Mechanisms of Change in Addiction Recovery Revisited
In an earlier blog posted in 2017, I offered some preliminary observations on mechanisms of change in recovery and the variation in such mechanisms across pathways of recovery, stages of recovery, clinical populations, and cultural contexts. A recent collaboration with Dr. Marc Galanter in designing a study to investigate such mechanisms of change among members of Narcotics Anonymous has stimulated further thinking about the precise catalytic elements that contribute to addiction recovery.
Mechanisms of change involve precise behaviors that when performed over time elicit radical changes in personal character and identity, personal lifestyle, and interpersonal relationships. They involve decisions, actions, and rituals that strengthen motivation for recovery, serve as building blocks of a recovery-centered lifestyle, and elevate the quality of personal and family life in long-term recovery.
Recovery-focused behavioral mechanisms (repeated actions) lead to intermediate processes that enhance recovery stability and the progressive movement towards global health and social functioning. Such intermediate effects include increased hope for recovery, increased self-confidence in achieving recovery, improved decision-making and coping skills, increased family and social support, and spiritual awakening (sudden epiphanies and turning points; clarification of values and life goals; increased life meaning and purpose).
In my earlier blog, I noted the following: “Addiction recovery involves processes of destruction, retrieval, and creation. Destruction entails breaking entrenched patterns of acting, thinking, feeling, and relating. Retrieval involves the reacquisition of lost assets. Creation requires new recovery-nourishing daily rituals, character traits, relationships, and reformulating life meaning and purpose. These recovery processes can be thought of in terms of subtraction, addition, and multiplication.”
Understanding the mechanisms of change in addiction recovery requires 1) identifying a menu of potential actions, 2) investigating which precise actions or combinations/sequences of mechanisms have the greatest potency and 3) determining how the use of these mechanisms varies across the stages of recovery initiation, recovery maintenance, and enhanced the quality and meaningfulness of one’s life in long-term recovery. A menu of potential change mechanisms could include such actions as the following:
__ Altering the frequency, intensity, or circumstances of drug use
__ Stopping all drug use
__ Seeking specialized addiction treatment
__ Seeking other counseling
__ Seeking treatment for other health conditions
__ Using prescribed medication to facilitate withdrawal and to reduce craving and drug-seeking
__ Using medication as prescribed to treat conditions that contribute to drug use, e.g., anxiety, depression, pain, etc.
__ Participating in face-to-face recovery support meetings
__ Choosing a home group / meeting for regular attendance
__ Participating in online recovery support meetings
__ Attending other recovery-focused events
__ Sharing my recovery story
__ Celebrating anniversaries of being drug free
__ Participating in the service structure of a recovery mutual aid fellowship
__ Reducing or ceasing contact with drug-involved friends and family members
__ Severing unhealthy, addiction-supportive relationships
__ Reconnecting with weakened or lost family and social relationships
__ Socializing with other people in recovery and people supportive of recovery
__ Reading recovery-focused literature
__ Reading other change-inspiring literature
__ Choosing and meeting regularly with a recovery sponsor / mentor / coach
__ Serving as a recovery sponsor / mentor / coach for others
__ “Working” recovery program Steps/principles
__ Working to improve coping and communication skills
__ Centering activities, e.g., praying, meditating, reflecting, journaling
__ Participating in recovery community center activities
__ Participation in religious services and practices
__ Participating in recovery advocacy and peer recovery support activities
__ Pursuing further education or training
__ Resuming old pastimes or cultivating new interests, hobbies, and pastimes
__ Helping others / acts of volunteer community service
__ Improving physical health (e.g., increased exercise, improved nutrition, regular sleeping schedule, smoking cessation)
__ Changing living environment
__ Relocating to safer and more recovery-supportive environment
__ Changing occupation or employment setting
Important research related to such mechanisms of change is progressing. Below are my predictions on what we will ultimately discover from these studies.
Mechanisms of change in addiction recovery include a core of essential mechanisms (without which recovery for most people is not possible) and a larger set of secondary and complementary mechanisms.
Such common factors are widely shared among people with diverse recovery stories, with some differences shaped by age of recovery initiation, gender, ethnicity, sexual orientation, primary drug choice, degree of problem severity, levels of recovery capital, and degree of religious orientation.
Mechanisms of change differ across stages of recovery, with some having greater salience in recovery initiation and others coming into greater play in the transition to recovery maintenance or enhancing quality of life in recovery. We will likely find variations in such effects across cultural contexts, where personal recovery must be integrated into a larger rubric of cultural values and rituals. Differences may also exist in these mechanisms across secular, spiritual, and religious pathways of recovery.
Particular combinations and sequences of actions will be identified that are particularly catalytic in recovery initiation or facilitating the transition from one stage of recovery to another.
The mechanisms of change (actions) in addiction recovery are woven together within two very different processes: story construction and storytelling. Those experiencing addiction, affected family members and friends, and those seeking to offer help all have a need for sense-making. There are numerous theories about the sources and solutions to addiction that become woven into personal and professional narratives that may or may not have anything to do with the actual processes through which such change occurs. The ultimate truth and the best news is that such change is possible and increasingly common. Behavioral prescriptions for recovery initiation, maintenance, and enhancement will become increasingly clear in future research on mechanisms of change. That is cause for considerable optimism and anticipation.