APPROACHES TO RECOVERY

Briefing for uchooseit Advocates

Alcohol and other drug related (AOD) problems have been a significant health problem throughout history.  Responses to these problems have been organised around three paradigms:

1. Pathology
This views addiction as either a sin or a sickness, depending on whether people come from a religious or a medical background, as was the main approach from the 18th century to the 1930’s.  The hope within this view was that it would be possible to identify the cause or causes of addiction in the same way as identifying the cause or causes of a disease.  While this approach has failed to find ‘a cause’ it has helped us to understand that that there are a range of processes that initiate and sustain addiction.

2. Intervention
The failure to find a singular cause for AOD problems led to the development of a range of interventions – both social and personal.  This has created a multi-million industry aimed at preventing drug use e.g. controlling drug supplies, punishing drug offenders and treating those with severe addiction problems.  This paradigm assumes that by scientifically evaluating these interventions and control strategies particular types of intervention can be identified which can then be matched to particular communities, types of user and individuals.  This view has given us significant new knowledge which has shown the importance of bridging the gap between clinical research and clinical practice in addiction treatment.

3.Resilience and Recovery
The fact that AOD problems remain as much as an issue for society, despite pathology and intervention approaches, has led to a shift in focus towards resilience and recovery,  As early at 1984 there were calls from researchers to ‘explore the natural process of recovery’.

The recovery approach focuses on at-risk individuals, families and communities who have managed to avoid developing severe addiction problems and the lives of individuals, families and communities who have successfully resolved, or are resolving, AOD problems.

Advocates of the recovery paradigm suggest that ‘lived through’ solutions that individuals, families and communities have found for their AOD problems will reveal principles and strategies which will provide a foundation on which broader, more effective social policies and interventions can be built.      

Knowledge about AOD problems is substantial but little is known, from a scientific point of view, about the long-term solutions to these problems.  While knowledge about recovery exists, the addiction field does not draw its main knowledge from this source.  Today professionals routinely talk of multiple pathways to recovery but, from a scientific standpoint, we know little about these pathways.  As addiction interventions become shorter, treatment professionals have less and less contact with, and therefore knowledge about, the long-term recover process.

Recovery Definitions

Recovery is the process through which severe drug or alcohol problems are resolved alongside the development of physical, emotional, ontological (spirituality. life meaning), relational and occupational health.  
Severity is usually defined as AOD problems meeting the criteria for substance abuse or substance dependence.  



AOD problems vary, spanning a bad reaction to a single episode, problems over a few months or years and those that span significant periods of a person’s life.  These problems also vary in intensity and severity:

Sub-clinical problems: problems that come and go but do not meet the criteria for abuse and dependence
AOD problems that meet the criteria for substance abuse – clinically significant impairment marked by one or more of the following in a 12 month period: repeated substance abuse resulting in failure to carry out major obligations, repeated use in situations that are physically hazardous, repeated substance related legal problems and continued use in spite of problems caused
AOD problems that meet the criteria for substance dependence – clinically significant marked by at least 3 of the following in a 12 month period: tolerance, withdrawal. loss of control of use, failed efforts to stop using, significant time spent in getting hold of substances, using them and the recovering from them, giving up social, occupational or recreational activities due to substance use, continuing to use despite physical or psychological problems       

The term recovery is more applicable to the process through which severe and persistent AOD problems are resolved.  Terms such as quitting, cessation and resolution are used to describe the problem solving processes of people with less severe issues.  Recovery suggest reversing bigger problems and more lasting problem solving processes.

Family Recovery
This is the way that family members affected by severe and persistent problems regain there health in three areas:

individual family members
family subsystems: adult intimacy relationships, parent-child relationships, brother and sister relationships
family as a system: redefining family roles and rules, agreeing rules and boundaries with people and organisations outside the family

Ironically the recovery of an addicted family member can actually threaten and destabilise a family unit if professional and social support is not available to soften what has been called ‘the trauma of recovery’.

Recovery Prevalence
Complex systems are in place to measure changes in the use of alcohol and drugs and the consequences of this.  However, no similar systems exist to measure recovery so its prevalence is largely unknown.

Recovery Scope and Depth
Recoveries from addiction can differ in their scope (the range of measurable changes) and their depth (the degree of change in a particular area).  Stopping a destructive relationship with alcohol or drugs is at the core of addiction recovery, but recovery experiences can include stopping use in an otherwise unchanged life to a complete transformation of a person’s identity and interpersonal relationships.

There are variations in the relationships between primary and secondary drug use :

one pattern of alcohol or drug use can be stopped while another pattern continues.  For example there is a high rate of nicotine dependence among adults and young people both before and after treatment for dependence on alcohol, opiates, cocaine and cannabis’
secondary drug can increase following cessation of primary use.  For example an increase in alcohol or cocaine use after stopping using heroin.  This kind of drug substitution is a common problem, particularly for those with a history of poly-drug use
a third pattern involves individuals who use secondary drugs therapeutically during early recovery to manage withdrawal and the stress of early recovery e.g. ex-heroin users using cannabis to prevent relapse.  In this pattern secondary use stops or slows down within the first two years of recovery

The ability to understand when drug substitution is an effective, time-limited strategy to manage early recovery (requiring professionals to understand it, if not wholly accept it) and when it is just a mutation of the existing problem (requiring prevention, early intervention or treatment) is an important research agenda.  Some researchers have found secondary drug use more likely to be an issue for people with a family history of AOD problems, those who began addiction at an early age and those who experienced problems with a secondary drug before developing their primary addiction.

The scope of recovery can go far beyond patterns of primary and secondary usage.  Historically the definition of recovery has shifted from a focus on what is deleted from an individual’s life (alcohol, drugs, arrests for criminal acts, hospitalisations) to what is added to a person’s life (the achievement of health and happiness).

This shift is reflected in terms such as mental sobriety and emotional sobriety (a state AA co-founder Bob Wilson coined to describe a state of emotional health far beyond the achievement of not drinking.  Wilson described it as “real maturity….in our relations with ourselves, with our fellows and with God”).  This broader vision of recovery is also reflected in the term wellbriety currently being used by the Native American recovery advocacy movement.  Wellbriety describes recovery as the pursuit and achievement of physical. emotional, intellectual, relational and spiritual health – or ‘whole health’.  Wellbriety in the NA context is related to a new set of core values: honesty, hope, faith, courage, integrity, willingness, humility, forgiveness, justice, perseverance, spiritual awareness and service.

Because severe AOD problems impact on many areas of life, recovery from such problems needs to be measured across multiple zones or domains of recovery:

the relationship with the substance which an individual abused and/or was dependent on
the presence, frequency, quantity, intensity and personal and social consequences of secondary drug use
physical health
psychological, emotional and spiritual health
family and relational health
lifestyle health

Seen as a whole the goal of recovery is what can be referred to as global health.

Like other severe and potentially chronic health problems the resolution of substance misuse problems can be categorised into levels:

full recovery – complete and enduring cessation of all AOD related problems and the movement towards global health
partial recovery – covers two different conditions :
reduced frequency, length and intensity of use and a reduction in related health/social problems  
complete abstinence or stable moderation but failure to achieve gains in global health

Partial recovery can be a permanent state, the stage before full recovery or a period of stopping use before returning to a previous or greater level of problem severity.

In between those in no recovery or full recovery are individuals who move in and out of periods of moderate use, problematic use and abstinence.  People who are incapable of permanent abstinence at particular  points in their lives may achieve partial recovery.

Partial recovery is also reflected by individuals who go through multiple episodes of treatment, initial recovery and relapse.  This is evidence that recovery is not fully stabilised, but the fact that individuals are continuing to seek help also suggests that their addiction is no longer stable.  In fact, moving in and out  
of recovery or a chronic state.

Partial recovery can also cover problems that remain after stopping alcohol or drug use. For example while recovering alcoholics establish levels of personal and family functioning comparable to non-alcoholics  early recovery can been marred by poor levels of adjustment e.g. depression, anxiety, poor self-esteem, guilt, and impaired social functioning.  

Some researchers recovery status by length of recovery.  A study of 317 members of AA concluded:

early months and years of recovery from alcohol marked by continued impairment of emotional and social functioning
these symptoms continue to improve over the first 10 years of recovery
some problems with cognition may continue into long-term recovery – this is common with alcoholics who begin their recovery after long drinking careers

In the main the principle that global health and functioning improves with earlier onset of recovery and length of abstinence is further confirmed in studies of people recovering from cocaine addiction.

Some people experiences changes so profound across all the zones of recovery that they come to see their addiction an recovery as gifts that have brought a depth of experience and meaning far superior to their pre-addiction life.  These individuals believe in an enriched state of recovery. This enriched state is seen in all traditions.

A final scope and depth dimension of recovery involves individuals who are in recovery for two or more conditions or experiences e.g. trauma, psychiatric illness, AIDS.  The overlapping processes in recovering from addiction and other physical or behavioural/emotional disorders can be described as serial recovery.

Problem Severity and Recovery Capital

Recovery can occur at different stages of a person’s drug or alcohol career.  High levels occur among people who have not yet suffered severe losses related to their AOD use.  Low levels are achieved by individuals in the later stages of addiction who have experienced severe personal and social disintegration before achieving recovery.

In addition to the degree of problem severity, a person’s recovery capital influences their chances of full recovery.  Recovery capital is the quantity and quality of the internal and external resources that an individual can bring to beginning and maintaining their recovery.  The severity of the AOD problem and the amount of recovery capital shapes both the prospects of recovery and the intensity and length of support and resources required to initiate and sustain recovery.

Pathways and Styles of Recovery

Pathways of recovery refers to the different routes people take to start the recovery process.  The phrase recognises the numerous ways that people successfully resolve their AOD problems.  One of the earliest origins of the idea of pathways and choices was AA co-founder Bill Wilson’s comment in 1944 that “the roads to recovery are many”.





Cultural pathways of recovery are the paths that people take that are influenced by culture.  These could be:

early months and years of recovery from alcohol marked by continued impairment of emotional and social functional
Developmental consciousness – for example resolving AOD problems through growing older and taking on adult responsibilities
Medical consciousness – e.g. responding to an alcohol or drug related health problem
Religious consciousness – for example a conversion or joining an abstinence based faith community
Political consciousness – e.g. rejecting all drugs and alcohol as a ‘tool of genocide’

Styles of recovery describes variations in beliefs and recovery support rituals that exist within particular pathways.  For example, 12-step programmes are one of the major recovery pathways but observing several different 12-step groups would show a wide range of ways of ‘working the programme’.

Abstinence Based, Moderation Based and Medication Assisted Recovery

Abstinence based recovery calls for complete and sustained cessation of a person’s primary drug(s) and the non-medical use of any other psychoactive drugs (with nicotine and caffeine historically not included).

Moderation based recovery involves reducing use of substances to a level that no longer meets the criteria of abuse and dependence.  This approach has triggered huge debates and controversy, especially in America.

Medication assisted recovery supports recovery with medical interventions such as detoxification agents, stabilising agents, aversive agents, antagonising agents, anti-craving agents and psychoactive drugs prescribed for dual-diagnosis.

Discussion of these approaches requires understanding that substance misuse problems differ in severity and that this severity influences the pathway to problem resolution.  Abstinence based and medication assisted are more common where there is severe dependency whilst moderation based recovery predominates where problems are less severe and individual’s have more recovery capital (younger, married, employed, higher status, higher social support and stability, positive marital, family and work relationships).

There is evidence to support moderation based recovery but, given that substance misuse problems appear to come and go over time, it is questionable whether using alcohol or drugs again following addiction is sustainable.  As problem severity declines moderation based recovery increases.  This is most frequently noted in studies of people who developed AOD problems in the transition from adolescence to adulthood but later moderate their use. Early members of AA made a clear distinction between themselves and other heavy or problem drinkers, suggesting moderation was an option for some problem drinkers but not for ‘alcoholics’ like themselves.

Medication assisted recovery continues to be controversial – with the general public, within recovering communities and within the professional treatment community.  There is some evidence that this attitude may be softening and influencing this change are newer products in the treatment of alcohol e.g. naltrexone, acamprosate and opiate dependence e.g. buprenorphine.

The most widely used approach to medication assisted recovery is Methadone Maintenance Treatment.  Major health policy authorities support it and have concluded that optimal dosages of methadone combined with psychosocial support given by competent practitioners decrease death rates,  reduce transmission of BBVs, eliminate or reduce illicit opiate use.  They also conclude that methadone treatment reduces criminal activity, enhances productive behaviour in employment, academic and vocational activity, improves global health and social functioning and is cost-effective.

The Context of Recovery Initiation

Natural recovery involves using one’s own resources and family, friends and social networks, to resolve AOD problems without treatment or involvement in mutual support organisations e.g. AA, NA.  According to some studies, natural recovery is the most common pathway but its prevalence declines as problem length and severity increases.  Natural recovery is a more viable approach for people with shorter and less severe AOD careers and those with higher incomes and more stable social and occupational support.

Natural recovery exists across all types of substance misuse and seems to be influenced by age, for example younger people maturing and taking on adult responsibilities or a later life pattern associated with people suffering the consequence of long-term alcohol or drug use.

Those who achieve natural recovery give a range of reasons for avoiding treatment services and support groups, these include:

a desire to protect their privacy or not wanting to share their problems with others
a desire to avoid stigma or being labelled
a belief that they can solve their problems without professional treatment
a belief that treatment and mutual support groups are ineffective or not personally suited to them

Treatment assisted recovery involves the use of professional help to initiate and maintain recovery.  However, there are complications in measuring within this area:

only a small proportion of people with AOD problems seek professional treatment
people who seek treatment tend to have high personal vulnerability (e.g. family history of AOD problems, use from a younger age, trauma), greater problem severity, weaker social supports and fewer occupational opportunities or successes
recovery is compromised by a large number of people dropping out of treatment
the number of treatment sessions available to service users often fall well below the standards recommended for optimal outcomes
individuals may have had professional treatment but this treatment may not have played a role in their later achievement of stable recovery    

In spite of the above issues the vast majority of people who suffer severe AOD problems (in contrast to those with less severe addiction problems) enter recovery through professional treatment, but this link may not be as direct as it first appears.  Recent studies show that a significant proportion of people with the most severe substance misuse disorders achieve recovery only after multiple treatment episodes – suggesting a cumulative effect.

Peer assisted recovery involves the use of structured recovery support groups to initiate and sustain recovery with AA being the most widely used community resource.  Mutual aid has been shown to play a significant role in the movement from addiction to recovery and for those seeking support from such groups the possibility of recovery increases with the number of meetings attended in the first three years of recovery and the level of involvement and participation in group activities.  Peer assisted recovery is also reflected in the growth of the recovery movement and the increase in non-clinical, peer based recovery services.

It is important to note that natural, treatment assisted and peer assisted recovery are not exclusive and an individual’s recovery career can contain elements of all of them.

Recovery Initiation Frameworks

There are significant differences in recovery styles depending on whether religion or spirituality is an important element of a recovery framework.

Religious frameworks of recovery (sometimes referred to as faith based) involve solving severe AOD problems through religious experiences, beliefs, ways of daily living, rituals of worship and the support of a community of shared faith.  In various religious traditions abandoning addiction is seen as part of the experience of a religious conversion and the reconstruction of a faith-based personality and lifestyle.

In this framework recovery is a divine gift of grace rather than something a person does.  Religion is not seen as something that enriches recovery but the thing that causes and sustains it.  Religious pathways are marked by:

a religious rationale for the roots of addiction e.g. the Islamic interpretation of alcoholism as a fruit from the tree of Jahiliyyah (ignorance, idolatry)
a mythical/magical personification or demonisation of addiction e.g. the Islamic view of drink and drunkenness as an ‘infamy of Satan’s handiwork’
a religious basis for sobriety and abstinence e.g. the body as ‘the temple of God’
rituals of confession, restitution and forgiveness as a means of psychological reconstruction
the use of prayer, reading, service to other as rituals of recovery
involvement in a community of faith that meets the needs once met by a person’s addiction

Spiritual frameworks of recovery overlap with religious pathways in that they both come from the idea of the human condition as ‘wounded imperfection’, involve connection with resources both within and beyond the self and have a core set of values e.g. humility, gratitude and forgiveness.  Spiritual frameworks of recovery, such as AA and NA, focus on defects of character (self-centeredness, selfishness, dishonesty, resentment, anger, preoccupation with power and control) as the root of addiction.  They provide methods for reaching into oneself (self-inventory, developing honesty, humility and tolerance) and outside oneself (reliance on a higher power, confession, acts of restitution, service and participation in a community of shared experience).

The spirituality framework involves embracing a ‘paradox’ (the sober alcoholic) and gaining a degree of control by admitting to powerlessness.  Spirituality is rooted in a belief that human beings are born with a vacuum inside them that craves to be filled with meaning and can temporarily and artificially fill this need through the use of drugs and alcohol. However, more real and lasting frameworks of meaning can stop this craving for intoxication.

Secular frameworks of recovery do not rely on any of the above ideas but on belief in the ability of each individual to direct their own self-change processes.  Secular recovery groups view the roots of addiction more in terms of irrational beliefs about oneself and the world and ineffective coping strategies, rather than in terms of biology, morality, character or sin.  They reinforce the message of ‘not using, no matter what’ through a variety of cognitive and behavioural self-change strategies.

Where spiritual and religious frameworks involve transcending self, secular frameworks involve an assertion of self.  Spiritual and religious approaches emphasise wisdom (emphasis on experience, search for meaning, freedom in accepting your limitations, transcending self by connecting with a greater whole), secular frameworks emphasise knowledge (emphasis on scientific evidence, asserting control, self-mastery through knowledge of the self and one’s problems, strength flowing from personal competence).

All the recovery frameworks share a re-visioning of self and life context and a restructuring of life-stance and lifestyle.  They also have a ‘three part story’ style in which people report in a general way what they used to be like, what happened and what they are like now.  However, there are critical differences in the instrument of recovery – the gift of being changed versus ownership of that change, different rituals and different views of the role of the support communities in the recovery process.




Recovery Initiation Styles

There are three styles, quantum change, conscious incremental change and a less conscious process that sociologists call drift.

Quantum change, also referred to as transformational change, is distinguished by its vividness (emotional intensity), suddenness (lack of intention), positivity and permanence of effect.  It can occur as a breakthrough of insight (an epiphany) or as a religious/mystical experience.  Both produce fundamental change in a person’s vies of themselves and the world and being free of alcohol or drugs, and their related problems, come from this change in identity and values.

Quantum change is usually experienced as a Damascus type conversion (religious, spiritual or secular) that precisely and forever marks the end of addiction and start of recovery.  Such conversions are often a result of a calamity- often referred to as ‘hitting rock bottom’.  Quantum change has a long history and has often been the basis for historically important abstinence based religious and cultural revitalisation movements.

Incremental change, in contrast to the lightening strike of quantum change, involves a longer staged process of change.  Researchers have described many models of addiction but all suggest that the process of recovery begins before alcohol and drug use is moderated or stopped and that, while moving straight through all the stages is possible, the more common experience in recycling through stages before recovery is achieved.  The repeated sequence that comes before recovery stability can be described as follows:

escalating pain (I need to recover)
the desire to change (I want to recover)
belief in the possibility of change (I can recover)
commitment (I am going to recover)
experiments in abstinence (I am recovering)
sobriety identity (I am an ex-addict, I am a recovered/recovering alcoholic/addict, I no longer use drugs or alcohol)

Quantum and incremental change have been described as two discrete phenomena but recovery stories can have dimensions of both.  For example individuals who have repeatedly gone around the preparatory stages of recovery but who’s point of recovery stabilisation was marked by a profound, life altering quantum change experience.

Drift is the gradual cessation or reduction of use and related problems as a result of circumstances rather than choice. Here the addict ‘goes with the flow’ only to find that events and/or circumstances have led them away from drugs and the drug sub-culture.  Growing older and changing environment can change habits in ways that do not follow the conscious styles of change in other models.  For example, studies of heroin users show recovery not as a goal, but as a result of severing contact with former drug-using situations and relationships.  Some people drift out of addiction in the same way people drift into it, including finding an intense alternative activity that gives new meaning to their lives.

Recovery Identity
This is the extent to which AOD problems and the recovery process influence a person’s identity and the degree that a person identifies with others who share the recovery process.

People with recovery neutral identities have resolved severe addiction problems but do not identify themselves as alcoholics, addicts or people in recovery, while for those that are recovery positive the status of recovery from addiction had become an important part of their personal identities.  Those with a recovery negative identity acknowledge to themselves that they a recovered or recovering addicts but do not share this status with others due to a sense of shame.

These identities are not exclusive and can be used by individuals at different stages of their recovery career.  Take the example of addiction workers.  Early workers were very open about their recovery status as their main credential but began withholding this status in the 1980’s and 90’s as the need for academic qualifications grew and AOD problems became stigmatised.  With the dawn of a new recovery advocacy movement many of these addiction workers are again going public with their status.  It would therefore appear that evolution in identity is normal in recovery.

Recovery Relationships

There are acultural styles of recovery in which individuals initiate and sustain recovery without significant involvement with other people in recovery and without identifying with a larger recovering community or culture of recovery (a local network of recovering people with their own recovery-based history, language, symbols, literature and values).  This doesn’t mean this style of recovery does not include social support, but that support usually comes from family and friends rather than a larger community of recovering people.

In contrast bicultural styles of recovery are when people sustain recovery through being involved both in a recovering community and in the larger ‘civilian’ culture (activities and relationships with people who do not have addiction/recovery backgrounds.  Finally there are enmeshed styles where individuals initiate and sustain recovery almost completely within a recovering community or culture.

Again these are not mutually exclusive and can change over time.  For example many people will start with enmeshed styles and move on to bicultural and acultural later in their lives.  Some people will use recovering communities for both initiation and maintenance while others use them to initiate recovery which they then sustain through their own personal, family and social relationships.  

A fairly recent phenomenon is virtual (internet) recovery with little or no participation in face-to-face support meetings.  The internet seems to encourage a greater degree of participation among women and people in high status jobs than treatment services or face-to-face support groups.

Recovering communities conveys the existence of multiple recovery groups and the concept that treatment professionals should refer people to these groups with the goal of matching the individual to the relevant group.  How a person relates, or does not relate, to these communities are part of what is described as a person’s recovery career.  The idea of a career has been used to describe the process of addiction and to link up different episodes of treatment.  Recovery career is an extension of this and refers to the different stages of an individual’s recovery stability, identity and support relationships over time.           

Varieties of 12-step Experience

Peer based support groups represent a major resource for resolving AOD problems.  They are attractive, geographically accessible, affordable, have no formal admission procedures and place no limits on length of participation.  12-step groups began with AA in 1935 and, although there were many recovery groups before this, AA continues to be the standard against which other groups are measured.

Varieties of AA experiences are reflected in:

the diversity of meeting experience e.g. open versus closed meetings
the trend to organise around specific populations and special needs
different styles in ‘working the programme’
meetings organised by age, gender, sexual orientation, language etc.
differences in the degree of religious orientation, some very Christian, some groups for Atheists and Agnostics

These varieties multiply even more with the adaptation of AA’s 12-steps to cover other drug problems (Narcotics Anonymous, Cocaine Anonymous, Methadone Anonymous etc.) and to co-occurring problems e.g. Dual Diagnosis Anonymous.

The massive growth of AA in the 1980’s and 90’s and the growing influence of the treatment industry and criminal justice system on AA, led to concerns among older AA members (old timers) that AA was being corrupted.  Efforts were made to recapture the ‘old’ AA and AA historian Ernie Kurtz proposed five criteria to distinguish ‘real’ AA from meetings that had taken on the flavour of treatment groups:

AA vocabulary – defects of character, higher power, self-inventory rather than treatment vocabulary
Humour and appreciation of paradox
A story style that describes in a general way ‘what we used to be like, what happened and what we are like now’
Respect for, and adherence to, AA traditions
A conviction by participants that they need rather than want to be there

The growing range of AA experiences led to the scientific community to define the ‘active ingredients of AA’ i.e. the aspects that were most powerful in altering the course of alcoholism and strengthening recovery.  Studies have looked at motivational enhancement, the development of 12-step cognitions (commitment to abstinence and continued participation), recovery coaching and advice, exposure to recovery role models and the therapeutic benefits of helping others.

The fact that some people did not respond, or only partially responded, to spiritually focused 12-step programmes meant that explicitly religious and secular peer recovery groups developed.  As noted earlier religious groups see addiction in terms of sin or demonic possession.  Recovery is as based on total surrender to a religious deity, immersion in a faith based community and religiously based reconstruction of personal identity and values.

Secular recovery groups are distinguished by meeting locations (people’s homes, religiously neutral sites), lack of references to God or other religious deities, emphasis on personal empowerment and self-reliance, an openness to ‘cross-talk’ (direct feedback and advice between members) and encouragement to complete a full recovery and move on to a full, meaningful life (rather than to sustain meeting participation for life) and the use of volunteer professional advisors (not in personal recovery) to facilitate and speak at meetings.

Individuals who take part in 12-step alternatives may do this exclusively, alongside AA meetings or use one framework to initiate recovery and another to maintain their recovery over time.

Recovery Durability

It has become clear that short periods of abstinence and lessening use of alcohol or drugs do not predict sustained recovery.  Some researchers claim that stable recovery can be predicted by only six months of sobriety, but the stability and durability of recovery increases with length of time in recovery.  A large number of studies suggest recovery from alcoholism is fully stabilised after 4 or 5 years and is more stable for those with late, rather than early onset, problems.  Studies of heroin addicts also confirm that short periods of abstinence are fragile.  One third of those who achieve 3 years of abstinence eventually relapse and a quarter of those with 5 years abstinence return to heroin use.

While recovery stability does vary across drug choice the principle that recovery becomes more stable over time seems to apply to all patterns of addiction.  People who have achieved full, uninterrupted recovery for 5 years, like people in remission from health conditions like cancer, can be described as recovered.  In general this means that risk of future relapse is at the same level as people who have no history of addiction.

Those who have achieved full recovery of less than 5 years, or partial recovery, can be best described as recovering or in recovery.  These terms are also used much later on in recovery to remind the individual that recovery is an ongoing process requiring vigilance and maintenance.  However such use, by inadvertently suggesting the lack of a permanent solution for AOD problems, may add to the stigma and pessimism attached to addiction problems.

Recovery Termination

This is the question of whether recovery from addiction is ever completed.  The stage models suggest 4 broad stages of recovery:

Recovery Priming - experiences that open the doorway into early recovery
Recovery Inititiation – discovering a realistic strategy to stabilise the problem
Recovery Maintenance – achieving recovery stability and sustaining and refining broader strategies of problem resolution with a continued focus on the recovery process
Recovery Termination – achievement of global health with less preoccupation with recovery

The last stage, referred to as Stage II recovery (rebuilding the life that was saved in Stage I) goes beyond concern with addictive behaviour and focuses on reconstructing personal character, identity, beliefs and interpersonal relationships.  It is also referred to as completed recovery or the 13th step – an advanced state of recovery marked by global health and an increased capacity for intimacy, serenity, self-acceptance and public service.

Implications for the Professional Treatment of Addiction problems

Paradigmatic Shift

There will be increasing calls to shift addiction treatment and addiction counselling from problem-focused or intervention-focused to recovery focused. This will shift emphasis from one of brief biopsychosocial stabilisation to sustained recovery management i.e. pre-recovery engagement, recovery initiation, sustained monitoring, stage-appropriate recovery education and coaching, assertive linkage to communities of recovery, and, when needed early re-intervention.

Recovery Definition and Scope

There will need to be considerable discussion between the professional addictions field and diverse communities of recovery about the very definition of recovery. These discussions will be contentious and will cover:

Abstinence shifting from its status as a goal and a requirement of recovery to the status of one method of achieving recovery (and the preferred method for those with the most severe AOD problems). The goal will shift to the resolution of AOD problems by any means possible and include moderation for those with less severe problems
The focal point of recovery (changes in a person’s primary drug relationship) will broaden to include a healthy relationship or non-relationship with all psychoactive drugs and the achievement of global health. Addiction treatment programs will increasingly be held accountable for multiple recovery outcomes, e.g., changes in primary and secondary drug use as well as changes in physical, emotional, family/relational and occupational/academic health and functioning.
There will be a shift in focus from what recovery eliminates (AOD use and related problems) to what recovery adds to individuals, families and communities (global health, occupational and academic productivity, active citizenship)
The rising importance of the concept of family recovery will increase pressure for new approaches to family assessment, intervention and sustained monitoring as well as a push for more family-oriented recovery research
The concept of partial recovery will be given more status and legitimacy in the addictions treatment field, and cases of enriched recovery (dramatically improved health, functioning and community service) will be documented and culturally elevated to help reduce the social stigma that continues to be attached to AOD problems.

Recovery Capital

The pathology and intervention paradigms that have guided addiction treatment mean treatment systems have focused almost exclusively on problem severity and complexity.  The recovery approach calls for measuring recovery capital and assessing its role in natural, treatment-assisted, peer-assisted recoveries. This means that recovery capital will need to be taken into account in clinical decision making.

The most important implication of the concept of recovery capital is that not all individuals experiencing AOD problems need professional treatment. Individuals with lower problem severity and high recovery capital can be encouraged to explore natural and peer-based resources as a less restrictive, less expensive, and less stigma-laden alternative to addiction treatment.

Medication-Assisted Recovery

Tension is growing between groups that are anti-medication, the growing availability of a wide variety of
products and the growth in scientific evidence supporting their effectiveness. It is likely that medication will become to be seen more positively in professional and recovering communities and integrated within the large spectrum of treatment and recovery support services.

If this does not happen then it is possible that scientifically and medically based treatments will split off into a separate field within primary medicine.

Recovery Frameworks

Religious, spiritual and secular frameworks of recovery need to be more completely examined and evaluated, with a particular focus on how they apply to particular cultural and clinical groups. For example, researchers
have extensively studied AOD problems in some communities (some would say over-studied), but no similar   quantity of literature exists on the varieties of recovery experience within these communities.

For example, do members of secular frameworks of recovery differ from those in religious or Twelve Step frameworks of recovery? What mechanisms of change are shared across religious, spiritual and secular frameworks of recovery and what mechanisms of change distinguish frameworks from each other? Definite answers to such questions do not yet exist.

Recovery Styles

Differences in how recovery is initiated and how recovery shapes personal identity and interpersonal relationships show how varied experiences in recovery are. Further documentation of such styles and their relative prevalence across cultural and clinical subpopulations is needed to guide the delivery of treatment and recovery support services.

Varieties of Recovery Mutual Support Societies

The growth in numbers and the growing diversity of peer-based recovery support groups suggests the need for all addiction professionals to become students of such groups, develop relationships with these groups, provide clients information about such groups, and develop a style of active linkage to these groups. The diversity of recovery support groups has prompted calls for matching individual clients to particular groups by such factors as age, gender status, drug of choice, smoking status, and attitudes toward religion and
spirituality.
Celebrating the growing diversity of recovery pathways and a philosophy of choice are features of the best
treatment programs. Recent reviews of treatment effectiveness have linked this philosophy of choice to enhanced motivation and treatment outcomes.  All recovery support structures, like all treatments, will people who respond fully, partially or not at all. This calls for continued monitoring and support to get the best possible fit between each individual and a particular method of treatment or recovery support. Combinations of natural resources, peer recovery networks and professional treatment may increase  recovery outcomes for those individuals and families with the greatest problem severity and complexity.

Websites for further study

http://www.wiredin.org.uk – Wired In was developed as a way of empowering people to tackle drug and alcohol use problems. This online community aims to provide an environment of opportunity, choice and hope, to enable individuals and families to find their path to recovery from substance use problems.  It brings people together with the common purpose of helping themselves and others, and making sure that society is more understanding of and helpful towards people affected by substance use problems
 HYPERLINK "http://www.findings.org.uk"
http://www.findings.org.uk - Aims to provide practitioners with the evidence they need to demonstrate and improve the effectiveness of their interventions to treat, prevent or reduce drug and alcohol problems. Mike Ashton and colleagues describe research findings, set them in context, and explore the implications for practice.
http://www.facesandvoicesofrecovery.org - This organisation is committed to organising and mobilising millions of Americans in long-term recovery from addiction, their families, friends, and allies, to speak with one voice. It is dedicated to changing public perceptions of recovery, promoting effective public policy, and demonstrating that recovery is working for millions of Americans.

http://www.smartrecovery.org - Supports individuals who have chosen to abstain, or are considering abstinence from addictive behaviors (substances or activities), by teaching how to change self-defeating thinking, emotions, and actions; and to work towards long-term satisfactions and quality of life. Supported by leading experts in US.