Month: February 2015

The Family Afterwards…

Today we listen to the research wisdom of William White in relation to family recovery, especially long term.

Family recovery is much overlooked and not adequately supported long term in terms of “after care” which is incredible when one considers that interpersonal factors such as family relationships contribute in a major way to  relapse?

Instead of spending millions upon millions on cue reactivity and attentional bias studies which look at how recovering people are supposedly constantly drawn to alcohol and substance cues in the environment like lemmings to a cliff (when this does not seem particularly evident in the literature, particularly in relation to being relapse factors) or on anti-craving medication when me and scores of other alcoholics and addicts in recovery rarely have these once they have ultimately accepted in our innermost selves that they are alcoholic/addict (and if we do, we can deal with them via our support networks), why does research funding via various funding bodies and various universities not look at the efficacy of supporting families in long term recovery, certainly to around the 3-5 year mark, at the very least?

I suspect one would find that support of family recovery long term, possibly in extended recovery communities, may be the most potent way to assist long term recovery?

Why doesn’t research address what works, and why it works rather than trying to develop the next miracle pill? 

Craving is also a symptom of an underlying condition, it is this condition that recovery should be treating?

We have the solution already? Why not support it to increase it’s efficacy long term?  We, via research and funding, could very possibly increase long term recovery, period.

Just a couple of ideas to put out there?

Back to William White and …

The Ecology of Recovery –  there appears to be a historical shift in recovery away from intrapersonal dynamics to a more interpersonal dynamic. From a recovery within with self, looking at the self,   to a fuller recovery involving others in one’s recovery life such as families and recovery communities.

Family Recovery – if we attend to families at all in recovery, it is brief and very short term. Unfortunately,   research suggests that recovery is actually “horribly destabilising” for families. 

The Trauma of Recovery

Families are at a high risk of disintegrating in the early stages of recovery. So we need to build “support scaffolding” for these families. Recovery  does little to prepare or support families in recovery. Stephanie Brown refers to this as the “trauma of recovery”!  We still do not know the extent of what that means or the extent of our roles in recovery in guiding families, according to William White.

Please also click to this link to watch a series of videos on family recovery by SAMHSA which are very illuminating about the process of recovery and describe a process of recovery I have gone through myself with both my  wife, nuclear and extended families.

Recovered?

When does sobriety for today predict sobriety for a life time?

When does the risk of relapse plummet?

How long do you have to be in recovery before this risk falls below 15% which is a figure used with other diseases?

According to William White it is constantly demonstrated to be between four and five years recovery! For opioid dependence it is a little longer. Even at 5 years there still appears to be a 25% relapse rate in this group.

The 5 year mark for durable recovery is the same as with other major disease states such as cancer. Unlike cancer there is really never any effective follow up with those in recovery although there is after care with, say, cancer. Why should this be the case?

Why are recovery people not monitored and followed routinely for 5 years?

In other words, why do recovering people, recovering from the devastating consequences of addiction not get the same medical care?

Recovering My Identity

We continue to mine the research wisdom of William L White on the next few blogs. William White is one of a growing number of researchers looking into recovery. This is an oft neglected part of research although we are beginning to see  research into the neurobiology of recovery as we have discussed in various other blogs.

William White takes a more qualitative approach than our previous research blogs. It is important to marry quantitative and qualitative research moving forward. For example, William White makes an important point in his research writing about durability of recover, i.e. at what point (or how long does it take for) recovery to be considered durable?

Is there a period at which we can say these individuals in recovery will most likely continue to stay in recovery long term?

From a quantitative perspective it would be illuminating to image the brain of these individuals at say 5 years and compare to early recovery brain images to show what functions of the brain improve, what neurobiology is replenished (balanced) which neural networks are connected or reconnected via altered behaviour-based neuroplasticity etc.

Everyone should have access to information on the processes involved in  getting well, what this wellness looks like and how to get there. If you went to your doctor about any other illness or condition you would expect some information about treatment, likely chances of treatment success, likely outcomes of treatment and how you are likely to be in the long term. So why not have this information available in relation to addictive behaviour recovery?

Anyway on with next video on the experience of recovery.

Recovery Identity

There appear to be three types of recovery identity according to William White’s research

Positive – extremely enthusiastic about being in recovery and want everyone to know that they are in recovery!! I can relate to this I’m afraid. Especially int he earlier months of recovery when I was converting the world to the 12 step world of spiritual awakening!! The preaching phase of my recovery.

Neutral

Negative – In recovery but deeply ashamed about being in recovery because of the social stigma related to having the disease of addiction.

Interpersonal Styles of Recovery

Acultural – individuals who initiate and sustain  recovery without relationships with other people in recovery.

Bi cultural – can move within distinct cultures of recovery but can also function quite comfortably with “normies”or “earthlings” i.e. normal people at large in society.

Culturally enmeshed – deeply enmeshed within the culture of recovery. They live within the culture of recovery so much  and so exclusively that they have almost no contact with the mainstream culture. This is not unusual in early recovery but may not be encouraged in much later recovery.

At some point we all should be encouraged to, as William White states, “get a life” which is to leave to comfort blanket of exclusively 12 step life to start walking across that bridge to normal living. I know from my own recovery that suddenly, after 18 months, having to start working in a school with troublesome boys and kids with learning differences improved my recovery immeasurably.  Although I did not want to do it initially and was half terrified of doing so.

The best recovery is often in the world of people, this connectedness to others helps the recovery process no end. All recovery seems to most effective in a social setting. It helps test our so-called spirituality no end. We can only be sages in an AA meeting but in real life we really find out how spiritual we really are!!? 

It also helps with self esteem and self confidence in our own abilities. I have found in recovery, that I am recovering a person I have never known or met before. Recovery is an adventure in a sense. We continually disprove our over critical heads which is constantly telling us we can’t when we can.

I leave it to my higher power, which I call God, to reveal the me He wants me to be. 

Drugs were never this exciting!

 

Recovery: can you feel “Better than Well!”?

Degrees of Recovery?

Better than Well – I love this concept and reality and relate to it myself. This is a reality for many recovery people who feel they had an amplified recovery or in simple terms, people who got better than well!

This people did not simply have the pathology of addiction extracted from their lives. These people did not only go on to recover but went on to live incredibly rich lives in terms of the quality of their lives and the service to their communities.

These are people who talk about addiction and recovery as a blessing! These are individuals who suggest that what they achieved after recovery was not in spite of their recovery but because of the strength they drew out from their addiction recovery.

Their fulfillment of life was greater perhaps than if they had never been addicted and suffered from addiction. Their recovery from addiction gave them a meaning that they may not have had, if they had not been addicts.

I believe I am 25% smarter in recovery (can be proved in terms of exam grades), I understand people now in recovery, I am a more empathetic human being in recovery. My life is immeasurably better than it was before. I have a contentment unknown to me previously. A peace of mind I thought impossible.

My roots grasp a new soil! I feel like I have been reborn.

This kinda fits in also with Bill White’s description of recovery as a method of transcending the self or “getting out of self”. This idea and reality relates to various previous blogs on why we need to live “outside” self regulation” systems of the brain as these appear to have been hijacked by the effects of drug and behavioural addiction.

One way of doing this is by using our self in a different way, to use self to serve others. This way we can use our stories to help others in recovery and improve our own self regulation as it strengthens areas of the brain like the ventromedial pre frontal cortex used in self referential information and emotional regulation.

We can get reward not from drugs or behaviour but by helping others which supplants the depleted dopamine, natural opioids, oxytocin of increased attachment and bonding and the serotonin of well being. It improves our orbitofrontal cortex as we become more empathetic, begin to become emotional literate, reading emotional expression in other’s faces.  It reduces stress and distress. Lowers glutamate and increases GABA. We become less fearful and more serene.

Helping others helps us so profoundly.  It changes the neurobiology and hence neuroplasticity of our brains.

The video ends with a brief look at the “hot flash” spiritual awakening of recovery a la Bill Wilson and  the slower more incremental or “educational” variety of spiritual awakening. For me, spiritual awakening can mean emotional catharsis, sometimes so dramatic that it immediately changes how we think and feel about the world and our place in it or the more experiential, where our views and attitudes to the world gradually change. Each leads to the same goal of long term recovery. The latter being, by far, the most common.

 

Recovery – a need for change?

A need for change?

Addiction is a chronic condition but is treated as if it was an acute disorder. Treatment has become disconnected from the longer processes of recovery. Hence is there a need to redesign “treatment” to address the reality that recovery is a long process, not something that can be treated in weeks or months? Should there be a greater focus on interpersonal and family relationships, especially as they are demonstrated to be a major reason for relapse.

Toward a new Recovery Paradigm?

What do we know about this thing called recovery?

First we have to define recovery, so let’s start with “What is recovery?”  Do we need to move from a pathology and treatment paradigm to a recovery paradigm? Although it is feasible that these paradigms could be interlinking? Or at least considered more than at present.

At present we focus almost exclusively on what is wrong with addicts not how they get better via recovery and the ways in which they get better too? We need more research to evaluate the processes in recovery, the different types of recovery, we need research into the success of recovery, i.e. how many people actually recover, the durability of recovery etc.

We need to clearly say where we are headed and what we can hope for by coming into recovery!

We could fill libraries with what we know about the neurobiology of addiction but barely a library shelf with what we know about recovery from addiction.

 What exactly do we know about the neurobiology of recovery?

In recovery are there any ways recovering persons can help with altering vulnerabilities, such as developing the verbalising of emotion, to help with emotion processing and regulation which we know have a aetiological influence of the risk of later addiction?

In short can we affect the epigenetics of addiction (how genes are expressed in environments) by recovery? Can we reduce the stress that potentiates dopamine and reward and acts as a vulnerability to adolescent drinking which in itself is linked to later alcoholism? Can we counter the child maltreatment and insecure attachment that propels addiction?

So many questions remain unanswered. Can the people who suffer addiction, in recovery, be the most potent agents in actually affect vulnerability to later addiction? Can certain, seemingly unavoidable eventualities be addressed and changed?

Can our recoveries help our at risk children? Can we modify the effects of genetic inheritance? Is it inevitable that addiction occurs, can it not be “treated” in early childhood. Can we intervene to disrupt or alter the course of addiction?

This is the research question of the next decade?

Where did this Road to Recovery Start?

William L White is one of the foremost writers on the History of “recovery” from the 1730s up until the present day and the advent of the new recovery movement (in the US). The first two of ten short videos looks at the early history of mutual groups leading up to the founding of AA and beyond.

It is fascinating to see how certain types of treatment and views about addiction appear to have a cyclical nature, coming in and out of fashion at different times in history.

Listen here to White’s authoritative accounts of the formative years of recovery movements up until the present day formation of “recovery communities” which reduce the stigma of addiction by being up front and visible as recovering people. In reducing this stigma they may help many more addicts and alcoholics start recovery as stigma around this chronic illness appears to impede many in seeking initial treatment and recovery.    As one person has mentioned, why let others define us by our silence?

The future of recovery? There are up to 25 million recovering person in the US alone, should we not be shouting about this from the roof tops?

We will look at these recovery communities and the nature of recovery itself in our next few blogs.

Although we may be in recovery it does not mean we are aware of the fuller picture of recovery.

William White is a leading expert in trends in recovery and will be our guide over the next few days also.

 

The Road to Recovery

Following on from our recent blog on “So what is Recovery?” we now look at the process of recovery itself and important changes that contribute to successful recovery.

Many recovering persons report quitting drugs because they are ‘sick and tired’ of the drug life. Recovery is the path to a better life but that path is often challenging and stressful.

However, the main message from this study (1) is that those individuals who manage to get to 5 or more years abstinence have an 86% chance of long term recovery !

Not only do the recovering persons benefit in many ways but families and societies also see major benefits of recovery too. The initial cost of recovery, i.e. if via treatment facilities, is offset by increased employment, less penal costs, financial contributions to society of recovering persons etc.

Not only does it make ethical, moral and medical sense to spend much more on treatment facilities it makes makes very obvious financial sense.

“Although substance use disorders are increasingly recognized as chronic relapsing conditions that often span decades and require multiple episodes of treatment and/or self-help (Anglin, Hser, and Grella 1997; Anglin et al. 2001; Dennis, Scott et al. 2003; Dennis and Scott [in press]; Hser et al. 1997; Hser et al. 2001; McAweeney et al. 2005; McLellan et al. 2000; Moos and Moos 2005, 2006; Scott, Foss, and Dennis 2005a, 2005b; Simpson, Joe, and Broome 2002; Vaillant 1988; Weisner, Matzger, and Kaskutas 2003; White 1996), approximately 60% of the people with lifetime substance disorders do eventually reach a state of sustained abstinence (Cunningham 1999a, 1999b; Dawson 1996; Dennis et al. 2005; Kessler 1994; Robins and Regier 1991).

This has led to multiple calls to define and better understand and study “recovery” in terms of not only abstinence but improvements in health, mental health, coping, housing, social and spiritual support, illegal activity, and vocational engagement (Betty Ford Consensus Panel [in press]; Laudet, Morgen, and White 2006; Laudet, White, and Storey [in press]; White 2005).

Using data from 1,162 adults living in a large metropolitan area who sought substance abuse treatment in 1998 and who were subsequently interviewed annually between Years 2 and 8 (greater than 94% follow-up rate each year), this study addresses the following four questions:

1. How do health, mental health, and coping vary by duration of abstinence?

2. How do illegal activity, incarceration, employment, and family income vary by duration of abstinence?

3. How do housing, clean and sober friends, recovery environment, self-efficacy to resist relapse, and social and spiritual support vary by duration of abstinence?

4. How does the likelihood of sustaining abstinence another year vary by the duration of abstinence?

Health, mental health, and coping. Abstinence is generally associated with better health, mental health, and coping. Among people in the community, less substance use is associated with lower rates of chronic health and psychiatric problems, which are in turn associated with high societal costs and death (Mokdad et al. 2004).

Abstinence is also associated with less “avoidance” coping styles, such as cognitive avoidance and emotional discharge, as well as more “approach” coping styles, such as logical analysis, seeking guidance, problem solving, seeking alternative rewards, and positive reappraisal (Carpenter and Hasin 1999; Chung et al. 2001; Finney and Moos 1995; Holahan et al. 2003; Moggi et al. 1999; Moos and Moos 2005).

Abstinence has generally been associated with reductions in illegal activity, incarceration, poverty, and improvements in vocational activity. Reductions in substance use are associated with relatively rapid reductions in illegal activity and illegal income (Dismuke et al. 2004; Scott, Foss et al. 2003).

Although this often involves some period of residential treatment or incarceration, such costs are typically offset by reductions in other costs to society, increased employment, and increased productivity (Bray et al. 2000; French, Salome, and Carney 2002; McCollister and French 2003; Rajkumar and French 1997; Single et al. 1998).

Abstinence is generally associated with being housed and having some friends, fewer problems in the recovery environment, and more personal, family, social, and spiritual support.

Risks (e.g., substance use among family, friends, and victimization) and protective factors (e.g., treatment and self-help participation, peers in recovery) in the recovery environment and self-efficacy to resist relapse were also among the major predictors of transitions from using to recovery and relapse (Humphreys, Moos, and Cohen 1997; Schutte et al. 2001; Scott et al. 2005b).

The general association between relapse and stress has also been found to be moderated by the extent of support one gets from self-perceived personal strengths, family, and social peers (Jessor, Turbin, and Costa 1998, Laudet et al. 2004; Miller 1998; Miller et al. 1996; Procidano and Heller 1983; Schutte et al. 2001).

We found no studies to date using the “duration of abstinence” to predict the likelihood of sustaining abstinence for another year. However, a recent extensive review by Moos and Moos (2007) found one or more of four dozen studies reporting that the odds of sustaining abstinence was positively associated with abstinence self-efficacy, approach coping styles, vocational engagement, income, having clean and sober friends, and having social and spiritual support and inversely related to an avoidance approach coping style.

Findings – This study demonstrates that duration of abstinence is related to changes in other aspects of recovery but at different rates and times.

Use of coping mechanisms started out high and decreased as the number of years of abstinence increased, suggesting that the high rates of these coping strategies previously reported by others (see Moos and Moos 2007) may actually be a characteristic of early abstinence. Mental health problems peaked during 1 to 3 years of abstinence and decreased thereafter.

The rapid decrease in illegal activity and illegal income sustained across varying lengths of abstinence was consistent with the literature given that many of the crimes were drug related. Following 1 year of abstinence, the number of days worked and legal income generated significantly increased and days with financial problems decreased. After 3 years of abstinence, there were also significant reductions in the percentage of families living below the poverty line, which indicates continued gains in financial status.

Consistent with the literature, the duration of abstinence was associated with reduced environmental risks and increased number of clean and sober friends, level of social support, spiritual support, and self-efficacy to resist relapse.

The odds of sustaining abstinence increased dramatically during the first 3 years and then leveled off. Among people with 5 or more years of abstinence, there was still some risk of relapse (14%) – but equally a 86% chance of remaining in recovery!

Consistent with earlier findings by Grella et al. (Grella, Scott, and Foss 2005; Grella et al. 2003; Grella et al. [in press]) that women were more likely to enter and stay in recovery.

Implications for Practice, Policy, and Research

Findings suggest the need for a shift from focusing on acute episodes of treatment to the management of recovery during longer periods of time.

Most of the drug abuse treatment research to date has focused on reducing days of use or abstinence in the first 6 to 12 months after treatment (Dennis and Scott [in press]; Prendergast et al. 2002). More health services research is needed on managing long-term recovery, both in terms of how to deliver it in ways that are both effective and cost effective for multiple years. This includes research on ways to integrate these other kinds of services, minimize some of the negative trends (e.g., the early peak in mental health problems), and accelerate the positive trends (e.g., more positive recovery environment and vocational activity).

Conclusion

Although much of the research on substance abuse treatment outcomes has focused on abstinence in the first 6 to 12 months after treatment, this article suggests that initial abstinence and the initial time period do not fully represent the changes associated with long-term recovery. This research shows that risk of relapse is particularly problematic in the first 3 years of abstinence and never completely goes away, suggesting the need for promoting strategies and programs that support the long-term management of recovery.

References

1. Dennis, M. L., Foss, M. A., & Scott, C. K. (2007). An eight-year perspective on the relationship between the duration of abstinence and other aspects of recovery. Evaluation Review, 31(6), 585-612.

So What is Recovery?

So, what does recovery mean? It is total abstinence? Is recovery strictly a question of substance use or is there more to it than that?

This study (1) addressed two primary research questions: (1) Does recovery require total abstinence from all drugs and alcohol? and (2) Is recovery defined solely in terms of substance use or does it extend to other areas of functioning as well?

Many of those in this study who defined recovery as abstinence went on to express the idea that using any mood altering substance would lead back to full-blown relapse.

Recovery meant  in descending order: a new life (22%), well-being (13%), a process of working on yourself (11.2%), living life on life’s terms (accepting what comes – 9.6%), self-improvement (9%), learning to live drug free (8.3%), recognition of the problem (5.4%), and getting help (5.1%).

“I’m in recovery myself because I want to stay clean. And I want to be a responsible person or responsible human being. To do what I was … what I should do or what God put me here to do. And, you know, I got to – I got to remain sober to do these things.”

“To me recovery means getting back what I lost. Myself. I am not talking about materialistic things. I am talking about me.”

“Recovery, I just.. What is it for me? It’s going back to me…

“My definition of recovery is life. Cause I didn’t have no life before I got into recovery.”

 

Qualitative data on recovery definitions provided by the 20.4% of individuals who did not consider themselves in recovery are particularly noteworthy as they echo some of the popular connotations the term ‘recovery’ carries in the general public. Some of the answers were expected, including those of individuals who may have never considered themselves in recovery (e.g., “I wouldn’t know how to define recovery because I’ve never been in it,” “I’ve heard of the term, but I don’t know. What is it? I guess, it’s being committed to being straight”), and individuals who may have relapsed (e.g., “it used to feel free and happy without using”).

About one third of the answers from individuals not in recovery echo the public’s perception that recovery means people are ‘trying’ to remain abstinent: “Someone who is currently on guard about falling off the wagon at any moment.” The idea that for some, recovery suggests a struggle with drugs and/or alcohol is further supported by a number of respondents who indicated that they are not in recovery because they are not experiencing drugs and/or alcohol problems; for example: “Recovery… I don’t know, a glass of wine ain’t nothing to me” and “it’s not a battle for me- I don’t have to recover from anything.” The connotation of recovery as a struggle with substance abuse problems and statements from participants who felt they had overcome their problem suggest that recovery is understood by some as having had a severe problem. This is consistent with the image of AA being a place only for ‘skid row drunks.’

The majority of qualitative recovery definitions among participants who didnot consider themselves in recovery indicated that a specific action … was a necessary part of recovery.

The bulk of the answers implying a specific recovery requirement, however, concerned needing or seeking help – getting treatment and/or participating in 12-step recovery: “Being in treatment and not using drugs or alcohol,” “Abstaining and seeking outside help.” Several answers suggested that recovery implies needing to seek outside help because you cannot quit on your own: “Having trouble quitting, needing help,” “when you get some help, like detox, a program or something-not when you just stop on your own,”…

Benefits of recovery – While participants’ definitions of recovery may speak as much to semantics (i.e., the use of the term ‘recovery”) as to their experience, answers about what is or would be good about being in recovery illuminate the recovery experience itself. Regardless of the term used,significant behavior change takes time, it is challenging and stressful.

The most frequently cited benefit of recovery, mentioned by one third of participants, is that it is a new life, a second chance (“like being born again, not living a state of denial, enjoying life better, whole new wonderful feeling, health, financially”); one quarter (23%) cited being drug-free; other benefits cited in were: self-improvement (22.7%), having direction, achieving goals (17.5%), improved/more positive attitude (17.2%), improved finances/living conditions (16.2%), improved physical and/or mental health (16.1%), improved family life (13%) and having friends/a support network (11%).

Recovery: Process or endpoint? –

One of the more controversial issues when speaking of ‘recovery’ is whether it is process (with no specific endpoint) or a state (i.e., whether one is ever ‘recovered”). This question has potentially critical ramifications especially in terms how recovery is perceived by the public and indirectly, in terms of stigma and discrimination (e.g., prospective employers who view recovery as a lifelong process may be more likely to not hire a prospective worker in recovery for fear he/she will relapse or be unreliable). Findings were reviewed earlier suggesting that the public defines recovery as an attempt to stop using drugs and alcohol, suggesting that it may not be attainable.

Thus while maintaining recovery may be a lifelong process (e.g., maintaining certain practices), it is important to determine whether or not the process is lived as having an end (being recovered). In the US, the view of addiction as a chronic disorder, paired with the strong 12-step influence (“once an addict always an addict”) would suggest that recovery is a never-ending process.

Participants made qualitative statements that speak to whether one ever ‘gets there” – i.e., becomes recovered, suggesting that consistent with the disease model of addiction, recovery is a process with no fixed end point, and that it requires ongoing work

“Recovery is getting back some sort of order in your life, the disease is in remission- it’s not a cure- it has to be maintained daily.”

“Recovery is somewhere people think they’re going to get to and you’ll never get there.”

“I don’t think you ever recover from it, it’s learning how to manage it, stay abstinent & become a productive member of society.”

“you’re never recovered, I mean, it’s always ‘gonna be back there.”

“I think recovery’s a process. Um… for me, it’s just always trying to better myself. Um… and realizing that there may not be an end point, but just a… you know, they always say, like, sometimes it’s better to go through it than to get there.”

“I’m still on this journey because there is hope, you know. There is not a cure. But there is hope.”

“And I keep myself in the right, atmosphere or attitude or what not because there is a whole lot to recovery, you know. It ain’t just getting sober and staying clean. It is like you gotta do a lot of work.”

 

Discussion

Prior exposure to treatment and to 12-step fellowships, both of which encourage embracing abstinence as recovery goal, was significantly associated with defining recovery as total abstinence. Interestingly, both individuals who do and do not consider themselves in recovery embraced abstinence as their definition of recovery. While substance users are often ambivalent about quitting drugs, individuals with a long and severe history of substance use who seek remission may come to the conclusion that total abstinence is required from personal experience with relapses and attempts at controlled use. Most failed remission attempts are based on moderation and abstinence proves more successful (e.g., Burman, 1997; Maisto, et al., 2002). Greater lifetime addiction severity was associated with endorsing abstinence, and some participants who did not consider themselves in recovery indicated that recovery implies struggling and/or needing outside help.

BACK TO ME: DISCOVERY AND RECOVERY

With respect to scope, recovery goes beyond substance use for most. This is consistent with 12-step tenets (e.g., “but sobriety is not enough,” Alcoholic Anonymous, 1939/2001, p. 83). Frequently used expressions to define recovery were ‘a new life,’ ‘a second chance,’ or, life itself. The verb “to recover” is defined as (1) to get back : REGAIN; (2) to bring back to normal position or condition; (3) to make up for; (4) to find or identify again; and (5) to save from loss and restore to usefulness: RECLAIM (Merriam Webster).

Several participants framed this notion as regaining something that was lost – the opportunity of becoming what they were meant to be before they started using drugs and alcohol (section 3.4.2). The Big Book expressed this as “We were reborn” (AA, 1939/2001, p. 63).

NO SUCH THING AS GRADUATING: RECOVERY IS A PROCESS RATHER THAN AN ENDPOINT

Reclaiming oneself is a process of growth and a process of change in attitudes, thinking and behaviors consistent with the rich descriptions and experiences documented by Stephanie Brown (1985).

Recovery as a process should not be interpreted as inconsistent with recovery as abstinence; rather abstinence (a state) is viewed as a requirement of the ongoing process of recovery.

The work of change is what distinguishes recovery from mere abstinence (“You could stop doing anything that you want. It’s about the change that comes in—into it, that’s the recovery part.”). The process aspect of recovery has been reported previously in studies conducted among alcohol- and drug-dependent samples both in the US and abroad (e.g., Blomqvist, 2002; Flynn et al., 2003).

A small-scale study of drug-dependent persons abstinent for an average of 9 years sheds light on the stages of the process(Margolis et al., 2000). Participants reported first passing through a phase almost solely focused on staying abstinent, particularly the first year. Only once this foundation (abstinence) was established could they concentrate on “living a normal life,” where abstinence was no longer the main focus.

Finally, following that transitional period, the individual enters late recovery, a time of individual growth and search for meaning. Our findings on the focus of recovery definitions are consistent with these stages: individuals in remission 18 to 36 months (the transition phase) were more likely to define recovery as a process whereas those in remission three years or longer were more likely to focus on the ‘new life’ aspect of recovery and less likely to define recovery in terms of substance use.

Recovered?

Conceptualizing recovery as a process leads to the question of whether one ever ‘gets there” – whether one is ever “recovered.” This is rarely discussed in scientific literature. Most participants regard recovery as “an ongoing process. There’s no such thing as graduating.” This is consistent with the disease model and with prevalent view of addiction as a ‘chronic’ condition (McLellan, Lewis, O’Brien, and Kleber, 2000; White, Boyle and Loveland, 2002); it is also consistent with reports that resolving addiction often takes multiple attempt and treatment episodes (e.g., Dennis et al, 2005; Laudet & White, 2004).

Other biomedical fields have reached consensus about what clinical ‘remission’ means (e.g., five years disease free in oncology). Whether and when SUD remission ever becomes ‘stable’ in terms of substance use (i.e., when the risk of return to drug use is minimized) remains somewhat unsettled.

Three to five years is the timeframe most commonly used (Finney and Moos, 1991; Flynn et al, 2003; Longabaugh & Lewis, 1988; Timko et al., 2000; Vaillant, 1983/1995) and it corresponds to the experiences of persons in long-term recovery (Margolis et al., 2000). While the risk of relapse does not completely disappear after three or even five years of continuous abstinence (e.g., Hser et al., 2001), it appears to be minimal (e.g., Vaillant, 1983/1995).

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Addiction is a chronic condition; there may not be a complete or permanent solution (i.e., the risk of relapse may remain for multiple years) but it can be treated and managed. There are many paths to recovery (e.g., Moos & Moos, 2005) but treatment is most often needed when dependence is chronic and severe.

Our findings suggest that for severely dependent individuals, recovery is a process of change and growth for which abstinence from alcohol and others drugs is a prerequisite.

McLellan and colleagues (2005) have made the argument that “Typically, the immediate goal of reducing alcohol and drug use is necessary but rarely sufficient for the achievement of the longer-term goals of improved personal health and social function and reduced threats to public health and safety—i.e. recovery” (p. 448). This conceptualization of clinical outcome is consistent with the World Health Organization’s conceptualization of health as “a state of complete physical, mental, and social well-being, not merely the absence of disease” (1985, p.34).

The question remains : whether we are willing to pay for positive health (wellness) oriented services for substance dependent populations is unclear.

Present findings suggest that the benefits of recovery are many (improved health, life conditions, social life etc.) and they are highly valued. Quality of life (QOL) among active users is poor and abstinence, especially sustained abstinence, is associated with QOL improvements (e.g.,Donovan et al., 2005; Foster et al., 1999; Laudet et al., 2006; Morgan et al., 2003).

Higher life satisfaction prospectively predicts sustained remission (Laudet, Becker & White, in press; also see Rudolf & Priebe, 2002) and low QOL may heighten relapse risk (Claus, Mannen & Schicht, 1999; Hoffmann & Miller, 1993). Thus the clinical goal of addiction treatment must go beyond fostering reduction in substance use to improving personal and social health.

The addiction field can seek guidance from the mental health field where…in a working definition set forth in the New Freedom Commission on Mental Health: “Recovery refers to the process in which people are able to live, work, learn, and participate fully in their communities” (2003, p.5).

How do clinicians foster recovery? Vaillant (1983/1995) described the conditions necessary to the recovery process as abstinence, substitute dependencies, behavioral and medical consequences, enhanced hope and self-esteem and social support in the form of unambivalent relationships. Persons in recovery consistently cite the support of family and peers (and the need to seek and accept support), spirituality, inner strength and the desire to get better as critical sources of strength (e.g., Blomqvist, 2002;Flynn et al., 2003;Laudet et al., 2002,).

Many clients initiate treatment due to external pressures (family, legal, employment) and may not be initially motivated for change; however, once in the therapeutic environment, even externally motivated clients (e.g., legally mandated) may reflect on their situation and accept the need for treatment (Kelly, Finnney & Moos, 2005). The cessation of substance use is often preceded by a period of cognitive preparation (akin to the contemplation stage Prochaska & DiClemente, 1992 – e.g., Burman, 1997and2003; Sobell et al., 2001); participating in treatment during this period may significantly enhances motivation for change by introducing the notion that behaviors and activities that are not drug-related could have healthier consequences and provide more satisfying reward possibilities (Burman, 2003), thus ‘raising the price’ of subsequent substance use and enhancing the likelihood of abstinence.”

 

There are also the financial implications of spending money on effective treatment for those who wish to recover rather than counting the cost of increased crime, prison sentences, extensive medical care,  etc etc. It makes economic sense to spend money in a preventative sense in addiction, as well as being simply a moral decision  to medically treat those who are chronically ill. First do no harm is part of the Hippocratic Oath. Can we say that spending huge amounts of money on harm reduction, controlled use programs, methadone scripts etc etc is actually “treating” alcoholics and addicts?

To quote Russell Brand, that is “like putting a sticking plaster on a broken soul” – it only sustains the problem not alleviating or treating the underlying conditions.

We can help society and families recover also from the effects of alcoholic and addict behaviour. Recovery involves improved well being for family and society members too.

We have to offer a chance to start over, to have access to a new life much better than we could ever have imagined.

Recovery cannot really be about giving you reduced amounts of whatever is poisoning you, ailing you. It cannot be about substituting one drug for another. Substituting one addictive behaviour for another. It cannot be about yet another chemical straight-jacket or prison.

Recovery has to be about getting better. Improving well being. This is what increased in health when a treatment is successful so why should it be different for addicts and alcoholics.

Many millions of people recover from their addictive behaviours, that is fact! We need to start getting this message out,  “We do recover!”

Recovery is much much better than drinking and drugging ever where. This is what we need to get across.

To be in a fairly constant state of contentment is priceless and something no drug could ever achieve!  

References

1. Laudet, A. B. (2007). What does recovery mean to you? Lessons from the recovery experience for research and practice. Journal of Substance Abuse Treatment, 33(3), 243–256. doi:10.1016/j.jsat.2007.04.014

 

No more Raining in my Heart.

I watched this video in early recovery to help me relate to the progression of the disease of alcoholism concept.

I could not get my crazy head around what the idea of “progression” was and how it could be possible?

Now I have, after years of research, found conclusive proof of this progression.

One way that demonstrates this to me is that a certain part of the brain is activated in line with addiction severity and is only activated in chronically addicted individuals.

This part of the brain the dorsal striatum, is implicated or said to be linked to automatic or habitualised action and behaviour.

For me it showed that the more chronic one’s addiction or alcoholism is the more this area activated.

In other words the activation of this brain region is linked to compulsive addictive behaviour and to the activation of automatic thoughts about alcohol or drugs (particularly when stressed/distressed). These thoughts happen to us rather than us having these thoughts. This is a crucial distinction.

This showed me clearly that this area of the brain, which is an unconscious part of the brain, when activated prompts behaviour with an accompanying greatly reduced knowledge addicts and alcoholics will have of the outcome of their subsequent behaviour.

It compels addicts and alcoholics to act with hugely reduced knowledge of likely outcome of their addictive actions, with chronically impaired knowledge of the negative consequences to follow. This may help explain why alcoholics and addicts relapse when they do not wish to and are well aware of the negative consequences which will ensue from relapsing.

It is also part of the brain implicated as activated in schema knowledge. It contains the addictive self schema and very importantly this schema contains justifying and rationalising schemata as it is also the only part of the brain which an individual subsequently has to or retrospectively (after the action) has to  justify or rationalise its activated behaviour because it often occurs automatically and without explicit or conscious awareness.

In other words, this is the only part of the brain in which one has to act in a post hoc manner to attempt to rationalise whatever actions have taken place. With more explicit parts of the brain one can engage in these conscious processes whereas this part acts implicitly and without much conscious deliberation so an individual has to then give a reason why they acted they way they did.

For me this tallies with the Big Book “the alcoholic at certain times has no effective mental defense against the first drink“. In other words the alcoholic has not explicit, reflective, or even conscious defence against the first drink. Until he/she realises what is happening in these relapse situations and accepts that this is effectively their alcoholism in action and then takes certain steps to treat it.

It shows how addiction is a neurobiological disease as motivation to act moves here or progresses here from the ventral striatum, which is more linked to substance abuse,  it is the increasingly severely impaired addicted brain that does the “thinking” for us or rather it is the addicted brain which acts, often during distress, as if it is under threat, in an emergency situation which demands an automatic action or behaviour.

It does not wait for more reflective or evaluative parts of the brain to get involved. The distress of endpoint addiction is the stimulus that provokes this compulsive, automatic responding.

Anyway, there is a guy in this whose drinking and severity of his alcoholism was similar to mine, he is the gentleman who in the end finally gets the solution to his problems via his starting to attend AA meetings.

There is a solution!! Please always, always remember that, there is a solution. And it can be found in most neighbourhoods or at the very beginning of the telephone directory.

It saved my life and can yours too! 

 

“Rain in my Heart”
Gritty, very real and heartbreaking, it is an upfront, unapologetic glimpse into the world of addiction and alcoholism.