Our time would be better spent trying to help people recover in whatever way is most effective for them rather than pushing and shaming everyone into one particular recovery pathway.
I’ve lost count of the number of times I’ve heard someone say that a person might be sober, but that they’re not in recovery, or describe them as a “dry drunk,” because the person doesn’t attend some defined program of recovery. I find that attitude divisive, dogmatic, and unhelpful, particularly because it shames others to believe in only one gold standard of recovery. This simply isn’t true. And it’s harmful; we have too many people dying of substance use disorder. Our time would be better spent trying to help people recover in whatever way is most effective for them rather than pushing and shaming everyone into one particular recovery pathway.
This kind of mindset originates from 12-step fellowships — where members often believe that these programs, combined with abstinence, are the only effective way to recover — and from the outdated professional definition of recovery provided by organizations like the American Society of Addiction Medicine (ASAM). However, with the emergence of recovery science, this outlook is beginning to change. Leading researchers are painting a much broader, more inclusive picture of recovery. Instead of accepting dogmatic perspectives, we can now turn to science, which shows us how people recover, the impact of the language we use, the complexities we face as people in recovery such as trauma and co-occurring disorders, and offers more cohesive definition of recovery.
In 2005, according to ASAM: “A patient is in ‘a state of recovery’ when he or she has reached a state of physical and psychological health such that his/her abstinence from dependence-producing drugs in complete and comfortable.” Over the years, this definition has evolved. Other thought and policy leaders in addiction recovery have also updated their definitions, including the Betty Ford Institute (2006), William L. White (2007), the UK Drug Policy Commission (2008), the Scottish government (2008), the Substance Abuse and Mental Health Services Administration (SAMHSA, 2011), researchers John Francis Kelly and Bettina Hoeppner (2014), and the Recovery Research Institute (2017).
One of the most popular definitions, and one I’ve favored as a writer in this field, is SAMHSA’s: “Recovery from mental disorders and substance use disorders is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” What I like particularly is that SAMHSA doesn’t define how someone should recover and they have no opinion on abstinence or the use of medication in the process of recovery.
Cognizant of the varying definitions and the lack of general consensus among experts in the field, recovery scientists and professionals from across the country came together to formulate a new concept. The Recovery Science Research Collaborative (RSRC) met in December 2017, evaluated various definitions of recovery, and reviewed essential components of recovery in order to more clearly define the process.
I spoke with Robert Ashford, one of the recovery scientists in the collaborative, about the process of formulating a new definition.
The Fix: What would you say were the main limitations of previous definitions that led to your aim to define a new concept of recovery?
Robert: We were hoping to bring together our understanding of recovery with the real-world empirical and practical evidence. Our desire for inclusivity was due to the high prevalence of co-occurring disorders (mental health and substance use disorder (SUD)) and the lack of inclusion of non-prominent recovery pathways (e.g. medication alongside abstinence modalities). We wanted to give the individual autonomy in self-directing their recovery process, both with and without clinical and other professional or peer recovery supports.
In reaching a consensus for a new definition, what were the main components that were critical to include?
It was a direct reflection of previous work describing the contention in recovery definitions, both real and perceived, by those in different “recovery” camps and between mental health and substance use disorder. Personally, I don’t believe recovery is reserved for the most severe and symptomatic individuals. If we conceptualize recovery as a series of interpersonal growth stages over time and in different settings or contexts, then recovery is a broad phenomenon that can apply to a range of issues. Our definition allows this to exist as a self-directed and intentional process that frames recovery as different in approach, style, and intensity depending on the range of diagnosis. Perhaps a good way to frame this, within the context of a continuum of SUD, is that recovery is also possible along a continuum that is proportional to the severity and type of SUD (mild, moderate, or severe), with most not needing to ascend along that continuum completely.
Our definition: “Recovery is an individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness.”
One of the main disputes within the recovery community is the belief that “true” recovery means complete abstinence. How did this belief factor into your discussions? And what would you consider to be the challenges of such a point of view?
I think the field at large stands to benefit, at least from an empirical perspective, because not having the focus solely on abstinence allows us to capture, estimate, and perhaps even predict, recovery in different pathologies, different severities, and at different life stages. This recovery typology is only possible with an inclusive definition in mind. The advocacy community also stands to benefit. Inclusive definitions allow the size of the population, or the prevalence of recovery, to increase — which is a good talking point and a strong policy lever for behavioral health. There is a potential for the “watering down” of recovery for the most severe of cases and for those traditionally following an abstinence modality, but this potential is moderated in my mind through the potential benefits.
At the end of the day, abstinence shouldn’t be excluded from the idea of recovery, but it should be situated where it best fits — as a potential outcome for a person who needs it. The definition of recovery can expand without diminishing those who are in abstinence-based recovery, and the expansion doesn’t negate anyone. If anything, not doing it negates the reality of millions of people seeking wellness.
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