The Addiction Files: How Do We Define Recovery?

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America’s most visible portraits of recovery from addiction are not pretty. There’s the spoiled, out-of-control celebrity entering rehab to get a career boost (see Lohan, Lindsay), or to atone for bad behavior (see Gibson, Mel), then immediately relapsing into even more trouble. According to a 2004 poll conducted by the recovery advocacy group Faces and Voices of Recovery, most people think of recovery as the attempt — and typically, failure — to get well.

In celebration of Recovery Month this September, Healthland will begin exploring the real nature of recovery, in a series of conversations with researchers and others at the forefront of the addiction field. Over the last 20 years, new research on addiction has overturned old dogmas about recovery. Now, after long-standing resistance to change, the addiction-treatment establishment has begun to reconsider its fundamental nature.

Does successful recovery require time spent in rehab or in a 12-step program like Alcoholics Anonymous? Can an alcoholic who continues to drink in moderation be considered “in recovery”? What about a heroin addict who has quit illegal drugs, but drinks socially in healthful amounts? (More on Time.com: Is Drug Use Really on the Rise?)

My first conversation was with William White, a senior research consultant at Chestnut Health Systems, an addiction and mental health services provider in Bloomington, Ill., who is himself in long-term recovery from methamphetamine addiction. He is also a noted historian of the addictions field and the author of one of the most comprehensive and compelling histories of American addiction treatment, Slaying the Dragon (1998).

In 2007, White served on a consensus panel convened by the Betty Ford Institute to create a new definition of recovery. That consensus definition — to which White has offered a slight modification — is increasingly accepted in the U.S. and around the world.

Q: Why convene a consensus panel on recovery?

A: When the Betty Ford Institute was created, one of things it wanted to do was focus on critical issues within the field. What was clearly evident in the early discussions was that there was a shift from focusing on pathology and interventions to a broader vision of recovery as an organizing framework.

There was an emerging recovery language — things like “recovery management” and “recovery oriented systems of care.” [There was a growing recognition of] the diversity of recovery pathways. People were calling for research on recovery.

The idea was that we were shifting to a recovery-focused agenda and no one had any definition of what recovery is. (More on Time.com: Drug Use in the Over-50 Crowd Doubles)

Q: What definition did the panel arrive at?

A: The Betty Ford Institute consensus [pdf] ended up [saying that recovery "is a voluntarily maintained lifestyle characterized by] sobriety, personal health and citizenship.”

Q: What do “personal health” and “citizenship” refer to?

A: If you go into any recovery fellowship, even within AA, there is this concept of a “dry drunk.” [If someone is a dry drunk,] the family will say, “I liked him better when he was using.” What they’re talking about is that the elimination of the alcohol and drugs provides an opportunity for a transformation of character to unfold — sometimes quickly, sometimes it takes forever, sometimes it never occurs. People count their clean days because they see everything else as contingent on that.

Bill Wilson, [the co-founder of Alcoholics Anonymous,] wrote about “emotional sobriety,” this idea that recovery is more than just the elimination of alcohol and other drugs from an otherwise unchanged life.

If you look at the literature, it’s all got some notion of moving toward global health and better quality of life.

Q: Why should citizenship matter to recovery from addiction? We don’t expect patients with diabetes to become nice people in order to recover.

A: We did say, “Wait a minute are we creating arbitrary standards for recovery that we don’t apply to other disorders?”

Here’s what we talked about: we don’t apply that to diabetes because there’s nothing that we know that so transforms personal character and violates relationships to the community [as addiction]. In addiction, there is this sort of gutting of relationships and there are wounds that one inflicts on the community.

There needs to be a nexus between what the disorder does and what recovery is. If the community gets wounded by addiction, then recovery must somehow involve some kind of reintegration.

Q: So someone who drinks moderately, is productive and is a good citizen would be in recovery. Dan Bigg of the Chicago Recovery Alliance defines recovery as “any positive change.” What do you think about that definition?

A: If you don’t have any boundaries about what recovery is, then the term ceases to have any meaning. If we proposed to define recovery from cancer by any sign of progress, people would think we were out of our minds.

We tried to [convey some of that idea, however]. I’m proposing that we use the terms “partial recovery,” “full recovery” and “amplified recovery,” because some people get far better than well.

If someone has been completely abstinent for x amount of time, is clearly in remission, but his life is a bloody shambles and no one wants to spend more than two seconds with him, that’s partial recovery — even if the person may claim to have 30 years of recovery.

Q: By the consensus definition, would someone who is taking a prescribed medication to treat addiction, like methadone or buprenorphine, for long-term maintenance be considered sober?

A: Yes. That was a pretty powerful declaration coming from that kind of an institution. [The Betty Ford Center has traditionally viewed total abstinence and 12-step participation as essential to recovery.] I think there’s going to be a whole re-evaluation of methadone in the next decade.

Q: How is your own definition of recovery different from the consensus definition?

A: The only nuance I have [that is different] from the Betty Ford Institute consensus is that [I use the word] remission [instead of sobriety], and that includes deceleration of use, particularly for those with lower problem severity. The research shows that people whose problems with alcohol or other drugs that were not that severe are more likely to be able to successfully [moderate, rather than quit entirely]. (More on Time.com: The New Drug Crisis: Addiction by Prescription)

Q: What role does choice play in recovery?

A: We’re still trying to figure out a whole philosophy of choice. People need to have choices relevant to their pathways to recovery. But how do you talk about a philosophy of choice, when traditionally, people in AA said [sarcastically], “Your best thinking got you here.”

This is part of the frontier we’re working on right now. It’s quite exciting. Where does a philosophy of choice fit in terms of your stage of recovery? If addiction means being robbed of choice, at what point do I regain the power to make choices, at what point do I become a free agent where I really can [make good decisions for myself]?

Q: I’m uncomfortable with that idea because I don’t think the data supports the notion that addicts can’t really make any free choices. And it also supports treating people like children, making their choices for them and behaving in a disrespectful and coercive fashion.

A: I think there are two ends of a continuum. The other end is to see the addict as a completely free agent: “O.K., go kill yourself.” There is a continuum of volitional control.

Q: But when about half of patients in addiction treatment are forced into it by the criminal justice system, how can you really even talk about choice?

A: As long as the criminal justice system as is a feeder to [treatment], why do treatment centers need to worry about choice and attraction of people into treatment? It’s sort of like the client right now in addiction treatment is not the person with addiction, but the institutional referral sources.

That’s why the third tenet in the consensus definition is that recovery is voluntary. That was sort of a very important kinetic idea: you can mandate treatment all you want, but there’s no such thing as mandated recovery by definition.

Of course, to say that recovery is voluntary doesn’t discount that there may be some therapeutic effect for some people in coerced treatment. We don’t find a lot of differences in outcome between coerced and voluntary clients. You can initiate abstinence or my definition of recovery under external pressure, but long-term recovery can only be sustained by voluntary choice.

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