Stringy Expectations for #Addiction #Recovery

Proverbial Ball of StringHow long does it take to ‘get better’ after being impacted by an addictive behaviour, like a substance use disorder (SUD)?

Hard as I might try, I can’t easily bring to mind a larger more variable million-dollar question so, to coin that other well-known and appropriate idiom… how long is the proverbial piece of string?

In the landscape of addictions recovery and all flippancy aside, many people not least those who are struggling with their addictions, will (rightly) look for answers to the question; how long will it take you/me to change my behaviour(s)? What they often say is actually something along the lines of “how long will it take to cure/fix me?”

For all manner of valid reasons, mostly dependent upon the individual, it’s almost impossible to provide any finite measurement of recovery time-frames. Irrespective of the fact that being ‘fixed’ (or getting ‘cured’) is usually a consequence of an individual’s own actions and thought processes i.e. their responsibility, as opposed to under the ownership of somebody providing treatment and support… you really can’t ‘fix’ someone unless they want to be fixed.

For many, ‘getting better’ implies that addiction is (arguably) a disease or an illness but also (IMO), it tends to invoke a belief (in many) that the ‘illness’ is beyond their control… not so (in most cases), despite the known or perceived difficulties. But all that said, I have no desire to revisit that ageing and ongoing academic discourse about addiction being a disease or a lifestyle choice. I’ve done that previously (see here) and on several other occasions since.

Substance Use Disorder Defined

Substance use disorder (SUD) is defined in the DSM-5 guidance of the American Psychiatric Association as; “a compulsive pattern of drug use despite negative consequences. Both physical and psychological dependence are important parts of this disorder.” Alcohol, barbiturates, and benzodiazepines are central nervous system depressants that affect GABA neurotransmission.

Perhaps more simplistic is the common UK definition, as used by the NHS (amongst other agencies) says; “Addiction is defined as not having control over doing, taking or using something to the point where it could be harmful to you.”

Whilst considering that most ‘disorders’ involve a spectrum of physical/psychological impacts, my personal preference for defining addictive behaviour usually runs along the lines of; if your behaviour actually costs you more than money alone, despite that issue also being a problematic issue for many, it is probably costing you way too much!

Recovery Defined

The process of addiction ‘recovery’ as a concept, along with the word – recovery – as description of that process, has a long and chequered history. In many respects ‘recovery’ is a legacy of the prominent 12-step methodology, an aftermath of addressing the ‘disease model’ of addiction. However, the modern ‘recovery’ era (in Britain) finds its roots in the so-called ‘Recovery Agenda’ …created by ‘new’ Scottish and English Government policies, that were first delivered during the initial decade of the 21st century (around 2007-8).

Even ‘experts’ and the people with lived-experience of addictions are usually unable to envisage recovery in the same way. The definition of ‘recovery’ has been so contested but is also so crucial to funding and resource provision, that special commissions have been set up to try to reach a consensus.

Many words in the addiction field have been tossed around for years without being clearly defined or even being meaningful. “Recovered,” “recovery” and “being in recovery” are examples. In most of life, “being in recovery” means a person is making progress even though s/he isn’t “cured.” (Psychology Today)

The non-governmental UK Drug Policy Commission of 2008 put 16 ‘experts’ together to chew it over but even they couldn’t find agreement about a singular definitive wording. They did however agree to suggest ‘recovery’ (whatever it is or isn’t) can be characterised by an individual’s; “voluntarily-sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society” – crystal clear, got it?

But, what does it actually mean to be “in recovery’? The phrase ‘recovery’ is often so confusing that it becomes less than helpful. Little more than a stereotype ‘label’ or possibly a proudly worn badge of honour but one also one that often fails to equate with that individual’s persona or individual beliefs. A label that (often) fails to match a person’s levels of wellness and/or wellbeing.

Among the issues raised by the recovery agenda was the fundamental issue of whether we accept repeated and widespread post-treatment relapse, as a sign of the intractability (or as US guidelines have it, the persistence of drug-induced brain dysfunction) of addiction, or a sign that treatment, commissioners and planners have failed truly to embrace the changes needed to re-orientate to recovery. (Drug & Alcohol Findings)

This convenient and sometimes too freely used ‘recovery’ label can also become counterproductive for the efficacy of desired outcomes and goals.

Recovery Pathways & Process

It’s generally acknowledged that addiction ‘recovery’ is realised via varied and multiple pathways (see here). These personal ‘journeys’ can include various clinical treatments, harm-reduction interventions, a period spent in a residential rehab, elements of self-help, the support of mutual-aid groups and as is often the case; a  combination of all the above. And the more an individual can mix these processes with some additional wellbeing activities the better. Recovery journeys are as diverse as the individuals who tread the pathway.

Social Identity in Addiction Recovery

It’s unclear whether any particular demographic characteristics shape a person’s recovery journey. Or, whether particular recovery pathways are associated with improved long-term sustained well-being (see Australian Life In Recovery Survey). These research findings also suggested that; “people in recovery may experience high levels of well-being, irrespective of the pathway they take” however; “social factors may be influential in which pathways people take.”

A persons’ identity is replaced by negative self concepts, which have been associated with poor psychological well-being (Haslam, Holme et al. 2008). However, SIMIC shows that this effect can be reduced or moderated by certain social factors. Life changes do seem to affect some people more than others. (British Psychological Society)

Research around the Social Identity Model of Identity Change (see here) recognised that; although “maintaining social identities and support over time is good for health and well‐being, particularly during stressful transitions” perhaps it could also be harmful. Researchers examined the circumstances under which maintaining social identities – such as ‘substance user’ (or ‘in recovery’) – may also be harmful to health.

So, does successful transition from one social grouping (or ‘label’) always constitute identity change (for the better) or simply, serve to maintain the past problematic issues (in part) and the associated behaviours of that identity?

The ‘recovery journey’ is predicated on the idea of “substance user empowerment and self-determination” – Overcoming alcohol and other drug addiction as a process of social identity transition: the social identity model of recovery (Best et al 2015)

“The Social Identity approach offers a unifying framework for understanding recovery from addiction as a process of identity change, associated with change in social network composition.” Research findings (see here) highlighted the clinical importance of “assessing a person’s group-based relationships in treatment and early recovery.”

As the influence of social group norms have a correlation with substance use, surely ‘social identity’ grouping also presents impacts for behavioural change within any given social identity ‘labelling’? Could people who choose to overtly identify under a label – “I’m in recovery” – actually be doing themselves a disservice?

Irrespective of the justified personal pride about achievements and change, during an individuals ‘recovery’ journey; could the ‘in recovery’ label also be presenting additional social stigma? Could overtly lauding that process of personal achievement also present negative impacts, for a person’s ‘social identity’ or, serve to undermine the overall efficacy of their individual journey?

Treatment Service ‘Recovery’ Goals

As already mentioned, there is often some disparity around the desired ‘recovery’ goals of those individuals that are ‘in recovery’ and those people who are working to treat and support a diverse range of individual service-users. Sadly, some of this disparity finds its roots in the impacts presented by political direction and funding shortfalls born in austerity.

Generally, based upon my personal experiences and observations, across services in differing areas of the country;  I don’t see significant differences between what a service-user wants, and what their treatment clinician or key-worker are trying to effectively support i.e. escape from problematic addictive behaviours, to live a more healthy life.

Disparity in goals usually find their foundations in logistical factors like; funding impacts born of austerity, silo thinking and poor partnership working across stakeholders. Along with some inadequate or mismanaged system process. Sometimes these failings come from personal or organisational agenda factors, which is sad but in my experience, this is thankfully not the norm.

But, for many of the reasons already outlined, treatment and support services are often backed into a time constrained environment, where required ongoing support is limited. This clearly has an adverse impact for many who seek support with their addictive behaviours. Time allowed for ‘recover’ may be a finite resource, due to system based variables however; recovery will take as long as it takes for different individuals.

Your ‘Recovery’ Goal(s)?

How do you actually see ‘recovery’ as a process (for you) and importantly, what do you (as an individual) see as your personal direction? Do you see your ‘recovery’ as a new personal lifestyle status and perpetual social identity? Or, is your recovery journey merely a temporary life-phase, something that you intend to move forward from, irrespective of the timescale involved in your personal journey? What ‘recovery’ goal(s) do you want to achieve?

I would argue that; constantly dressing your social identity under an overt jacket of perpetual recovery (all be that a personal choice), also serves to develop something of a fake persona. Just like the materialistic person who constantly adorns themselves with sleek loudly labelled designer names, to press all the fashionistas’ buttons you are mostly creating an image for others, not yourself.

Recovery Tribalism

Irrespective of the fact we all need to connect (some more than others), with our peers and other humans, within supportive and protective social groups; self-worth, self-belief and self-empowerment usually doesn’t evolve from subconscious (blind) tribalism. We may feel that we have gained some acceptance or understanding from our labels (individual or designer) but, social grouping also serves to water-down and dissolve our individuality.

The Ultimate Recovery Goal

The key messages from the UK Life in Recovery survey (Best et al 2015) was; “recovery is attainable, is sustainable and is beneficial to a range of individuals and groups.” Irrespective of pathway choice and length of journey.

That said, as a society (and the diverse ‘recovery’ cohort within it), it’s helpful if we try to advance our individual understanding of the recovery process and concept. At the very least, in the context of what ‘recovery’ means for each of us as an individual, across our chosen social grouping, within our wider society.

We need to make sure that treatment and support structures are available for all who need them. Importantly, we also need to drive process that takes full account of individual needs. We need to offer pathways that are selected by individual service-users, as a direct result of their fully informed choice. People shouldn’t be expected to undertake any journey that is constrained by unrealistic time expectations.

Additionally, there is still a great deal of work required to… “reduce the stigma and discrimination that so many in active addiction and recovery experience” during their personal journey!

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