The Boundaries of “Recovery”
In 2007, I penned an essay published in the Journal of Substance Abuse Treatment (JSAT) on the definition and conceptual boundaries of addiction recovery. The essay was prepared for the Betty Ford Institute (BFI) Consensus Conference that produced its highly influential definition of recovery that was also published in JSAT in 2007 and subsequently updated in 2010. The BFI definition was followed by others in the U.S. (e.g., Center for Substance Abuse Treatment) and the U.K. (e.g., U.K. Drug Policy Commission)–reflecting the emergence of recovery as a new organizing paradigm in the alcohol and other drugs (AOD) policy and service practice arenas. Since that time, considerable discussion has ensued on the definition of recovery and its import for people seeking resolution of AOD problems, affected families, the professional and research communities, and AOD policy makers.
Work to date on defining recovery from addiction has focused on three essential ingredients. The first definitional element is resolution of the AOD problem, though disagreement continues over whether this requires 1) complete and enduring abstinence from ALL addictive substances, 2) reduction of AOD use and its consequences to subclinical levels (diagnostic remission), or 3) progress towards 1 or 2. The second recovery ingredient, focused on broader dimensions of quality of life, consists of measurable improvements in global health and social functioning. The third definitional element of recovery consists of positive changes in the person-community relationship–what the BFI consensus panel referred to as “citizenship” and the UK Drug Policy Commission referred to as “participation in the rights, roles and responsibilities of society.” While there is wide consensus that recovery is more than a dramatically altered person-drug relationship, consensus has yet to be reached on these additional defining ingredients and how to best measure the degree to which they are achieved.
Three recent developments are noteworthy within these ongoing discussions. First, a landmark survey of more than 9,000 people in recovery has just been published by Dr. Lee Ann Kaskutas and colleagues. The majority of those surveyed defined recovery in terms of 1) abstinence (no use of alcohol, non-prescribed drugs or misuse of prescribed drugs), 2) recovery essentials (e.g., self-honesty, drug-free coping, avoiding other destructive dependencies), 3) enriched recovery (e.g., personal growth and development, inner strength and harmony, social contribution, self-care), and 4) spirituality of recovery (e.g., gratitude, service, tolerance, self-transcendence). Of interest based on the discussion below is the minority position among those surveyed of what was NOT included in their personal recovery definition: no use of alcohol (5.5%), no misuse of prescribed medication (7.8%), and no use of non-prescribed medication (11.7%). More than a quarter of those surveyed believed that nonproblematic use of alcohol or drugs belonged or somewhat belonged in the definition of recovery.
A second development of note is the assertion of harm reduction perspectives on defining recovery. Ken Anderson, founder and CEO of HAMS (Harm Reduction, Abstinence, and Moderation Support), in a presentation at the 2014 National Harm Reduction Conference, challenged the traditional definition of recovery by asserting that, 1) recovery means “no impairment, distress, no problems,” which means that recovery can entail “abstinence or non-problematic use” and “that abstinence or a spiritual program are NOT requirements for being in recovery.” This view is further illustrated in a recent blog by Maia Szalavitz posted on substance.com. Maia asserts: “Addiction, as I see it, is compulsive use or behavior despite negative consequences–and if you have resolved that condition in any way that leaves you socially and occupationally healthy in a stable way, you are ‘in recovery’.” The question now being raised is whether abstinence is best viewed as the goal and defining essence of recovery or as one style of addiction recovery–and perhaps the style best suited for those with the most severe, complex, and chronic substance use disorders.
A third development is emergence of the question: Can people be considered “in recovery” “recovered,” or “recovering” from addiction when they continue to be dependent on a drug (nicotine) that continues as a major contributor to disease and death among those recovering from other drug dependencies? Interestingly, 32.5% of people in recovery in the study by Kaskutas and colleagues believed that no use of tobacco belonged or somewhat belonged in the recovery definition. This view dovetails efforts by David Macmaster and others to confront the role that the professional addiction treatment field and addiction recovery mutual aid organizations have historically played in enabling nicotine addiction. (I have outlined in earlier papers for people seeking recovery and for addiction professionals the research findings on the nicotine addiction morbidity and mortality among people seeking recovery from other drug dependencies.)
The personal stakes are high in this process of defining recovery. Everyone affected by and concerned about AOD problems should have a place at the table in which such definitions are forged. As I noted in 2007:
Imposed or self-embraced words that convey one’s history, character, or status have immense power to wound or heal, oppress or liberate. At a personal level, a definition of recovery will attract or repel people seeking to resolve AOD problems, provide a benchmark for when this state of recovery is achieved, and convey directly or indirectly what actions are required to sustain this status. A particular definition of recovery, by defining who is and is not in recovery, may also dictate who is seen as socially redeemed and who remains stigmatized, who is hired and who is fired, who remains free and who goes to jail, who remains in a marriage and who is divorced, who retains and who loses custody of their children, and who receives and who is denied government benefits (White, Journal of Substance Abuse Treatment, 2007, p. 230).
Efforts to define recovery within the AOD problems arena involve multiple dangers, including 1) defining recovery so broadly that the value of abstinence is obscured, particularly for those with the most severe AOD problems, and 2) defining recovery so narrowly as to deny the viability of alternatives to abstinence, particularly for those with less severe, developmentally transient AOD problems. Personal/family health and public health will be greatly enhanced by recovery definitions that address the whole spectrum of AOD problems and their available solutions.