Season 1: Health Equity
Season 2: Nutrition
Season 3: Substance Use Disorders (SUDs)
Elizabeth Bowen, PhD
Associate Professor | School of Social Work
Join us for an enlightening conversation with Elizabeth Bowen, PhD, an expert in addiction recovery and recovery capital. Listen as we discuss the invisible population of persons experiencing homelessness and the unique issues this community faces, trauma informed care, and the need for supportive housing.
Nada Fox 00:00
Greetings, public health enthusiast, and welcome to another episode of the Buffalo HealthCast podcast. My name is Nada Fox, and I'm going to be your host. And I'm beyond thrilled today to have a distinguished guest with us someone whose experience and expertise spans the vast landscape of Social Work and Health Research. Dr. Elizabeth Bowen, thank you for taking the time to speak with us today.
Dr Elizabeth Bowen 00:23
Thanks so much. I'm excited to do this.
Nada Fox 00:26
Can you tell our listeners a little bit about your background and your experience,
Dr Elizabeth Bowen 00:31
Of course, this is a big part of why I do the research that I do. But so my name is Elizabeth Bowen. I'm currently an associate professor in the School of Social Work here at UB. But my background, before I went the research route, my background was in social work practice. So after I got my master's degree, I was working as a social worker in Chicago, and happened to find a job working in supportive housing programs. So these were programs that helped people experiencing homelessness get into stable, affordable housing with supportive services. And a lot of the clients that I worked with had a history of addiction and substance use problems along with other kinds of physical health problems, sometimes mental health issues, lots of trauma, so a lot of cooccurring issues. But in any case, in this work, what I saw was that, it seemed like my clients were getting this message that if they were unable to manage their substance use problems. And if they were not succeeding in recovery, it was kind of their fault. So they had often been in and out of various treatment systems. And they had gotten this message that, you know, if they were motivated, it would work. So if they were struggling in recovery, it was because they didn't want it bad enough, or they weren't motivated. And so people, I heard that from my clients in many different ways over time. And often people internalize this message. And it caused a lot of shame, it caused people to feel bad about themselves when they struggled with recovery. But from my perspective, coming into this, I didn't see it that way. It felt to me like it wasn't that they weren't motivated. It was more that they lacked stable housing, they lacked basic resources, it was just nothing in their life was really set up to be conducive to recovery. And so that felt really unfair to me that they're getting this message that it was their problem that they weren't motivated, rather than looking at the environment and looking at how things could be better set up to support them for recovery, including that really vital thing of having stable housing. So I know that's a long answer. But that's the clinical practice experience that always stuck with me. So then years later, when I decided I was interested in doing research, this was one of the things that remained interesting to me and kind of stuck out in my head was that disconnect between the messages that people get about recovery, and just the realities of the kinds of challenges that people struggle with. And then I came across this idea, this theory of recovery capital. So it's not my theory, it was developed by two other researchers, William Cloud and Robert Grandfield. But once I started reading about recovery capital, it really clicked with me because I thought this is exactly what I was observing as a practitioner. So from the get go, I was interested in doing some research related to recovery capital. And that kind of brings me I guess, to where we are today that I've had the chance to dive into that topic further and continue to do research on it. And ultimately, I'm really interested in using recovery capital to shift the lens that we use to look at addiction, especially for people that are homeless people that don't have a lot of income, people that are marginalized or otherwise lacking in resources.
Nada Fox 03:49
Thank you so much. So you've highlighted the intersection of homelessness, homelessness, excuse me, and health issues such as addiction recovery, could you delve into how stable housing plays a role in supporting individuals with substance use disorders on their path to recovery?
Dr Elizabeth Bowen 04:08
Absolutely. So I think there's first of all, I think sometimes there's a stereotype that if people are homeless and struggling with an addiction issue, that that addiction is the cause of their homelessness. And while it could be a contributing factor for some people, that's not always the case. And fundamentally, homelessness is really about a lack of affordable housing in this country. And being homeless is very traumatic for a lot of people. So often substance use is a way to cope with that for a lot of people with the trauma that comes with losing one's home and everything that goes along with that. So that's just to point out that it's often not as simple as somebody having an addiction issue and that leading to them becoming homeless. So that said, there is a lot of cooccurring between these problems between Homelessness and substance use problems with regard to all kinds of different substances. But to me, the kind of key takeaway here is just that it's so difficult to address a substance use problem without addressing the housing piece. And historically, that's kind of what we asked people to do. So housing, services and services for people experiencing homelessness, traditionally, were set up that people really had to kind of prove themselves to get into housing. So people had to first go into a shelter system, then establish sobriety worked towards various goals and kind of prove they were, quote, unquote, ready for housing. And then finally, they could be rewarded with getting access to some kind of affordable housing program. So that's like the, the history here of a lot of homeless services. And some programs still do operate that way. But there has been a paradigm shift in the past couple of decades in the United States and in other places toward this idea of housing first, and that was the kind of program that I worked for, in my social work practice experience. So Housing First is exactly what the name sounds like, it flips that idea of having to prove that you're ready for housing, and tries to get people into housing as soon as possible with the idea that once somebody has housing, then they have that foundation of stability from which you can work on other things. And often these issues are all tied up together. So it's not just addressing somebody's substance use problem, but it's also addressing other kinds of health issues that might also being doing treatment for mental health issues for underlying trauma, linking people to employment resources, or education, all these things affect one another. But it's hard to work on any of them without stable housing. So that's what the housing first model does is get people into housing more quickly, so that you can connect people with resources and start to work on their goals with regard to recovery, or however they define addiction recovery, as well as any other goals that they might have.
Nada Fox 07:04
I think it's very interesting, because it's kind of dealing with the issue in a Maslow's sort of way like we have to deal with well, you know, the very first bottom of the pyramid, their physical safety those needs stable shelter and housing in order to even think about the next steps.
Dr Elizabeth Bowen 07:19
Nada Fox 07:20
It's interesting that you bring up that that wasn't always the case, because we kind of put the burden on the individual for a long time then, and expected them to be able to solve all of these problems prior to addressing that most basic, basic right. So thank you so much for putting that into perspective for us. Now, you talked about housing first and working in those types of groups. And you've collaborated a lot with local service providers, like the homeless alliance of Western New York, and it's just a practical application of your research. So how do these partnerships contribute to addressing addiction and substance use disorders within this community?
Dr Elizabeth Bowen 08:02
Yeah, there's a lot of I think, really great services in Western New York, and a lot of excellent providers that are trying to do exactly that. But the whole idea with Housing First is that it's really individualized, depending on the individual persons goals. And so there's not you know, one way that programs, address addiction and help to facilitate recovery, it really depends on you know, the individual client and what they want to work toward. And that was the same way with the program that I used to work in, in my social work practice experience. So housing first programs tend to take I'm sure there's some variations, but most take a harm reduction perspective, meaning that people don't necessarily have to define their recovery as being abstinent from whatever substance they were using. When you take a harm reduction perspective, you can work with people on whatever goals they have. So sometimes that is abstinence. It certainly doesn't preclude that. But sometimes their goal might be, you know, to switch from using one substance that's particularly risky, in various ways to a substance that might be safer and might have to do with using or drinking less it might have to do with the situations in which a person uses a substance that might have to do with the effects on their health or on their life, and how can they, you know, reduce those negative effects but not necessarily commit abstinence, if that's not where they're at or what they're ready for. So that's my I think biggest thing that I've observed about various programs here, as well as just with housing first, in general, is I think, programs often do a really good job of trying to honor that and work with people to meet them where they're at and to let people define the recovery way that they wanted to find it and then connect people with resources based on their specific goals.
Nada Fox 09:59
Thank you so much. I think it's so interesting that you've kind of defined like a harm reduction approach to it, and how recovering might not necessarily be a linear thing. It ebbs and flows, and people are trying, and we're all people. And sometimes we trip and make mistakes. But that doesn't mean. So I know you're you lead this big NIH study, and you came up with the multi dimensional inventory of recovery capital. Can you tell our audience a little bit about what this is? And how does this measure specifically address the needs of diverse populations?
Dr Elizabeth Bowen 10:09
Absolutely. Yes. I would love to. So I will back up a little bit and talk about what recovery capital is first, and then tell you about this measure. So as I said earlier, when I moved from practice into becoming a researcher, I happen to come across this great article on this theory of recovery capital, and I hadn't heard of it before. But when I read it, it really resonated with me right away. So developed by a William cloud, and Robert Greenfield. And Robert Greenfield is here at UB, by the way. So that was kind of a happy accident for me, when I started at UB was that I realized, Oh, I'll get to, you know, work with the developer of recovery capital. So in any case, they had done this study, looking at people who recovered from substance use problems without formal treatment. And so that's often called natural recovery or unassisted recovery. So meaning people that don't go to inpatient or outpatient treatment, often don't even go to AAA or NA or other 12 step meetings, just people that on their own, recognize they have a substance use problem, and are able to address it and recover. And this is actually a lot more common. I don't know the specific statistics off the top of my head, but it's more common than a lot of people think so not everybody that recovers necessarily goes through formal treatment, or through 12 steps. Um, so in any case, cloud and Greenfield, recognize that and we're interested in looking at, okay, so if people are able to recover without treatment, how do they do it? Like, what are their strategies? So they did a really nice qualitative research study where they interviewed various people, I think this was in Colorado, where they both were working at the time. And so they found people that had recovered in this way, and interviewed them about like, how did you do it? What strategies to use. And then based on that, analyzing those interviews, what they found was that people talked a lot about things like their social networks. So needing to change if they hung out with a lot of friends that were drinking or using, they had to change their social network, they talked about tapping into other kinds of social support. So maybe they weren't in treatment, but they just had a good friend or family members, who understood them and supported their goals and doing that. People talked about kind of their own knowledge, learning about addiction, being able to understand it better themselves, we use that they develop their own coping strategies, people talked about hobbies and other things that they were able to tap into in their lives instead of the substance use problem. And so through analyzing all of that thought, and Grandfield, came up with this idea of recovery capital. And so what that means is, it's just a term for the different resources that people have that can support their recovery from addiction. And there's four major categories to ID. So it's social capital. So that's the social connection, social support, your social network, a human capital, those are the characteristics of a person. So like your knowledge, your education, spirituality, just things about you personal characteristics that can help in recovery, physical capital, that refers to things like housing, like we were talking about earlier. So like those tangible resources, housing, employment, transportation, income, health insurance, just those basic resources that are really critical for Foundation for Recovery. And then the last one is cultural capital. And so this has to do with feeling like you can connect to a culture that support your recovery. And sometimes that might be something like a 12 step group, or some other kind of sober recreation group, or it might also just be connecting to however you define your own culture, and finding elements within that culture that support or affirm your recovery. So that's cultural capital. So those are the four categories. So again, I just read about that as a theory and thought, that's really cool. I'd like to do some research on this. And then I kind of dove into it deeper over the years. And one thing I got interested in was, how do you measure this? So this idea of recovery capital, I think is pretty popular at this point. In a lot of people research it, it's pretty popular in practice settings to like people are, are interested in this idea. And there are different ways to measure it. So other people have already made surveys to measure recovery capital, but I took a really close look at some of them, and found there often were some issues with them. So one problem was they sometimes deviate from this theory of recovery capital. So for example, recovery, capital doesn't say anything about abstinence, you can define recovery, however you want, and still talk about recovery capital. But then when I looked closely at some of these measures, and you look at the actual items they have on them, some of them would have items that would ask that would say things about, you know, abstaining, or not using, and I thought that doesn't exactly, you know, fit with the theory. So that was one thing. And then I also looked at a diverse population. So as a social worker, and given my practice background, I know that, you know, sometimes there's a tendency to assume that something that's tested mainly with white people, mainly with middle class people, sometimes mainly with men, so lack of gender diversity, there can be this assumption to assume that like, it's going to work for everybody, when we know, that's not often the case. And so I was interested in how were these measures developed, were they tested with diverse audiences, and I found that often they weren't, often they were usually a some gender diversity, but it was often mostly white people, mostly middle class people. So I thought, we don't even know if these are really, you know, reliable and valid for more diverse audiences or populations. So that's what ultimately led me to propose this grant and was fortunate to get funding to make a new Ultra Measure recovery capital. And I think the part I got most excited about is that we really got to do it from the bottom up. So that was another thing that often researchers just come up with the items that go on these tools, and then they test it out. But it's often the researchers coming up with it. And I wanted to really involve people with lived experience. So people who are in recovery themselves or people working in the recovery field, to get their perspective on what should we actually ask on this? And how should we phrase the questions because it gets, I know, that seems like a small thing. But that becomes really important, because we know words are important. And the way that you say something, can sometimes you know, just one or can make a difference with how people interpret it. So me and my team put a lot of thought into, we did come up with some initial like starting points of like, Should we ask about this. But then we did a lot of focus groups and interviews with people in recovery, mainly people in recovery, some people working in the service system, as well. And of course, there's sometimes some overlap between those two groups. So we got really great feedback from people about what we should ask what we shouldn't ask how to ask it. And then based on that, we were able to make a draft version of this measure called the multi dimensional inventory of recovery capital, I call it the Merck or mIRC, for short. And we did other testing, so then we gave it to a much larger group of people, but still with a lot of attention to diversity. So when we did test it, we were able to do it with an audience that was economically diverse, racially diverse, gender diverse. And it's not perfect, I think no research is but we were able to get a pretty broad group of people to fill this out. I should also say diverse with regard to recovery experience. So we had people that had been through treatment. And then we also have folks that would be in that natural recovery category who had not been through treatment. So we were able to get those perspectives represented as well. So after lots of work to test this, and then make some changes and refine it, we were able to finalize the measure last spring it and make it publicly available. So it is out there now for anybody who would like to use it. It's on we have a website through the UB school social work. So if you Google UB school, social work, recovery capital or Merck mIRC, it should come up and there's a little bit background on it. And then you can download the tool there. So it's out there. And my hope is that people, both researchers, and people in practice or somebody in recovery, that might be interested in using this tool for themselves. My hope is that people will use it and find it informative.
Nada Fox 19:19
Well, it's definitely informative. I went through and kind of did it on my own, just kind of do a self assessment, you know, which I think is kind of interesting and gives you a different perspective, and, and just yourself and what you're doing now. So as an educator, you teach courses on substance use and addiction. How do you approach these subjects in your teaching? And what insights do you aim to impart on future social workers in the field of addiction?
Dr Elizabeth Bowen 19:50
Yeah, thanks for asking about that. I think the way that I teach about addiction is very much in line with the way that we've been talking about it here. So I've tried to just emphasize this, there's not one definition of recovery that people can define that in a lot of different ways I do teach about recovery capital. So I do think that it's important for social workers and other people working in the recovery field, to know about that, and to have the sense that it's not just about what's internal to someone, not just about their motivation, but really about the resources. And that's a very social work view. We talk a lot in social work about people within their environments, and I tried to really drive that home, specifically in addiction practice and with recover. So we talked about the need for housing, we talked about how would you look at other forms of recovery capital that a person either has, so we can emphasize those strengths, as well as looking at where they might be struggling a bit, and how we can address those issues. And I talk a lot about equity issues as well when I teach about addiction. So, you know, I think you can't really talk about these issues without talking about drug policy, without talking about how that has been implemented in really racist and classist ways in the United States and looking at those, addressing those core systemic issues. Because ultimately, it's, it's not enough to just treat, I think the people in front of us that clinical practice is important. But I also want any students that I interact with to come across with that systemic lens, so that we're also looking at not just helping individual people, but thinking about changing the whole system. So that's at least what I shoot for. And then I also tried to go in with an open mind myself and to learn from my students, because that is something I found that I really do. Learn from people every time I teach, even when I teach the same class over multiple years, because the students are always different. And they bring different perspectives, different lenses, I often have some students in recovery in my classes, and who sometimes aren't open, you know, don't want to be that public about it. But then sometimes I have students that are very comfortable sharing about their own recovery backgrounds. So I always learn from that. And I always try to go in with that mindset, to hear from different people and to have my own perspectives challenged and expanded by what I learned.
Nada Fox 22:18
It's interesting because you talk about overviewing it from a systemic point, kind of looking at the big picture. And this is kind of the synergy between public health and social work, right? Like we're all trying to look at things from the big picture addressing the inequities talking about it. What do we need to do? How do we change this? How do we make this more equitable? Right?
Dr Elizabeth Bowen 22:40
I think there is a lot of overlap. A lot of synergy. Yeah. With Social Work and public health, for sure. Absolutely.
Nada Fox 22:45
And I think what people that like are kind of unfamiliar with public health, like it's always easier to explain it like it's very broad, big picture, I feel. Yeah. We're not treating an individual. But these anecdotal things lead to, you know, the evidence for what's going on in our in our communities in our state or however macro we want to get. So earlier today, you talked about your, you know, trauma informed care, and that sort of stuff. And you highlighted the how you use this in your framework. So I was hoping that you could answer this question, how does your policy analysis framework is based on trauma informed care? How does this approach contribute to addressing substance use disorders within the homeless population? And what policy changes do you believe could make a significant impact going forward?
Dr Elizabeth Bowen 23:47
Yeah, that's a great question. I love thinking about policy and talking about that. Um, so to just explain about this framework. So several years ago, a colleague, Shanta murshid, and I developed this framework for trauma informed policy analysis that was then published in the American Journal of Public Health. And what we were trying to do with that was take this idea of trauma informed care, which is something we talk about a lot in social work. And that's basically the idea that for any kind of services, so mental health treatment, addiction, treatment, housing, whatever it may be, that it's important to think about delivering those services in a way that's trauma informed meaning that recognizes a lot of people that seek services have been through different kinds of trauma, like I talked about with populations experiencing homelessness, and sometimes people can be re traumatized in the process of seeking services. So how can we try to help people feel safe and recognize what they've been through, recognize how that might be affecting whatever problems or issues they present with. And then also try to prevent retraumatization from happening while people are getting services. So that's the whole idea of trauma. informed care. And the UB School of Social Work has been a big leader in that we have some great resources on that, and on how to do that. But my colleague Shunta mercy, and I had gotten to talking about kind of taking the next step of taking it to that more macro level. So we just had started talking about what if we weren't, you know, just trauma informed in our services, but we tried to have policy that was more trauma informed I, with the aim of really trying to prevent trauma from occurring in the first place. Because if you think about traumas that happen in so many communities, they are systemic, and get they are potentially preventable. So that's how we got to talking about how you would implement principles like safety, and choice and empowerment, those are core principles of trauma informed care. So this paper that we wrote was about what those policies are, what those principles would look like in policy. So in laws and other kinds of high level policies. And so to answer your question about what that look like for people experiencing homelessness and addiction issues, to meet the most fundamental policy change, there would be expanding access to affordable housing. And I mean, the type of housing programs I was talking about, so Housing First, specifically, but also just affordable housing in general, because while a lot of people do need, those kinds of services that come along with Housing First there are, there are many people that experience homelessness, really, just as an economic issue, they might be in some kind of short term financial crisis or something like that. And some kind of just financial assistance, rental assistance, not even necessarily a huge amount of money, but at the right time, and being able to access that in a timely way that could prevent homelessness entirely for a segment of the population. So we really need more affordable housing across the board. And one thing I always try to communicate to people is that, you know, in the United States, we've never made housing and entitlement benefit. So meaning certain programs like Medicaid, or SNAP, which is what people sometimes called food stamps, those are entitlements, meaning if people are eligible for them, and they apply, they're entitled to get it. So the government can't say, like, oh, we ran out of money for that this year, you're eligible, but we're not going to give it to you. So we don't do that for certain programs. But that's not what we've done with housing. So housing has always worked the opposite way where people can be eligible and apply. And they have to wait years, sometimes, you hear about weightless for supportive housing, or for other affordable housing, that are years long, and of course, expecting people to wait years for something as basic as housing. What are people supposed to do in the meantime, it doesn't make sense. So that, to me, would be the most, the biggest trauma informed change we can make would simply be expanding access to housing, and that would take a big investment in various kinds of affordable housing. But it is something I think that's doable. And it's a policy choice that so far in this country, we've chosen not to do it. So that is the biggest change that I can think of.
Nada Fox 28:19
Thank you so much. We'll just continue along that and I think this kind of you might have already answered this. But what changes do you hope to see in public health and the social work landscape in the future? And it seems like a housing first policy, and affordable housing, is there anything else that you would like to you would hope to see in the landscape of public health and social work in the future?
Dr Elizabeth Bowen 28:43
Yeah, good question. So in addition to expanding access to housing through an increase in funding for affordable housing, I'm over a lot I would like and help to see just programs to move toward greater accessibility. And so I just think about specifically with addiction recovery services. Currently, I think there are some barriers that don't necessarily need to be there. And that do prevent people from getting help. And by that, I mean both financial barriers, so if people want various kinds of treatment, but can't afford them, but then also things like I have a colleague that does some research on methadone maintenance treatment, and how, you know, because of current policies that people have to go to a clinic generally to get methadone if they're getting that for their recovery from an opioid problem. And it's hard to get take home doses. And then obviously, it's hugely inconvenient to people to have to go somewhere every day, or almost every day to pick up this dose of medication and take it on site. A lot of people find those processes to be dehumanizing as well. So I look at things like that. And I think about how could we be trauma informed and how could we just increase recovery capital by make Seeing all kinds of various treatments more accessible to people. And so I think of my colleague who, you know, kind of put that issue on my radar. But I think about things like that. So if methadone and other kinds of medications for addiction treatment, for example, were more accessible to people so easier to get, if you could get it, you know, in your home, I think that would increase choice that for a lot of people would increase dignity and privacy as well as just making it more accessible in a practical manner. So that's one example. But in general, that's something I think about with policy change the intersects across social work and public health. Just how can we make treatment and recovery services more accessible to more people, as well as more trauma informed?
Nada Fox 30:49
People experiencing homelessness isn't an a population that's kind of popular or the most sought after in these sorts of discussions. And it's important that we highlight this community and they're not so hidden. And yes, they're at the forefront.
Dr Elizabeth Bowen 31:06
Well, right. And I saw the you know, with your theme being about addiction, exactly. People, when people are talking about addiction and recovery issues, they're not always thinking necessarily of a really marginalized population like that, like people that don't have stable housing. So I'm happy that I can kind of bring that perspective into the conversation. Yeah.
Nada Fox 31:25
And it's, and it's nice, because I think, not on purpose, but people tend to do this. It's their fault, sort of lens on this community. And that's, that's not fair to this community. It's, you know, it's not so thank you so much for, you know, giving the audience that sort of perspective. Last question for you. It's not too horrible. What is what if you could have one thing for our listeners to walk away with from this discussion today? What would that be?
Dr Elizabeth Bowen 32:01
Good question. If I had to say one thing for listeners to walk away with from today, I guess it would be just to think about recovery holistically. And to think about both addiction and homelessness as societal problems more than personal problems. So to look at how all of the different policy choices that we make, as a society, contribute to these issues, or access to treatment and recovery resources, and I just think it's so critical to shift the thinking from looking at these problems as individual failings, to looking at them more as a byproduct of policy failures and of choices that we've made as a society. So to bring that lens and specifically to be a lot more holistic in the way that we think about addiction recovery and have conversations about it. And recovery capital has been a big part of how I think about that. And I hope that that can be a useful tool that other people will think about and learn more about too.
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