Forgiving Others is the Number One Healer!?

“Resentment is the “number one” offender. It destroys more alcoholics than anything else… In dealing with resentments, we set them on paper. We listed people, institutions or principles with whom we were angry… The first thing apparent was that this world and its people were often quite wrong. To conclude that others were wrong was as far as most of us ever got. The usual outcome was that people continued to wrong us and we stayed sore. Sometimes it was remorse and then we were sore at ourselves. But the more we fought and tried to have our own way, the worse matters got…It is plain that a life which includes deep resentment leads only to futility and unhappiness…If we were to live, we had to be free of anger. The grouch and the brainstorm were not for us. They may be the dubious luxury of normal men, but for alcoholics these things are poison…We saw that these resentments must be mastered, but how?… (1)”

Later, p.77, it suggests  “a helpful and forgiving spirit.”

In the 12 Steps and 12  Traditions, p.78, in reference to step 8 it suggests “why shouldn’t we start out by forgiving them, one and all?

These truncated passages from the Big Book (1)  and the 12 and 12 (3) illustrates how resentments cause relapse and that they need to by treated with the antidote of forgiveness.

We suggest also that the myriad of resentments which swirl around our minds in early recovery are also negative emotions unprocessed and thus unregulated from the past. They continually haunt us because we have not put them “to bed” in long term memory.

We have not dealt with them, by clearly identifying, labelling, sharing via verbalising them with others and then by letting go of them via forgiveness. “Letting go” is another emotional regulatory strategy that healthy people use.

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Instead of constantly holding on to memories and incidents from the past, endlessly ruminating on them we maturely face up to them and consign them to the past.

We were thus interested in a study which was not using 12 step recovery but which came to the same conclusion but via another route (2).

“Anger and related emotions have been identified as triggers in substance use. Forgiveness therapy (FT) targets anger, anxiety, and depression as foci of treatment. Fourteen patients with substance dependence from a local residential treatment facility were randomly assigned to and completed either 12 approximately twice-weekly sessions of individual FT or 12 approximately twice-weekly sessions of an alternative individual treatment based. Participants who completed FT had significantly more improvement in total and trait anger, depression, total and trait anxiety, self-esteem, forgiveness, and vulnerability to drug use than did the alternative treatment group. Most benefits of FT remained significant at 4-month follow-up.

The levels of anger and violence observed among alcohol and other substance abusers are far higher than the levels found in the general population.

Alcohol and other substance abusers administered the State-Trait Anger Expression Inventory typically have been shown to have higher state and trait anger, to be more likely to express anger to others, and to have less control of their anger.

Reducing levels of anger and its related emotions is now seen as an important feature of recovery programs. For example, according to the Project Match 12-step facilitation therapy manual, “Anger and resentment are pivotal emotions for most recovering alcoholics. Anger that evokes anxiety drives the alcoholic to drink in order to anesthetize it. Resentment, which comes from unexpressed (denied) anger, represents a constant threat to sobriety for the same reason” (Nowinski, Baker, & Carroll, 1999, p. 83).

Marlatt (1985) emphasized the importance of anger and frustration as triggers for relapse in both the intrapersonal and interpersonal domains. He noted that 29% of relapses are related to intrapersonal frustration and anger and that 16% are related to interpersonal conflict and associated anger and frustration.

Litt, Cooney, and Morse (2000) reported that those alcoholics who had urges to use after treatment had higher degrees of alcohol dependence, anxiety, and trait anger than those without such urges.

Forgiveness is an important way to resolve anger and restore hope (Enright & Fitzgibbons, 2000). In helping clients move toward forgiveness, it is essential to differentiate forgiving from condoning, pardoning, reconciling, or forgetting.

Forgiveness is a personal decision to give up resentment and to respond with beneficence toward the person responsible for a severe injustice that caused deep, lasting hurt. FT helps the wronged person examine the injustice, consider forgiveness as an option, make a decision to forgive or not, and learn the skills to forgive.

Findings – Our clients came to the program with trait anxiety and trait anger scores substantially above the published norms for adults; after treatment, however, FT participants exhibited scores comparable to the average.  In other words, the treatment did not lead simply to a change in anxiety and anger (particularly the reportedly more stable trait anxiety) but to a change toward normal profiles. In contrast, patients in the alternative treatment condition had anxiety scores well above average, especially in terms of trait anxiety, which showed little change at post test and only minimal improvement at follow-up.

FT did not focus on drug vulnerabilities, whereas the alternative treatment did. Urges to use substances are not necessary for relapse, they are important indicators.

FT  treatment is centered more on clients’ thoughts, feelings, and behaviors about someone other than themselves: an offender who hurt them deeply and unfairly. In FT, a potential reason for substance use is examined, that of avoiding painful memories of betrayal, violence, or abuse. When patients are allowed to heal, their motivation to abuse substances may be substantially reduced…(it) is worth considering as a way to address core issues of emotional pain.

resentment

 

This can lead to a reduction in negative emotions and increases in self-esteem and forgiveness… it moves to the heart of the matter for some clients. Deep hurts borne out of unfair treatment seem to play a part in substance use and abuse. Even when clients have many people to forgive…we find that they seem to know which person is most crucial to forgive first before moving to other offenders. Substance use, from this perspective, is a symptom of underlying resentments and related emotional disruptions.

If we fail to realize this, we may end up treating only symptoms rather than underlying causes. ”

 

This process seems practically the same as the inventory of Step 4 and the forgiveness implicit to steps 8 and 9. This study also highlights that we through forgiveness we actually tackle the underlying condition of emotional dysregulation. It is this emotion dysregulation (or spiritual disease) which appears to drive addiction so needs to be fundamentally addressed. By addressing these issues via the steps especially step 4 we begin to see how it works!

It was interesting that forgiveness led to higher self esteem, as if being tied to the past was akin to being tied to a former negative self schema, that people from our pained past did actually have the power to control us! Especially how we feel about ourselves. We change how we feel about ourselves and our past by simply forgiving, it is such a powerful tool in recovery.

Importantly by viewing studies like this (2)  we get beyond negative views of 12 step recovery to show that the recovery program’s effectiveness is clearly highlighted by the success of other psychological treatments getting the same positive results by using exactly the same strategies.

12 step groups provide a battery of the most profoundly effective psychological therapies for addiction ever contained within one treatment philosophy.

Don’t we all need to re-appraise how we see 12 step recovery?

Can’t we all benefit from stepping to one side and looking via a different angle to see why 12 step recovery is effective?

 

Reference

1. Alcoholics Anonymous. (2001). Alcoholics Anonymous, 4th Edition. New York: A.A. World Services.

2. Lin, W. F., Mack, D., Enright, R. D., Krahn, D., & Baskin, T. W. (2004). Effects of forgiveness therapy on anger, mood, and vulnerability to substance use among inpatient substance-dependent clients. Journal of consulting and clinical psychology, 72(6), 1114.

3.   Twelve steps and twelve traditions. (1989). New York, NY: Alcoholics Anonymous World Services

Healing Communities via Recovery

Recovery is healing. From the personal to the communal. Here is a great example of recovering in recovery communities. It illustrates how recovery is a gradual move from isolation from,  to commune with other people.

We recover via communal contact and interaction with others. It is the new “secure attachment” with others which helps heal and also repair the neurobiology impaired by addictive behaviours.  It helps heal not only us but also our families and the communities we belong to. Love is the drug for me (and us).

The Healing Power of Recovery – Connecticut  Community of Recovery – how community recovery also helps individuals overcome feeling stigmatised by their condition and can feel more encouraged to seek treatment for their addictive behaviours.  So in a sense we can see recovery communities are passing the message of recovery on to others by putting a “face on recovery” acting as role models of recovery. Attraction and promotion.

For me this recovery community is showing the world “how it works” in a sense, the collective wisdom of recovery we often share among ourselves in recovery meetings but now share this with the wider society; this is what we got and what you can have.   We will help you get it too if you want it. This is how we all get better, recovering together.

 

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: “RecoveryI 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