Centre for Addiction and Mental Health, 33 Russell Street, Toronto, Ontario, M5S 2S1, Canada
Received September 28, 2010; Accepted March 07, 2011; Published March 07, 2011
Citation: Doukas N, Cullen J (2010) Recovered Addicts Working in the Addiction Field: How do Substance Abuse Treatment Agencies Work with Substance Abuse Relapse among Addiction Counsellors who are in Recovery? J Addict Res Ther 2:106. doi:10.4172/2155-6105.1000106
Copyright: © 2010 Doukas N, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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The potential for relapse among recovered counsellors if one accepts that substance abuse is a chronic illness, which often entails relapse, is a topic that has been neglected by the scientific community. The lack of research in this area needs to be addressed especially when bearing in mind the possible unresolved issues motivating some “ex-addicts” seeking employment in the field. Given that relapse among recovered counsellors is not a rare phenomena, the research posed certain questions with regards to how agencies work with employees who have had a substance abuse relapse. Using a case study design, the authors reviewed two diverse urban substance abuse treatment agencies with very distinctively different ways of working with recovered counsellors who have relapsed.
In the 1970's when the field of substance abuse treatment was still growing as a discipline, individuals in recovery were hired on by treatment agencies and given on the job training to help with the high rate of people seeking treatment  This influx of ex-addicts entering the field as addiction counsellors raised some concerns among writers. The potential for relapse among counsellors in recovery is not a rare phenomenon, especially when bearing in mind the possible unresolved issues motivating some ex-addicts seeking employment in the field, such as atoning for one's misdeeds, or eliminating past guilt  Writers also describe the propensity for recovered counsellors to over identify with clients [1,2] and become over involved with their work . The recovering counsellor may also be at a greater risk of burnout because they are involved in their own recovery as well as the clients they work with. Kinney  conducted a telephone survey of all counsellors who graduated from a nine-month addictions training program between 1972 and 1978 . Out of the thirty-five graduates, twenty-four were recovering alcoholics who had been abstinent for at least two years prior to matriculation. Of the twenty-four recovering alcoholics, eight had experienced a relapse since completing the program and one admitted himself to a treatment program to avoid relapse.
A counsellor's relapse threatens the credibility of the treatment program for which they work at, places additional pressure on fellow workers because they have to cope with the extra workload, and it causes the counsellor to lose their credibility and maybe their credentials [3,5]. The secondary problems which result from a substance abuse relapse extend further than few are aware of, and are often unaddressed by workplace policy  Wright et al.  maintain that over 30% of employees are affected by substance use through insurance claims, disability payments, firing and hiring, and other intangible costs, such as friction between co-workers, damage to public image and personnel turnover .
The literature on substance abuse in the workplace can be traced back to the 1950s where researchers were interested in examining the relationship between workplace factors and the development of excessive drinking. Out of these discussions emerged the Employee Assistance Program (EAP), which helped establish boundaries, workplace intervention efforts and cost containment issues [1-3]. As the topic of substance use in the workplace began to be recognized as a major concern, research focused on policy strategies, such as workplace drug testing, and ongoing supervisory training regarding substance abuse identification and referral [1-5]. Despite the extensive research conducted on policy strategies to minimize substance abuse in the workplace, the topic of relapse among recovered counsellors working in the addiction field is an area of policy work that is extremely under investigated, possibly because of the sensitive and stigmatizing nature of this topic.
Given that relapse among recovered counsellors working in the addiction field is not a rare phenomena, our research posed certain questions with regards to how agencies work with employees who have had a substance abuse relapse: Are potential staff screened during the interview process prior to being hired with regards to their recovery and what are the requirements? Do substance abuse treatment agencies have a policy in place to work with staff that have had a substance abuse relapse? Is there any support in place for staff who has relapsed, or who feel they are at risk for relapse? This paper uses a content analysis method and telephone interview to answer the above questions by analysing the policies of two diverse substance abuse treatment agencies with very distinctively different ways of working with recovered counsellors who have relapsed.
The chosen design of research was a case study, where we examined the substance use policy of two substance abuse treatment organizations, using telephone interview and content analysis methodology. We reviewed the written policy that was supplied by one agency and interviewed the Executive Director of the second agency to obtain the information because they did not have anything in writing. The website of both organizations was reviewed to obtain a background history and approaches most frequently used in their plan of treatment. The written content was categorized into three essential questions and these questions were asked in the telephone interview with the Executive Director: (1) Are potential staff screened during the interview process prior to being hired with regards to their recovery and what are the requirements? (2) Do substance abuse treatment agencies have a policy in place to work with staff that have had a substance abuse relapse? (3) Is there any support in place for staff who has relapsed, or who feel they are at risk for relapse? We chose this design because it presents with an opportunity to analytically compare two policies and how they might differently affect individuals and larger social structures within the field .
The two agencies being reviewed are quite different in the number of employees it staffs, approaches to treatment and background history. The larger of the two agencies is an urban centre, public hospital, providing outpatient and inpatient care for those seeking help for mental health and addiction services in Ontario, Canada. With over ninety-three addiction counsellors on staff, it provides client-centred service, using a harm reduction model in its delivery of care. The other privately run, urban centre agency staffs twenty-two addiction counsellors and was founded by an individual from Ontario, Canada who attended a substance abuse treatment centre in the United States that was based on the Minnesota model of recovery. This individual found this 12-step based model so helpful to his own recovery that he established one in Ontario, Canada several decades ago.
How do we know we've hired the right person for the job?
The agency that maintains a harm reduction philosophy and applies a holistic approach to therapy does not have any screening process to identify whether potential employees have a past history with substance abuse. The other agency that maintains a 12 - step model of care is known for hiring counsellors that are in recovery. The harm reduction based agency provides opportunities for potential employees in recovery to work alongside recovered and non-recovered counsellors, but staff are at their own discretion to disclose or not a past history with substance abuse. Unlike the harm reduction based agency's absence in inquiring about length of "clean time", or how sobriety was achieved and presently maintained, the 12 - step agency requires all employees to have a minimum of three years "clean time", with 12 - step programs for achieving sobriety being an asset. Addiction counsellors are also expected to maintain 12 - step meeting attendance while being employed with the agency (Executive Director. personal communication, January 31, 2011).
How do we work with the counsellor who has relapsed?
During an interview with the Executive Director of the 12- step based agency, he stated that there was no written policy in place to deal with staff having had a substance abuse relapse. He continued by stating that if a counsellor has relapsed, then their employment is terminated, because the individual has failed to meet the minimum three year of sobriety requirement to be employed with the centre (Executive Director. personal communication, January 31, 2011). This implies that the staff member represents his or her place of employment even outside of work hours. After being asked about counsellors who have been terminated as a result of relapse, the interviewer replied that in the twenty years that he has been working with the agency only one person has ever been terminated. He also added that there have never been any challenges from staff with regards to this policy because this rule is discussed in the interview process.
The centre that maintains a harm reduction philosophy does have a written policy in place and states that if staff, volunteers or students are in possession of, under the influence of, or using drugs while performing their duties they must provide an explanation to the Director of the facility. If this explanation is found unsatisfactory, the Director will encourage the staff member to seek help from the Centre Employee Assistance Program (EAP), a substance abuse treatment program, or other appropriate resources. The staff member is provided with a written documentation of the warning and a copy will be put into the staff's file. Staff will be permitted to return to work if they have fully complied with the treatment program's requirement and a certificate from a health professional indicating the staff's ability to return to work. During our past work with this agency we have been witness to the relapse of two staff members who were eventually dismissed. One individual declined when the agency offered to put him on sick leave until he successfully completed a substance abuse treatment program of his choice. The second co-worker whose incident was taken to the media by the client he chose to use substances with was not offered the same option because of the policy and taboo associated with becoming personally involved with clients of the centre. This incident had serious repercussions for the agency, which led to an agency representative having to give a public statement.
The harm reduction agency's substance use policy only refers to when individuals are on duty, unlike the 12 - step focused agency that expects their employees to abstain from all substance use whether at work or at home. This written policy continues by stating that if the Director does not feel that the staff member's work performance is maintained at an acceptable level in a specific period of time, management will take steps to deal with the unsatisfactory performance. In the event that a subsequent incident occurs again, then this could result in dismissal.
How do we support our recovered counsellors and help prevent relapse?
The harm reduction based organization does have a support group for recovered counsellors who meet regularly whether they have had a relapse or not. This agency also has an EAP available that employees can access, which offers specialized counselling in a variety of areas, including substance abuse problems. The 12 - step agency does this as well by insisting that each employee regularly attend 12 - step meetings, which acts as their support group.
The philosophy and culture of a substance abuse treatment organization will play a major role with individuals it attracts for hire and how ex-addicts seeking employment will feel about their past within the agency. The 12-step run agency will openly welcome the recovering addict in 12 - step fashion, fostering a sense of belonging, where there is no need for hiding one's past, because "the man [or woman] who is making the approach has had the same difficulty."(p. 18) . It is also understandable why this 12 - step focused agency will attract people in recovery who might have been positively affected in their recovery by the 12 - step approach [1-3]. However, for those in recovery who choose to be employed in an organization alongside nonrecovered counsellors, the experience could be quite different. They may be viewed as inferior by their non-recovered counter-parts because of their past association with substance use. This has forced many to go underground with their past and drop all reference to former addiction and recovery to avoid the potential of being stigmatized .
Finding suitable candidates to work in a substance abuse treatment setting is not an easy task, and quite often an inadequate screening process later reveals that the hired counsellor lacks the suitable emotional fibre to perform their job in an appropriate manner . McInerney  states that the suitability of addiction counsellors is measured based on the reputation of the institution that trains them and that agencies need to develop their own criteria in determining the suitability of employee candidates . Kinney  believes that agencies have to screen out those recovering individuals seeking employment as substance abuse counsellors whose sense of self-esteem is tied to helping others, or making restitution, or those who have little capacity for reflecting on their own experience or differentiating it from that of others . Developing better screening tools, such as improved and validated survey instruments to use in assessing the attitudes of counsellors with more accuracy can be helpful in these areas . Taking these measures might seem intrusive, but addiction therapists are in some way intruding into the lives of clients by virtue of the therapeutic power they posses that has been bestowed upon them by the institution they graduated from and by the agency that supports the application of that power.
In comparison, the two agencies have varying approaches when attending to expectations of substance use among their employees. Although the 12-step agency's approach might be found intrusive to some who prefer that their work and personal life remain separate, this full-time commitment to work and recovery allows all staff to be on the same page with recovery. It also provides clear and consistent expectations, and helps build cohesion because "having shared in a common peril is one element in the powerful cement which binds us" (p. 17) . The agency maintaining the harm reduction policy does express its leniency when working with a staff member's substance use problem and makes attempts to support the individual's return to duty, but it also implies that the individual's performance and pace is based on the Director's view. Not only does the staff member have to face the embarrassment of the stigma associated with this incident, which might lead to a social distancing by co-workers, but also be aware that his or her actions may be monitored by both management and staff. This creates the scenario often spoken about by addicts seeking treatment who describe their friends and family as being watchful of their behaviours, or expressing a lack of trust in the individual.
Reducing stigma by fostering a supportive, non-judgemental environment is paramount to an agency if it wants to encourage staff who are struggling with substance use issues to raise these concerns with their supervisor without the fear of being the topic of gossip. Many workers with substance use issues resist seeking help because they fear gossip, or distrust confidentiality at work [1,2]. This is mainly due to a lack of knowledge about policy and an organization's EAP . Despite studies that report the availability and effectiveness of EAP, this lack of information can lead to low trust in EAP confidentiality and stigma for seeking help [1-3].
Lack of information about an organization's substance use policies has raised concerns in the literature, especially with today's reliance on the Internet. An evaluation of college online alcohol policy information was conducted by Faden et al.  to see how difficult it was to locate this information . They found that many colleges failed to provide their alcohol policies in a web friendly, accurate and complete descriptive manner. One cannot draw conclusions without conducting a similar investigation to see if substance abuse treatment agencies were also limited in this area, but it is important to note that the written policy in the harm reduction agency that we examined led us to contact their human resource department for a copy of the policy because we were unable to locate it by Internet. When staff are not aware that this information exists and is not easily accessible, the individual may draw conclusions based on their perception of mistrust in the agency and/or their EAP. The 12-step agency on the other hand does not have a written policy on this topic, but all employees are aware and clear of the unwritten rule of having their employment terminated if they have relapsed. This increases the reluctance of an employee disclosing any substance use issues for fear of losing their job, unlike the harm reduction agency where a staff member can resume their work after they have successfully completed their rehabilitation and given a 'clean bill of health' from their doctor. Having a policy or procedure in place to deal with a staff member's inappropriate substance use is a sensible necessity, but having a support group in the workplace for recovered counsellors to meet speaks to an organization being proactive in reducing the possibility of recovered counsellors relapsing.
Another difference between the two is that one insists on the use of a support group that you are free to choose from across the city, and the other offers only one support group that you are not obliged to attend. Furthermore, in belonging to a 12-step group that your place of employment supports, the individual has no fear of being exposed as an ex-addict because self-disclosure of one's past is supported. Attending a support group in an organization with non-recovered counsellors might be difficult for the recovered counsellor to disclose, because exposing their past association with substance abuse might be difficult among colleagues - if someone identifies us as someone in recovery, this may result in stigma within the work community.
Research and policy
In the introduction of this paper we expressed the need to address the lack of research on the topic of relapse among recovered counsellors. And while this paper focuses primarily on a substance use treatment agency's policy for relapse, research is inextricably linked to this matter. Martin et al.  explain this link quite well by illustrating how scientific research feeds the framework of social policy: "Just as the truth of a criminal confession depends upon the system of criminal justice that frames its meaning, so the data of social scientists is collected, interpreted and communicated in a broader institutional framework of social policy. The more controversial the issue, the more importance accrues to the facticity of the data" (p. 396, 397) .
Bennett  advocates administering anonymous and confidential surveys for the evaluation and strategic planning of policy . This will help increase the confidence of those who fear exposing their views more openly because of anticipated repercussions. In addition, aggregating survey data across groups of individuals can be used to study sensitive topics, such as the potential for relapse .
The limited and outdated quantitative research conducted thus far on recovered counsellors has helped identify associations between variables, but this area of research can benefit greatly from a qualitative approach. This narrative approach would create a communicative understanding of the participants' experiences, meanings and interpretations as recovered counsellors, while data gathered can raise compelling arguments with real life immediacy . Allowing recovered counsellors to participate through open dialogue can be taken one step further as was done by Bennett and et al.  who used these collaborative techniques in a focus group format to explore employee insights on the affects of socially constructed policies .
In our research we also contacted another substance abuse treatment agency to add to the comparison. When we asked if they had a policy in place to work with substance use issues among their staff, we were told that they did not have one. It is not our intention to promote one agency's policy over another, because it is important for agencies to have their own unique culture of dealing with this type of issue. However, we do believe that all agencies should have some clear and concise way of acting when confronted with these challenges in the work place, whether it is written or expected through the agency's culture. Making policy easily accessible, accurate and complete encourages employees to look up information and helps address problems. In addition, the policy should clearly include information explaining the rules / requirements, consequences, and referrals, such as EAP and substance abuse counselling centres . Many organizations today do have an EAP to consult regarding these matters, but in a field where organizations entrust staff who are in recovery and are responsible with the personal lives of clients who depend on them on so many levels, it would be prudent to invest more energy in developing policies that are guided by research so that the field can maintain accountability to both staff and client.
A more comprehensive search is needed to identify substance abuse treatment agencies that have a procedure / policy in place that works with substance use issues among staff. Their guidelines should then be made public so that agencies can compare their procedures with that of others, and try to determine what guidelines would fit best with their agency's culture and principles. Agencies should conduct ongoing evaluation of these procedures and make their results available to fellow treatment agencies so that each organization can draw its own conclusions of what might work best for them. Sharing information will also identify the prevalence of the issue on a province wide, substance abuse treatment agency level. It seems as if the topic of relapse in this field is avoided because it is embarrassing for both staff and the organization, and often "becomes elevated to the unspeakable and cannot then be seen as a part of a chronic disease process which requires an appropriate therapeutic response, not embarrassment and hushed silence (p. 746) .
Examining the policy of two uniquely different agencies sheds light on how addiction counsellors in recovery are worked with regarding a relapse to substance use. These findings should not be generalizable to other agencies in Ontario, Canada, or anywhere else because other agencies may act on these issues in various unique ways specific to the culture of their organization. This is why a follow up-study should be conducted with several more agencies involved. Future research should also include the influence played by government and the political arena with regards to policy's developed on this topic.
The literature examining the topic of relapse among recovered counsellors is limited, outdated, and deserves to be addressed. Research will help inform policy making strategies, while ongoing evaluation will examine the strengths and limitations of the policy. Making the evaluated data available to all substance abuse treatment agencies will cast a wider scope on the prevalence of this issue, allow for an exchange of ideas, build cohesion across the field and reduce the stigma associated with recovered counsellors by giving voice to a taboo topic that deserves to be addressed. In addition, institutions and agencies have to take more responsibility to insure that the appropriate students graduate and suitable candidates are hired.
Policy can come from many ideologies, biases and prejudices and cannot be neutral because one group will benefit more than another. At the same time, to do nothing when an issue clearly demands addressing can also be seen as a policy that might serve a particular group. In this paper we hope to give voice and create discussion regarding a topic that has been dormant in the system for far too long.