Predicting Addiction/Recovery Trajectories
It has become fashionable by commentators in the addictions arena to point to research studies confirming three linked findings: 1) the course of alcohol and other drug (AOD) problems are highly variable rather than inevitably progressive, 2) the majority of people experiencing substance use disorders and broader patterns of AOD-related problems resolve these challenges without specialized professional care or mutual aid assistance, and 3) the majority of such resolutions occur through deceleration of the frequency and intensity of use rather than through complete and sustained abstinence. Those findings, drawn from studies of community populations, have been used to buttress attacks on addiction treatment, Alcoholics Anonymous and other abstinence-based mutual aid organizations, the conceptualization of addiction as a disease, and the characterization of addiction as a “chronic” disorder. There is within these critiques an implied underlying tone of moral indictment: “If such large numbers of people resolve AOD problems without the need for abstinence and professional assistance, then why can’t you?” The tone of moral superiority in which this question is posed suggests that such problems could be resolved if one would just “Suck it up and deal with it!”
The idea that some people can resolve alcohol problems on their own via an exertion of will is not a new one and is outlined clearly in the basic text of A.A.–authored before most contemporary critics were born. Such self-will and moderated approaches had not worked for early AA members, but AA made no effort to deny that option to others. In fact, AA took quite the opposite position.
Then we have a certain type of hard drinker. He may have the habit badly enough to gradually impair him physically and mentally. It may cause him to di a few years before his time. If a sufficiently strong reason-ill health, falling in love, change of environment, or the warning of a doctor-becomes operative, this man can also stop or moderate, although he may find it difficult and troublesome and may even need medical attention. (Alcoholics Anonymous, 1939, p. 31)
If anyone, who is showing inability to control his drinking, can do the right-about-face and drink like a gentleman, our hats are off to him. Heaven knows we have tried hard enough and long enough to drink like other people! (Alcoholics Anonymous, 1939, p. 42)
AA literature makes no claim that the collective experience of AA members constitutes a universal truth applicable to the broader universe of all alcohol problems. By distinguishing themselves (“real alcoholics”) from problem drinkers, early AA members defined their own recoveries in terms of abstinence and mutual support because that is what had been successful in their experience.
So if there are potentially two worlds of AOD problems reflected in the divergent conclusions of epidemiologists and clinicians, what separates those who naturally mature out of AOD problems without professional or peer support and those for whom AOD problems become prolonged, life-threatening medical disorders? Having closely observed both patterns for nearly half a century, I believe there exists a “clinical cluster” that predictively distinguishes those whose AOD problems are most likely to become the most severe, complex and enduring and that are less amenable to natural recovery and moderated resolution. This cluster includes the following elements:
* Family history of AOD-related problems
* Early age of onset of AOD use
* Euphoric recall of first AOD use
* Atypically high or low drug tolerance from onset of use
* Historical or developmental trauma: cumulative adverse experiences with traumagenic factors (e.g., early onset, long duration, multiple perpetrators, perpetrators from within family or social network, disbelief or blame following disclosure)–without neutralizing healing opportunities
* Adjustment problems in adolescence that contribute to adult transition problems, e.g., instability in education, employment, housing, and intimate and social relationships
* Multiple drug use
* High risk methods of drug ingestion (e.g., injection)
* Co-occurring physical/psychiatric challenges
* Enmeshment in excessive AOD-using family and social environments, and
* Low levels of recovery capital (internal and external assets that can be mobilized to initiate and sustain recovery).
Each of these factors constitutes a risk factor for the development of severe and prolonged AOD problems, but such risks are dramatically amplified when combined. Not everyone sharing such risk factors will develop severe and chronic addiction, and some lacking such factors will still experience prolonged addictions. Some in the former group will also resolve their AOD-related problems without professional or formal peer assistance. But addiction is a disorder of odds, and one’s odds of escaping addiction and achieving recovery without help from others decline in tandem with the accumulation of risk factors and the absence of factors that protect and promote resiliency.
In my professional experience, the prospects of natural recovery and problem resolution via moderation decline in tandem with the increased number and intensity of the above factors. The “apples and oranges” comparison problems can be minimized, if not transcended, if we realize that findings from studies of the resolution of AOD problems among persons without these risk factors cannot be indiscriminately applied to those who possess such characteristics, and vice versa!