Have you quit drinking – or cut way back?
That’s what I asked when trying to locate people for Sober for Good, more than 15 years ago. But in my recruitment notice, I purposely didn’t use the words “sober” or “ in recovery” because I thought some might be put off by those terms. Rather, the notice I used to attract interviewees said that I was seeking individuals who had “overcome a serious drinking problem for at least five years ¬– either by choosing abstinence or moderate drinking.”
While the vast majority – about 9 out of 10 – of the 222 individuals who took part in my book about long-term recovery had chosen abstinence, the others were able to drink moderately without problems caused by their drinking. But they all felt they were in remission from what most of us would call addiction. Their stories and completion of detailed questionnaires supported this.
Expert Definitions of Recovery
Those who adamantly assert that abstinence is ‘the only way’ often have heated debates with harm reductionists who maintain that recovery can include continued, non problematic use of substances.-Anne Fletcher
Those who adamantly assert that abstinence is “the only way” often have heated debates with harm reductionists who maintain that recovery can include continued, non problematic use of substances. But the truth is that there is no agreement about what defines recovery. Most definitions have come from experts, without input from people who have undergone the process, and typically have included “abstinence” and/or “sobriety.” For instance, a 2007 consensus panel convened by the Betty Ford Institute defined recovery as a “voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship” with “sobriety” referring to abstinence from alcohol and all other non-prescribed drugs.
While most treatment programs subscribe to an abstinence model, most also use the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to diagnose substance use disorders. Note that the DSM defines sustained remission (aka recovery) as having at least a 12-month period when none of the DSM-5 criteria have been met. But none of the criteria have anything to do with abstinence. They concentrate on problematic behavior, such as inability to cut down on drugs or alcohol, difficulties at work and home, and relationship issues. To be in remission, the focus is on the original drug of choice – not on whether you’re using another substance. Thus, you can be in remission/recovered from an addiction to one substance (such as alcohol) but still be using or even addicted to another one (such as cannabis).
…most recent definitions of recovery go beyond the concept of abstinence, including more global improvements in life.-Anne Fletcher
In a 2012 issue of the Journal of Addiction Medicine, Nady el-Guebaly, M.D. from the University of Calgary in Canada summarized his findings from searching peer-reviewed literature addressing general principles of recovery using the key words “recovery from addiction.” He noted that most recent definitions of recovery go beyond the concept of abstinence, including more global improvements in life. And, indeed, that same year, SAMSHA (the Substance Abuse and Mental Health Services Administration) came up with a comprehensive working definition of recovery that defines recovery as “a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential.”
The people I interviewed for Sober for Good certainly stressed that “sobriety” is more than not drinking – it’s about taking steps to obtain a new plane of living. Ward R., who had been abstinent from alcohol for more than two decades when I interviewed him, said that his “last drunk” made him realize that he had two choices: to either work on developing a way of life in which he didn’t want to drink or to say, “To hell with it” and keep drinking until he died. He made his choice by going to AA and developing a life with no room for drinking. He described it as, “I am now retired and my life is full with traveling, exploring other cultures, being an active AARP member, working on helping other seniors with telemarketing scam artists, being a volunteer deputy sheriff and a member of a gun club, working with other recovering alcoholics, and remodeling a fixer-upper. I just don’t have time to sit around in a bar.”
I am now retired and my life is full with traveling, exploring other cultures… I just don’t have time to sit around in a bar.-Ward R.
Consumers Have a Say in Defining Recovery
Like so many aspects of addiction, Alcoholics Anonymous (AA) has been the major player in defining recovery for the general public – and for setting the “standards” for those struggling with the problem. Thus, the traditional stance, also adopted by many treatment programs, is that recovery requires complete abstinence from alcohol (and other drugs) and developing “a new way of living” – using the spiritual framework described in AA’s 12 steps. People who don’t fall into the mold are often shamed or made to feel “less than,” even though their approach to resolving their problems can be just as valid. In fact, research shows that non 12-step and non abstinent recoveries are common.
To develop a definition of recovery defined by everyday people who recovered in a wide variety of ways and including elements that would be highly endorsed regardless of recovery pathway, the newly published “What Is Recovery?” study was conducted by a team of researchers headed by the Alcohol Research Group’s Lee Ann Kaskutas, DrPH. Just released in the November 2014 issue of the Journal of Studies on Alcohol and Drugs, the study is based on an internet survey that included 47 potential items defining recovery. More than 9,300 people who had said they’d recovered in any number of ways took the survey, indicating to what extent they felt the items belonged in a definition of recovery.
(The survey takers were recruited from treatment alumni organizations, 12-step and non-12-step support groups, medication-assisted [i.e., methadone and Suboxone] and harm reduction sources, radio programs, and Craigslist.)
The results affirm what I found in studying people who had overcome serious drinking problems – that recovery has different meanings for different people, ones that usually but not always include abstinence and that encompass much more than giving up or cutting back on drugs and alcohol. Eighty-four percent abstain from both alcohol and drugs, while three percent said they abstain from alcohol only, 11 percent from drugs only, and 2 percent use both alcohol and drugs. While three-quarters of respondents saw themselves as “in recovery,” 22 percent said they’d “recovered” or “used to have an alcohol or drug problem.”
Overall, the six recovery elements endorsed most frequently (more than 90 percent) as definitely belonging in participants’ definition included the following:
- Being honest with myself
- Handling negative feelings without using drugs or alcohol
- Being able to enjoy life without drinking or using drugs like I used to
- [Recovery is] a process of growth and development
- Reacting to life’s ups and downs in a more balanced way than I used to
- Taking responsibility for the things I can change
The researchers noted that although more likely to be endorsed by people with 12-step exposure – and these ideas do reflect 12-step principles – they appear to be “somewhat universal” among participants. This suggests that you don’t need to go to 12-step meetings to grasp their importance for recovery.
…more than 90 percent of people endorsed the ideas that recovery is about giving back and about helping others to not drink or use drugs…-Anne Fletcher
Also of note, more than 90 percent of people endorsed the ideas that
recovery is about giving back and about helping others to not drink or use drugs like they used to. In contrast, the recovery element endorsed by the fewest respondents (63 percent) as definitely belonging in their definition was that recovery is spiritual in nature and has nothing to do with religion.
The authors suggest that a take-home message from the study for providers is that it can help pinpoint treatment directions – for instance, self-care, concern for others, personal growth, and developing activities that sustain recovery such as suggesting sober fun activities and opportunities for volunteering. Certainly, treatment should already be incorporating such concepts, but this study may encourage providers who aren’t doing so to spend more time in these areas and less on encouraging clients to accept the disease concept of addiction.
For clinicians, the findings emphasize the importance of not assuming a shared meaning, but asking individuals what meanings they bring to the treatment process and monitoring whether and how those change over time.-Dr. Daniel Kivlahan
When I asked respected addiction researcher Daniel Kivlahan, Ph.D. from the University of Washington for his take on the study’s findings he said, “‘Recovery’ is a loaded term. The study illustrates that just as there are many pathways to recovery with some approaches more common than others, there is variation in the experience of recovery with some prominent themes and others that are widely recognized but less commonly held. For clinicians, the findings emphasize the importance of not assuming a shared meaning, but asking individuals what meanings they bring to the treatment process and monitoring whether and how those change over time. The findings also provide a point of reference to help individuals identify what recovery means to them and have the potential to help clients identify their common and distinctive elements compared to those in the broader recovery community.”
It also brought to mind a quote from a colleague that Dr. Kivlahan paraphrased as, “Anything you say about people with addiction will be true about some of them, but not true about all of them.”
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