Five and a Half Things I Love About This Job
Wait– three posts in three weeks? Are we back to curing addiction every Saturday? Let's say mostly, or hopefully. Thanks for rolling with it.
I recognize that this newsletter, along with most of my writing and teaching content, has a critical and somtimes angry tone. One attendee of my first moral injury course reacted as if they had to defend our field and justify why this work is worth doing. And yes, one way to see this newsletter and all my out-of-clinic work is as terrible PR for my own career choice!
But I don't think you can learn or care much addiction treatment without facing up to the facts that it's a sick, exploitative industry and that even "experts" often don't know how to help addicted people. We don't even necessarily know what addiction is. I write and teach from this unstable ground because the only alternatives seem to be leaving the field or playing dumb. And I don't apologize for my perspective because the people alongside me in this job, or who are training for it, don't need more platitudes that have no bearing on our actual work conditions or our patients' actual suffering. These platitudes, by the way, usually come from people who have not done direct service in years, or who never did direct service in substance use at all.
So to clarify that there are good reasons to do this job, this post is on what I love about it, 13 years in. If you're a clinician or clinical trainee and these points do not resonate, that does not mean I think you're in the wrong place. People find all kinds of rewards in their work, suited to who they are; these are just the rewards I especially value, and reflect who I am.
1) There is no work more interesting and engrossing. When a problem looks deep, complex, and entrenched, some people wrinkle their noses and change the subject. My reaction is, Interesting! Tell me more! Am I the Enneagram Type 5 who was born to figure this out? Am I the Intense Perfectionist who has finally arrived to show everyone how it's done?
Even if it in fact cannot be done, making the effort in as many ways as possible is meaningful and instructive. Each client's life is a subtle and complicated novel (set in Maine, but realistic!) insofar as the protagonist-narrator shares with me. Yes, people thank me and say I am helping them. But even when they don't and I'm not, it is always interesting.
2) I am challenged to learn and grow on a weekly, if not daily basis. This work cannot bore you. It involves handling new ideas and situations at any time, making dozens of (at least preliminary) judgments on the spot. If a client seems to have been "stuck" in the same place for a long time, having nothing new to say, that calls for even more creativity and experimentation. I take this work very seriously, and both study and clinical experience have shaped my practice over time. But I am nowhere near a sense of mastery or completion, and I'm not even sure I– or my clients– would want that.
3) There are no abstractions from the mission; I have no removal from the mission. Direct service might be the most rigorous work one can do. Whatever ideas you may have about problem or solution are constantly being tested in the realest of real worlds. The same is true for the language we use, the root causes we identify, and the approaches we believe in.
This is humbling but also generative, because whatever philosophies emerge in and from direct service have to reflect lived experience– and a wide variety thereof. In direct service, people with addictions are "heard" not in a focus group or survey, but in an open-ended, individualized and intensive way, within a protected relationship, over years. This is no less true for clinicians who have their own lived experience of addiction. For them, the challenge is integrating clients' experiences and attitudes when they differ from the clinician's own.
4) I meet so many people, and learn so many perspectives, that I never would have otherwise. Maybe it's the real-life equivalent of reading a lot of very different novels? (See #1 above.) Many careers and lifestyles have us interacting mostly with people like ourselves: people from similar backgrounds, who do similar work, have similar politics, do similar things for fun, speak and dress in a similar way, and so on.
Addiction treatment is not like this! I make a point of working with all kinds of clients, the workforce is a diverse crowd as well, and I'm better for it. I feel like I have my ear to the ground. I don't surmise what "people are saying" from a news feed algorithm; I have numerous detailed perspectives from people who have little in common with me or with each other.
5) Exceptional leverage. Demand exceeds supply for addiction treatment providers. I've studied the history of the US treatment industry in depth, and it appears there have always been more people seeking addiction treatment than there were people qualified and willing to treat them.
Addiction treatment facilities have no revenue without us. This means being employable anywhere at any time, and negotiating for and within any given job from a strong position: as a valuable worker who is nearly impossible to replace. When that's not good enough, we typically have the option to work for ourselves as well (which I have since 2023). I never have to hustle for clients because demand is so consistent.
5 1/2) Exceptional autonomy. Therapists and other clinicians have a great deal of latitude in how we conduct treatment. I have always been free to choose what topics, theories and modalities I use with clients, including freedom to change anything at the last minute or even mid-course based on how the session unfolds. Even when you have a very hands-on boss, they're not paying much attention to the part of this job that actually matters: your time in the room with clients. They're looking at your documentation, billing and stats. If that is all in order, you're an outstanding performer and no one asks any questions.
Of course, this degree of autonomy also enables clinical incompetence and even abuse. That's why I have called it half a reason. I don't want any (more) people in this field simply because they couldn't make it anywhere else, or who have predatory intentions.
Rosalie Genova
In Reflection
I follow many peppy, high-energy fitness influencers on YouTube. One of my free trainers often yells panting, toward the end of a set, "What would it look like if I said ten more seconds?!" The idea is to go all out, because you're almost done.
I'm probably still in the early-middle of this sweaty ordeal that no one asked me me to take on: working in addiction treatment and earnestly trying to do it right, or at least do it better. I'm 44 now, so even if I retire on the earlier side...What would it look like if I said 20 more years? For those of you who are younger, what would it look like if I said 30 or 40 more?
Most people do substance use work for just a few years at most. These short stints may be for the best for individual workers, but at a collective level they create a perennially hollowed-out field. I don't claim to know how to make this work sustainable, but I'm committed to trying my best to stay. And staying only feels realistic to me through an honest, direct confrontation of all that needs to change in addiction treatment, as well as celebrating its rewards.
❓Do readers want more on what it means to enter or stay in the addiction treatment field? This post could have a Part II. Please comment if you're interested and definitely include specific questions if you have 'em!
