Recovery Curriculum 401

Workforce, advocacy, and what we owe the field that raised us

Some might say this field was born from trouble.

It wasn’t created in universities or boardrooms. It wasn’t created in the offices of licensing boards or the conference rooms of insurance companies. For more than 275 years, people recovering from severe alcohol and other drug problems have been providing peer-based support to sustain one another and reach those still suffering, long before any professional credential existed for it. When the modern field finally began to formalize, it did so in church basements, in living rooms, in the back of harm reduction vans, built by people who had been through it themselves and refused to leave their community behind.

The first meeting of what became Narcotics Anonymous was held on February 16, 1947, inside a federal prison hospital in Lexington, Kentucky, under regular police surveillance because any gathering of recovering alcoholics and addicts was considered suspicious enough to monitor. Early NA meetings were held on the Staten Island Ferry because no one would rent them a space. A coffee pot moved from location to location, week after week, because there was nowhere permanent to set it down. The people who built this field did it under conditions that were actively hostile, with no funding, no recognition, and no guarantee that any of it would last.

This is the last piece in the Recovery Curriculum, and it is the one least about the person in recovery and most about us, the people who do this work. Because somewhere between those Staten Island Ferry meetings and the prior authorization queue on your computer screen, something got lost. And the field is paying for it.

The Road That Was Taken

Addiction historian William White documented what he called the road not taken in the field’s own history. Between 1960 and 1970, two quite different models competed for what addiction counseling would become. One was community-based and peer-driven, built on the belief that alcohol and drug problems had to be addressed not inside a treatment center but within the community itself, that the intervention belonged as much to the neighborhood as to the individual. The other was a clinical model that located the problem inside the individual and the solution inside a professional office.

The clinical model won. And with it came something valuable: credentialing, reimbursement, training standards, a recognized profession. But something very important got lost too.

White describes the community model that existed in Iowa, of all places, in the 1960s. The role at its center wasn’t a counselor but a Community Alcoholism Agent. An outreacher, motivator, advisor, empathic friend, someone who functioned as a catalyst for the larger community process, doing nothing for the person in recovery that could be gotten from someone else in the community instead. The job was to mobilize natural resources, link people to them, and stay in it for the long haul. Years before motivational interviewing had a name; this model was built on meeting people where they were and staying until they were ready. It was built on the belief that the community was both the client and the treatment program.

To the extent that the centers turned to face the State Capital, they turned their backs on the alcoholics and the communities they had been serving. — Harold Mulford, 1978

That model fell out of favor as federal and state funding became available in the 1970s. The field, understandably in many ways, moved toward the structures that came with the money. Harold Mulford, who documented the Iowa model extensively, said the field “sold out” in its search for federal and state funding. White draws the parallel to social work, which made the same turn decades earlier, relocating from community to consulting room, shifting emphasis from social and political action to clinical technique, gaining professional status while losing community rootedness.

We aren’t making accusations here. We are describing a pattern that repeats itself across helping professions. And recognizing the pattern is the only way to interrupt it.

The National Association of Alcoholism Counselors and Trainers, the organization that eventually became NAADAC, was founded in 1972 by Matt Rose, who had led community-based alcoholism programs funded through the federal Office of Economic Opportunity (OEO), the Johnson-era agency that seeded grassroots social programs across the country under the War on Poverty. Rose was unpaid and worked from his home in Arlington, Virginia. He didn't set out to build an institution. He was trying to organize people who were doing important work and getting no recognition for it. The organization that now represents tens of thousands of addiction professionals in every state grew from that, from one person working without support because the work mattered and someone had to do it.

Is Burnout Really What We Mean?

Addiction counselors report burnout at rates higher than almost any other helping profession. The field has high caseloads, low pay, inadequate supervision, and a client population whose needs are complex and whose outcomes are sometimes slow and nonlinear. All of that is real, and all of it contributes to exhaustion.

But exhaustion alone doesn’t explain what a lot of clinicians in this field are actually describing when they talk about why they’re leaving.

The more accurate term is moral injury. Originally studied in combat veterans, moral injury describes the wound that comes not from danger itself but from being forced to act, or to watch others act, in ways that violate your own moral code. It has been applied with increasing precision to healthcare workers, and it maps onto addiction counseling with uncomfortable accuracy. It looks like the documentation requirement that takes time away from the client sitting in front of you. It looks like discharging someone you know isn’t ready because the insurance authorization ran out, or they ran out of “chances.” It looks like watching a sober living program bar a client from medication that would keep them alive, and knowing the policy isn’t yours to change today.

One workforce researcher described it plainly: more time spent justifying the work, less time doing it, as death rates from addiction dramatically increase. He called it occupational moral injury. When we must spend more time on the administrative justification for the work, we spend less time doing the work, and the people we are trying to reach and support are dying. That isn’t to say the administrative aspects aren’t important. It’s that they have become so ubiquitous and consuming that they take away from the person-to-person connection work that is needed so badly in recovery. The administrative becomes a barrier to access that leaves people who desperately need help out in the cold.

Burnout responds to rest, caseload reduction, better pay. Those things help moral injury too, but they don’t resolve it, because the source isn’t fatigue. The source is the gap between what you became a counselor to do and what the system requires of you to keep your job. You can take all the self-care days in the world and still feel the wound, because the wound isn’t in you. It’s in the structure you’re operating inside.

What the addiction counselor knows that other service professionals do not is the very soul of the addicted — their terrifying fear of insanity, the shame of their wretchedness, their desperate struggle to sustain their personhood. To witness that process of transformation is the most sacred thing in the field, and what would most need to be rediscovered if the field collapsed today. — William White

The field’s turnover problem is a direct result of this moral injury issue. We call it a workforce shortage, not enough people entering, not enough staying, wages too low for the acuity of the work. All of that is true. But the upstream problem is that we built systems around this work that treat compliance as the client. Prior authorization and insurance access and funding structures that determine level of care before a counselor has met the person. Drug testing used as surveillance rather than clinical information. Peer support specialists carrying some of the most credible and irreplaceable relationships in the entire field, treated and compensated as a cost-saving measure rather than genuine clinical partners. None of this is any one person’s fault. It’s what happens when a field built on presence and relationship gets absorbed into systems built to manage risk, bill insurance, and make some sort of profit.

If you’ve felt the particular exhaustion of doing something you knew wasn’t just or right because the system required it, you’re not weak and you’re not in the wrong field. You’re describing moral injury accurately, maybe for the first time. Naming it is the first thing that has to happen, because you can’t treat a wound you’ve been misdiagnosing.

Good Trouble, Not Comfortable Trouble

Civil rights icon Senator John Lewis talked about getting into good trouble, necessary trouble. He didn’t say comfortable trouble. He didn’t say trouble that fits inside a reimbursement structure or a board meeting agenda. He meant trouble that costs something, made in service of something that matters more than the cost. He made this concept his life's work.

His vision is the frame for what follows. Not a call to burn down the system, though some days we sure feel it. It’s a call to reform ourselves and organize to do the hard, unglamorous, daily work of insisting on our clients’ humanity within a system that would rather process them as a case number. What follows is a scaled framework to do just that.

Clinical Good Trouble

This is the smallest scale, and the one every person reading this can act on without putting anything at risk.

It lives in the things we most directly control: our own presence, our curiosity, the quality of our attention. It’s the decision to stay genuinely curious about a client’s ambivalence rather than labeling it resistance and moving on. It’s slowing down the intake process enough to actually hear someone before you categorize them. It’s asking what recovery means to this particular person before assuming the model you work in has the answer.

It’s also the harder work of noticing when the system has gotten inside us. Years of working within frameworks that sort people into categories, track compliance, and measure outcomes on narrow timelines can subtly shape the way we see. We start reading a relapse as a motivation problem rather than a feature of a chronic condition. We start carrying assumptions about certain clients before we’ve really met them. The industry’s agenda can become our own without us noticing.

Clinical good trouble is the daily practice of seeing the person before the file. It’s noticing when you’ve started looking at someone through the lens of their diagnosis or their treatment history, and choosing to look again at the human being actually in the room. It’s the willingness to say in a team meeting, “I’m concerned this plan doesn’t account for what we actually know about this person,” rather than signing off and moving on.

The systemic pressures in this field are real, and they create a constant pull toward processing people rather than being present with them. Staying a counselor when the system keeps asking you to become a technician doesn’t show up on a productivity report. It’s also the thing most likely to keep someone alive.

Supervisory Good Trouble

If you supervise other clinicians, your leverage is different, and so is your responsibility.

Supervision is one of the primary ways the field reproduces itself. The frameworks we use to make sense of clients, the instincts we trust, the biases we’ve absorbed without realizing it, all of it moves through the supervisory relationship into the next generation of practitioners. That’s either a problem or an opportunity, depending on what you bring into the room as a supervisor.

Supervisory good trouble starts with the same internal audit clinical good trouble requires: noticing where the system’s assumptions have become your own, so you aren’t passing them downstream as received wisdom. It means creating space for supervisees to name what feels wrong about a case or a protocol, rather than a clinical environment where discomfort gets translated into doubt about one’s own competence.

It also means being honest when the system, not the clinician, is the problem. “You didn’t make a mistake. The system put you in a position where every option was bad” is a sentence that can change how a newer counselor understands themselves and their work. Supervisors who help their staff distinguish between personal clinical failure and institutional dysfunction are doing some of the most important retention work in this field. They’re also modeling something that will travel forward, into every client that supervisee ever sits across from.

Agency Good Trouble

Every agency has one policy, one form, one protocol that makes care less human than it needs to be, and it needs at least one person willing to ask why it exists. Agency-level good trouble is identifying that thing and pushing on it. Sometimes that’s a quiet conversation with a supervisor. Sometimes it’s raising something at a staff meeting until it stops being easy to ignore. Small structural changes compound. An agency that lets one clinician change one intake question because it was retraumatizing has built a small piece of infrastructure for the next person to push further.

Field-Level Good Trouble

And then there’s the scale this curriculum has been building toward: what we do collectively, as a profession, when we stop treating advocacy as something separate from clinical work.

This is where affiliates like IAAP and NAADAC advocacy actually live. Legislative tracking and policy briefs aren’t bureaucratic add-ons to clinical practice. They’re the mechanism by which the conditions of clinical practice get decided, usually by people who have never sat in the room with a client. When state legislatures roll back licensure protections, scope of practice, or funding for SUD treatment, that doesn’t stay in the statehouse. It shows up six months later as a counselor asked to do more with less, or a client losing the level of care they actually need.

Iowa has lived this directly. Policy shifts at the state level have touched licensure pathways, scope of practice, and funding structures that affect addiction professionals and the people they serve, the kind of policy that moves quietly through a statehouse and lands, eventually, in the counseling office. Part of what professional associations exist to do is track that movement, translate it for the people doing the clinical work, and push back where it matters. That’s advocacy as clinical infrastructure, not as a separate civic hobby.

Federal policy is moving fast too. Funding instability for workforce development programs, shifting guidance around which populations treatment systems are expected to serve, a policy environment that changes faster than most agencies can adapt. The field’s response can’t only be clinical adjustment after the fact. It has to include showing up in the rooms where these decisions get made, before they are made.

There’s a version of this work that doesn’t require anything beyond the credential you already have. We have to do the tedious work, the boring work, and the sometimes risky work too. Just like we tell our clients in early recovery to do. It means showing up to a public comment period. Calling a state representative’s office, which takes less time than most people assume and matters more than most people assume. Writing a policy brief that translates what’s happening at the statehouse into language a working clinician can actually use. Mentoring the next person willing to do this work. Field-level good trouble doesn’t sustain itself. It gets handed down, the same way clinical wisdom does.

The opioid settlement funds moving through states right now represent something that hasn’t existed in this field in a generation: real money, arriving in communities, with at least nominal flexibility about what it builds. More than $50 billion in total settlement funds will be distributed to states and local governments over 18 years. Three years in, the spending is deeply inconsistent, some states building genuine community infrastructure, others routing the money back into systems that already exist and already have the same limitations. That choice is being made right now, in budget meetings most of us aren’t in the room for. Field-level good trouble means trying to get in the room, or at least making enough noise about the room’s existence and limitations so we are that much harder to ignore.

We can use this window to assert the field’s actual roots loudly enough that the systems forming around this money have to listen. Or we take the money and become more of what we already are.

 Who You Already Are

White writes that what would most need to be rediscovered, if the field collapsed today, is what the addiction counselor knows that no other professional knows: the very soul of the addicted, their terrifying fear of insanity, the shame of their wretchedness, their desperate struggle to sustain their personhood. That knowledge doesn’t come from a textbook. It comes from having been there, or from having been close enough to someone who was there that you carry those experiences too.

So many people doing this work are themselves in recovery. That’s not incidental to the field. It’s foundational. The first people who did this work did it because they understood something that couldn’t be credentialed: what it actually takes to come back from where their clients were standing. The credential that came later was supposed to amplify that knowledge, not replace it.

The fatigue you’re carrying, if you’re carrying it, is not a sign that you’re in the wrong field. It’s a sign that you’ve been doing something hard, correctly, inside a structure that wasn’t built with ease and access in mind. Moral injury heals the in the same way that fatigue was caused, not by trying harder alone, but by changing the conditions, together, that created it.

Jimmy K., the man most credited with founding Narcotics Anonymous as it exists today, held the door open through years when NA had almost no members, no money, and no literature. An early member remembered it this way: there was usually just Jimmy and one other. Jimmy always seemed to be the one who was always standing there with the door open saying, come on in and have a cup of coffee. That’s the whole tradition, in one image. One person. A door. A cup of coffee. And an insistence that the idea not die.

The people who built this field from nothing did it because someone needed them to. They took the road that led toward professionalization and gained things that mattered, and they lost things that mattered too. The window right now, with real money moving and real policy in flux, is a genuine chance to reclaim some of what got left behind on that road: the community rootedness, the peer credibility, the insistence that the person in the room matters more than the form that documents them.

Go home and make good trouble. All of it. As much as you can. That’s what we are really meant to do here. 

Across this series we’ve talked about access, treatment, medication, identity, community, and family, the whole architecture of what it takes for someone to build a life in recovery. None of it holds without the people doing the work, and the people doing the work don’t hold without each other.

This concludes the seven-part Recovery Curriculum series.

Sources referenced in this piece include William L. White, Slaying the Dragon: The History of Addiction Treatment and Recovery in America (1998, 2014); White, “The Road Not Taken: The Lost Roots of Addiction Counseling,” Counselor, 4(2), 2003; White, Budnick, and Pickard, “Narcotics Anonymous: Its History and Culture” (forthcoming edition of Slaying the Dragon); White and Evans, “The Recovery Agenda: The Shared Role of Peers and Professionals,” Public Health Reviews, 35(2), 2014; and Gleason, “NAADAC’s Critical Role in the Development of a Profession,” Advances in Addiction & Recovery, Fall 2014.

Gus Raymond is a Licensed Mental Health Counselor, Certified Alcohol and Drug Counselor, and National Certified Counselor based in Iowa. He is President of the Iowa Association for Addiction Professionals and publishes At the Margins at atthemargins.org.