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What is recovery?

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ResearchBlogging.orgA stumbling block to moving forward with recovery in the UK and elsewhere is lack of agreement about what recovery actually is. Highly specific definitions (e.g. recovery = abstinence) can lead to exclusion and fierce disagreement while non-specific definitions are too woolly to measure in services which are being asked to deliver measurable outcomes.

Research and Experience

Professionals and recovering people

Professionals are not the only group to be concerned with recovery. Those defining themselves as ‘in recovery’ have a stake too. The two communities have been too often running in parallel rather than working in coordination – indeed the voices and experiences of recovering people have largely been missing. In a newly published American paper, Lee Ann Kaskutas and colleagues explain:

“The scientific community (e.g., physicians, medical societies, SUD researchers, clinical treatment organizations) has used the term to represent a medically directed course for clinical diagnosis, treatment and rehabilitation. In contrast, the recovery community initially developed its concept of recovery from the fellowship of Alcoholics Anonymous (AA) whose the basic text (the ‘Big Book’) describes a ‘program of recovery’ that involves abstinence from alcohol and a ‘new way of living’ in a spiritual framework outlined in the program’s 12 steps.”

The researchers wanted to come at the question ‘what is recovery?’ from the perspective of those in self-defined recovery (from diverse pathways) and identify the ‘domains’ and ‘specific elements’ of recovery.

What did they do?

question markUsing an iterative, pretested questionnaire the authors surveyed over 9000 people on the internet who self-identified as being ‘in recovery, recovered, in medication-assisted recovery, or as having had a problem with alcohol or other drugs (but no longer do).’ The recruitment technique seems to have been broad and was designed particularly to pick up not only those who had been through treatment, but also those in ‘natural recovery’. An attempt to recruit a significant proportion of the last group was made through Craigslist where the word ‘recovery’ was avoided.

What did they find?

The authors felt the sample was likely to be representative; demographically it compared well to other samples of people in recovery. However while 72% had been to treatment only 4% reported being in natural recovery. Only 3% identified as being in medication assisted recovery. A significant number of people had been to mutual aid. Of that group, most had been to AA (85%) or NA (45%) with fewer to CA (13%) and SMART (8%).

Important emerging recovery domains
  1. Abstinence (interesting to see this rated highly)
  2. Essentials of recovery
    1. Being honest with myself
    2. Handling negative feelings without using
    3. Being able to enjoy life without drugs
  3. Enriched recovery
    1. A process of growth and development
    2. Reacting to life’s ups and downs in a balanced way
    3. Taking responsibility for things I can change
  4. Spirituality (including)
    1. Gratitude
    2. Giving back
    3. Helping others

The authors are clear that this four-factor structure:

“was robust regardless of length of recovery, 12-step or treatment exposure and current substance use status”

Implications from the research

“These findings highlight specific areas that chronic care models such as recovery-oriented systems of care could address to promote recovery and that researchers studying recovery should consider—e.g., self-care, concern for others, personal growth, and developing ways of being that sustain changes in substance use. For example, providers might add or suggest sober fun activities and opportunities for volunteering and emphasize contributing to society.”

Recovery-Journeys

Reflections

There’s always the challenge of trying to apply this North American research to the UK. I don’t get the feeling that a significant number of people on methadone or Suboxone in Scotland identify as being in recovery. However looking at the 3% of those in this research who identified as being in medication-assisted recovery, we may have that in common.

Given that we don’t know a huge amount about those on long term ORT,  it’s welcome news that The Scottish Recovery Consortium has just opened a new project to learn more about the reality of methadone use and recovery in Scotland. One of the things I’d be interested to know is how many of those on ORT have been actively linked to recovery communities. If people don’t link to other recovering people, how can they connect to the concept and identity of recovery?

Then there is the abstinence thing. Several pieces of research, which look at people who self-identify as being in recovery, show that most recovering people hold abstinence as very important. How do we recognise this in treatment services without being exclusive, while allowing flexibility and choice, and simultaneously, not inadvertently allowing folk to get stuck?

I like the idea though that the domains rated highest by those with lived experience of addiction and recovery could be used as benchmarks for evaluating recovery oriented systems of care. Way too much research still takes place around addiction and not around recovery – recovering people are hugely under-researched as a group. I also like the call in the paper to researchers that they start measuring the elements coming out of those domains (things like altruism, self care and personal growth). Such things give meaning and meaning is important to all of us – something not always acknowledged in scientific research.

(Thanks to Drs Kaskutas & Laudet for access to the paper and to Dr Kaskutas for feedback on interpretation which led to an alteration to the original blog on 3rd November 2014)

Kaskutas LA, Borkman TJ, Laudet A, Ritter LA, Witbrodt J, Subbaraman MS, Stunz A, & Bond J (2014). Elements that define recovery: the experiential perspective. Journal of studies on alcohol and drugs, 75 (6), 999-1010 PMID: 25343658

    4 Responses to "What is recovery?"
    1. Innocent Abroad says:

      Wanting recovery to be a straight path is part of the sickness, of course.

    2. Sian says:

      I found it an interesting article and far more should be done to research what service users feel is recovery instead of the services determining what they expect. That will not work for any service user. However, given time most service users reach a point where recovery is abstinence – their definition will change as they grow and change.

      Too often I see services dictating what will and will not happen to scripts if the S/U does not conform to their way of working. Even though I work in criminal justice with Drug Rehabilitation Requirements, where the bottom line is abstinence, I still appreciate that every person has a journey and for those with entrenched misuse, that is a long slow journey, not only of prescription, but an individual’s growth, increase of self esteem, facing the demons which refuse to drown, and an awakening to the pleasure of helping someone else.

      I witness services go from one extreme (it’s all harm reduction) to the other (it’s all recovery) with no understanding of how one fits into the other quite naturally – it isn’t an either or. In the age of new substances I also witness services turning people away unless they can be scripted! That scares me, that should never be the case when someone wants help.

      • djmac says:

        The idea of recovery as an evolving concept with changing definitions for the individual over time is appealing, albeit a potential nightmare for service commissioners. I do wonder if, over time and with the right circumstances, more people do embrace abstinence as a central feature in their personal recovery. The challenge is for treatment and support systems to be sophisticated enough to help people regardless of where they are on the road. There is still a lot of talk around about ‘harm reduction or recovery’.

        Your point about turning people away when there is no script option is well made. Addiction is addiction and when there is no option for scripting there is an argument that the response needs to be more intense and resourceful, not less.

    3. Dee Empty says:

      So, while many recovery specialists continue to argue that abstinence is not the main thrust of recovery, people in recovery asked ‘what is recovery?’ gave the highest rating to abstinence.

      Who would know better what recovery is than people going through the experience of recovery?

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