there is radical change, won’t be during recovery.

Why is this a problem? Because we are meant to engage. We are meant to contribute value to our families, communities and the world. Meaningful engagement goes straight to self-esteem. The establishing, or reestablishing of a career (or volunteer work) is a hallmark of recovery…giving back is baked into the DNA of the 12 Steps, and of recovery in general. The absence of this can be a breeding ground for addiction, and in early recovery, for relapse. The old saying, “idle hands are the devil’s workshop” has a grain of truth to it.

So, what do we do about this? How do we deal with the painful reality that many (in some settings, most) of our patients and clients were unemployed prior to treatment, and will likely remain so after unless significant change occurs?

I would challenge us to examine the very nature of treatment in the process of answering this question. If you think in terms of Maslow’s Hierarchy of Needs (you know the model, based on the concept that we can’t truly attend to higher order needs when we have significant unmet needs in the lower tiers of the hierarchy), we have to face the painful fact that most of what we call treatment for addiction occurs in the top three tiers of Maslow’s Hierarchy (Belonging needs, Esteem needs, and the need to self-actualize). Indeed, the whole framework of the 12 Steps and much of cognitive behavioral therapy is centered on work in those three zones of human need.  But the caveat is: we can never let the model cause us to assume that our patients, profoundly different from those of just a decade ago, have no significant unmet needs in the bottom two tiers in Maslow’s Hierarchy (basic physical, survival safety and security needs). Often, nothing could be further from the truth!

If we are trying to help a young man by focusing on his self-esteem, when in fact he is jobless, homeless, broke, with four drug dealers on his trail to satisfy drug debts, I would submit that we’re in disconnect with the reality of the situation. Until I have a handle on my basic lower-order needs (safe housing, food, heat and clothing, a reliable means of income and transportation, a relative sense of safety from physical or emotional harm, etc.), don’t expect me to give all my attention to doing a 4th Step, or examining family of origin issues!

Our patients have changed. We have to acknowledge that the damage done by opiates, and often other drugs of abuse, has been profound at the most basic levels of the human experience, i.e, one’s ability to reliably function on a daily basis (housing, income, transportation, safety, etc.). If we are failing to adjust to this more damaged patient by attending to these needs with housing assistance, healthy and ethical sober living placement, job training and placement, credit counseling, and a whole slew of additional fundamental prerequisites for recovery, I would submit we are treating today’s patient with yesterday’s approach to treatment, which assumed that these most basic needs are met relatively well, when often, they are not. 

So, my challenge to all of us in the treatment of addictive illness is that we be able to take off the psychotherapy hat, the 12 Step orientation hat, and any other hats, long enough to to assure that the "old school" social work approach required to foster health and functionality in the bottom two tiers of the Maslow Hierarchy is getting the proper attention. Not assisting the patient in taking action in those basic human areas of need can quickly sabotage early recovery. I'm much more likely to do my 5th Step and get a sponsor when I'm no longer couch-surfing every night, and sleeping with one eye open.