What is recovery? | Frameworks #2

Beyond stopping, beyond lack?

(this is post #2 of a series on recovery frameworks. to see post one, click here)

Blaise Pascal studying the cycloid, Augustin Pajou, 1785, Louvre, public domain

In every person, according to 17th century polymath Blaise Pascal, “the infinite abyss can only be filled by an infinite and immutable object, that is to say, only by God himself.” Filling this “God-shaped hole” has long been a central metaphor in addiction recovery: not just ending addictive behavior but also working toward thriving and well-being as essential components of the work. It’s been maddeningly difficult, however, to clearly define what “recovery” actually means.

I mentioned in my last longer-form post that I’m interested in frameworks for making sense of recovery, including defining recovery rigorously without grasping for too much certainty. A good starting point is actual definitions of recovery from professionals and researchers over the years. This has been a monumental undertaking, so I’ll put the more technical discussions in the footnotes and try to stick to what matters most to me and my work with patients. This post got longer than I thought! That’s the fun of a newsletter, I suppose, and I hope Rat Park will be a place to learn and think out loud, so let’s give it a shot and let me know what you think. These concepts are crucial for addiction research, treatment, and policy, not to mention the way people make sense of themselves, so I hope it’s useful.

So again, for decades, some of the best thinkers in the field have repeatedly dashed themselves against the walls of this impossible task of defining recovery. It is impossible, in part, because they are trying to take a concept and term that arose out of a particular time and place—i.e., mid-20th century 12-step recovery—and refashion it into something more inclusive and accessible. This is a worthwhile project, because we know after decades of research that people resolve their addictive behaviors in many different ways, not just through 12-step recovery. But the devil (or devil-shaped hole?) is in the details.¹

What is recovery? There can never be a simple, satisfying definitional answer to the question, at least not in the sense of a technical definition that works well across clinical, personal, policy, and research domains, just to name a few. But some of us still need to say something about recovery, sometimes, and it can be useful if done carefully. I also find it rejuvenating, for my own recovery, to use these types of definitions as a spur for thinking about my aspirations for recovery. In the same way that we all want to be happy, but we often find ourselves chasing after lower pleasures that don’t actually work for us, we can be misled by incomplete conceptions of recovery. It’s good to take stock from time to time.

It’s also important to note that even among people who have overcome significant substance problems, not all identify with the recovery label. In the best survey research we have, out of people who report having resolved a significant alcohol or other drug problem, just under half (46%) self-identify as “in recovery.” There are people who identify as having suffered from addiction—who have gone through hell, really—and who now feel quite stable, but who don’t feel any need to define themselves in the language of recovery, thank you very much. Previous podcast guest Zach Siegel is one of these folks, as far as I understand him, in part because he feels that “in recovery” is shorthand for traditional, 12-step-based recovery, with which he doesn’t identify. There are also people who shy away from claiming a recovery identity because they feel they “don’t deserve it;” they believe that recovery necessarily implies a more elevated or completed outcome, one they perceive themselves to be falling short of. Now, I don’t think anyone should adopt the label if they don’t want to, of course, but these examples strike me as missed opportunities, especially the latter cases. There are more inclusive and accessible notions of recovery out there.

Let’s take a look at some of the main ways people have tried to answer the question, “What is recovery?” and let them illustrate some main questions and themes.² If you’re contemplating the meaning of recovery, for your own recovery journey, or a clinician working through how to talk about recovery with your patients, I hope this is helpful. Recovery is hard to define, but in the end I think that difficulty is a good thing. The questions are where the most wisdom resides.

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“A voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.” -Betty Ford Institute 2007

This is not the first attempt to define recovery, but it’s as good a place to start as any. The Betty Ford Institute, at the Betty Ford Treatment Center, generally considered a stalwart example of traditional 12-step rehab, convened a “consensus panel” almost 20 years ago that proposed an influential definition.³ There’s a lot we could unpack here, but let’s start with just two themes:

Sobriety: One key tension is whether addiction recovery necessarily requires abstinence, and if so, what kind of abstinence? Is recovery status in any way conditional on an outcome or status, what someone puts in their body? The earlier generations of recovery definitions insisted on this, such as the Center for Substance Abuse Treatment in 2005 (“…a process of change through which an individual achieves abstinence…”) and the American Society of Addiction Medicine’s recovery definitions in both 2005 (“…such that his/her abstinence from dependency-producing drugs is complete and comfortable.”) and 2013 (“…individual’s consistent pursuit of abstinence...”). Generally, definitions have softened on this point somewhat over time, but not in all cases.

Of note, the panel chose the arguably open-to-interpretation term “sobriety” rather than abstinence, but in subsequent writings, members were clear that they meant sobriety to be synonymous with abstinence from alcohol and “all nonprescribed drugs.” But even abstinence is open to interpretation. What about tobacco? Coffee? There are also people with behavioral addictions who struggle to create such a clean binary.

Citizenship: Many recovery definitions talk about community as a relatively abstract factor of health, such as increasing “social well-being.” A few others, like this one mentioning “citizenship,” go beyond simple community inclusion or integration and invoke a particular type of relationship or even obligation to the community. Even more to the point, the Scottish Government’s 2008 recovery definition was based on people moving “towards a drug-free life as an active and contributing member of society.” Is it always best to conform oneself to a given society’s values and expectations? Krishnamurti said, “it is no measure of health to be well adjusted to a sick society.”⁴

To my ear, the addiction recovery discussions that invoke citizenship or related concepts tend to individualize the problem and focus too much on the imagined moral shortcomings of people with addiction.⁵ A fuller and more balanced notion of citizenship in recovery would also consider the responsibilities of society to suffering people. It goes both ways. The Yale researcher Michael Rowe has long worked on citizenship in regard to general mental illness, and a key concept is the “5 R’s:” a dynamic experience of connection with a person’s rights, responsibilities, roles, resources, and relationships. Citizenship, in this view, means people should be able to grow, learn, and exercise their capacities at baseline. As long as this is not the case, because of structural oppression, lack of access or care, or otherwise, it feels perverse to focus on how the person with addiction is not fulfilling their responsibilities to conform and contribute.

“A process of self-directed change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential.” -SAMHSA 2012

Just wellness: the Substance Abuse and Mental Health Association is an important agency within the Department of Health and Human Services. Their 2012 definition was the result of a significant effort involving people from both the mental health and addiction recovery communities, and the result is a broad, holistic, and unfortunately somewhat diffuse definition that sounds to my ears like “just wellness.” It’s not clear how this doesn’t just degrade into the overall set of general wellness and positive psychology practices, and therefore lose anything distinctive about the experience of recovery. The main question this definition evokes for me is: what exactly is distinctive about addiction recovery, and how do we articulate it?

“A process of sustained action that addresses the biological, psychological, social and spiritual disturbances inherent in addiction.” -ASAM 2013

This is only the first part of a long American Society of Addiction Medicine definition from 2013. It solves the problem posed by the SAMHSA definition by explicitly naming recovery as a process in reaction to addiction. Similarly, one Recovery Research Institute definition from 2017 is: “the process of improved physical, psychological, and social well-being and health after having suffered from a substance-related condition.”

Spirituality: I started with the Blaise Pascal quotation above to suggest the intertwining between religion and recovery. Sometimes the word “spirituality” actually makes it out into the open, as in this case, but even when unnamed, it’s often there, implicitly. There is a place for discussions of spirituality in medicine, but we should be careful.

We have solid research on how large groups of people who have overcome addiction themselves define recovery. A notable survey of more than 9,000 people revealed that nearly 1,000 of them, belonging to the "secular class," do not see spirituality as essential to their recovery process. A large portion said “recovery is physical and mental in nature and has nothing to do with spirituality or religion.” Does the wording of this definition imply that spiritual disturbances are necessarily a part of addiction? Shouldn’t we as medical providers be sensitive to the concerns of people who are averse to spirituality talk? More broadly, shouldn’t we be careful as a profession to be clear about our role as just one approach to suffering, among many other approaches and social domains?

I don’t intend to pick on the notion of spirituality, or on ASAM, which I like quite a bit. That same survey found a large number of recovery “traditionalists” for whom spirituality is central. We may not want to consider spirituality a required component of recovery, but we may not want to exclude it either.

“an ongoing dynamic process of behavior change characterized by relatively stable improvements in biopsychosocial functioning and purpose in life” -Witkiewitz et al, 2020

Wellness plus: This definition is a good example of recent attempts that focus mostly on well-being, without much (or anything at all) about changes in drinking/using or achieving abstinence, but with some further specific clarifications that are pretty useful. Another similar approach comes from the Recovery Science Research Collaborative, 2018: “Recovery is an individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness.”⁶ Some critics would like these definitions to talk more explicitly about prior problems with addiction, as discussed above, but leaving that point aside, there’s a lot to like here. I appreciate the overt acknowledgement of recovery as an individualized and heterogeneous process in the RSRC definition in particular. It’s also good to clarify that it’s intentional—you can’t be in recovery unless you say you are, I would think.

I want to bookmark this and say that these notions of “biopsychosocial functioning” and “wellness” need to be further explored; I’ll plan to talk more about that in my next post.

“Recovery is a dynamic process characterized by increasingly stable remission resulting in and supported by increased recovery capital and enhanced quality of life’’. -Kelly and Hoeppner (2014)

Remission/clinical terms: John Kelly and Bettina Hoeppner are leading recovery researchers, and this definition comes from a very good theory paper proposing that we think about addiction recovery along two axes: stopping problems on one axis, and recovery capital (i.e., internal and external resources) on the other.

A reader commented on my prior post that definitions of recovery “should incorporate a changed relationship with the destructive behaviour (transforming your substance use, gambling, etc.), but also a cessation of unwanted negative consequences connected with the behaviour. In clinical terms, remission is not recovery, but (full) recovery should include remission.” That’s a nicely put general principle: cessation, including a changed relationship to the addictive behavior, as a necessary but not sufficient condition for recovery. What I want to look at more closely is the challenge of defining “cessation.”

As the writer acknowledged, the second sentence of their comment uses the clinical term “remission.” That word comes up in the Kelly and Hoeppner definition above, and other definitions too, such as the NIAAA’s recent definition of recovery (2022): “a process through which an individual pursues both remission from alcohol use disorder (AUD) and cessation from heavy drinking.”

Remission is a clinical term; using the word suggests that the definition of recovery is somehow pegged to a medical term found in the psychiatric Diagnostic and Statistical Manual of Mental Disorders (DSM), which is not defining addiction but the psychiatric concept of “substance use disorder.” There’s a lot that can be said about the difference between addiction and SUD, but at a first pass, I’d suggest that addiction/recovery is generally a self-chosen identity, whereas AUD/SUD refers to a psychiatric diagnosis that, while containing certain subjective criteria, can ultimately be made from the outside, objectively, by a qualified professional or instrument operating within a particular social domain. “Addiction” and ”recovery” are words with deep, rich, humanistic resonances that sound across a variety of social domains, not limited to medicine. In contrast, “substance use disorder” and “remission“ are terms of art specific to medical research and practice; they are attempts to operationalize human suffering in a way that increases consistency, intelligibility, and all the other worthy pursuits scientists are working toward.

We must be careful about conceptual creep across those domains. More to the point, I’d argue we can get into trouble when we implicitly or explicitly tie recovery definitions to medical definitions, unless we’re trying to subsume recovery under medicine, which would be hubristic and misguided. Recovery is more than a medical phenomenon, just as mutual-help recovery is not a kind of “treatment.”

Process/outcome: Kelly and Hoeppner use the word “process;” so do many others. Some definitions, like the NIAAA’s, say recovery is both a process and an outcome (specifically, “a process through which an individual pursues both remission from AUD and cessation from heavy drinking”… but also “can be considered an outcome”). I find this deeply confusing. If someone is ”pursuing” cessation, do they qualify as in recovery? Is the simple intention to change—the desire to stop—enough to qualify as a pursuit? If so, why all the talk of remission and heavy drinking cessation outcomes? The NIAAA paper is trying to operationalize recovery for their own purposes, as scientists need to do, but the process/outcome talk has got my head hurting.

I’m not sure this binary between process and outcome is the right way to go. Let me try to illustrate from my own life.

When I say that I am in addiction recovery, I mean the following: I had a problem with alcohol and other drugs that was severe enough to cause myself and some others a lot of harm. I stopped. In the process of stopping, I realized that in order to truly get better, meaning not only to prevent relapse but also to feel some modicum of comfort in my own skin and to work toward right relationship with others, I had to continue a certain kind of work on my development which felt simultaneously part of and also beyond my history of substance problems. Today, even while abstinent from the substances that were most problematic for me, recovery still feels like a useful and necessary project, so I continue to claim the label. In that way, to say I am in recovery is not just an outcome or process but also a way of choosing an identity. It is not just a change in behavior but a change in self-concept. The real sticklers among you might ask, can there be a “process” of changing self conception? OK sure, but in keeping with a lovely comment on my last post, notions like ”self“ and ”identity” are often conspicuously missing from discussions of addiction and recovery.⁷

There is a theory of value that comes from analytic philosophy that says that assertions of value are “emotive,” expressing one’s attitudes and emotions, not anything meaningfully true. It’s also called the “boo/hurrah” theory: on this view, asserting that something is morally ”good" or "bad" is just like saying “hurrah” to this or “boo” to that. I’m making a tenuous analogy here, mostly because I just stumbled across a story about how a 77-year-old Freddie Ayer challenged Mike Tyson in his prime,⁸ but I think we can make a useful comparison to defining recovery. At the very least, recovery talk could benefit from a provocation similar to the way analytic philosophy provoked old ways of thinking about ethics. When I say I am in recovery, I’m not sure that can be boiled down to facts about my consumption or even my behaviors, as all these definitions seem to want to do. I am also expressing attitudes and emotions, which are in communication with collective attitudes and emotions. I’m saying, hurrah recovery, and hurrah to this new aspiration for myself to continue the work of recovery, even years after stopping the harmful use. Perhaps recovery is beyond process and outcome.

“You’re in recovery if you say you are” -CCAR, 1999

The Connecticut Community for Addiction Recovery is an advocacy group that, early in its history, decided to adopt as a foundational principle: “you’re in recovery if you say you are.” Maybe that’s all that can and should be said. I often think so, with some caveats.

Again, it’s useful to think of social domains and the different purposes of defining addiction recovery. The CCAR approach is the right approach for almost all clinicians. When I see patients, I’m not judging or defining their recovery identities for them. I might help them to step more fully into recovery, if that’s something they want, and especially if unhelpful shame or self-criticism is holding them back from giving themselves the credit and clarity of intention they deserve.

However, when it comes time to articulate principles of recovery to policymakers or the general public, we may need to say more. Both in working with patients and for myself, I like to think about the different ways to go beyond stopping the harm. In my own recovery, I find it immensely useful to think about different frameworks of well-being and how they inform my practices. In my own recovery, I need to do more than say I’m in recovery.

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One last thought, while we’re talking about identity, change, and loosening up: I started with Blaise Pascal’s “hole” to highlight a pervasive notion about addiction. The starting assumption for the “God-shaped hole” idea is deficiency, absence, or lack. If addiction was an attempt to fill that lack, that means our beginning state was insufficient and we must recover in the sense of re-cover, get something back. What if there was no hole, no lack? What if wellness was not a thing to acquire, like a commodity or a possession?

In my next longer-form post, probably after a few more podcasts and other shorter pieces, I’ll take up the notions of wellness and happiness in recovery. Until then, thanks for reading. Let me know what you think!

Again, we’re still early days here at Rat Park, so if you’re liking this work and want to support it, please share and consider upgrading your subscription.

1. Awais Aftab commented something relevant on my last post; briefly, terms and concepts have sociocultural histories that are significant due to the way a community of people relate to them and put them to use. Taking a term out of the context that gives it significance causes its utility to start deflating. One part of the task seems to be finding the healthy middle ground between traditionalist definitions of recovery and vague universalism.

2. I couldn’t be exhaustive here; that would be a book, and a ferociously boring one, at that. If you are craving that kind of completeness—out of professional curiosity or masochism or what have you—refer to the tables in two relatively recent articles authored by Katie Witkiewitz’s group and the Recovery Science Research Collaborative, linked below.

3. The members of the panel included Bob DuPont, Marc Galanter, Mark Gold, Lee Ann Kaskutas, Thomas McLellan, and William White.

4. HT Holly Whitaker.

5. William White and others have discussed this idea of citizenship, but even in an otherwise compassionate article, most of the focus is on what the recovering individual does or should do: i.e., most of the article has to do with ”community-facing recovery values” and “core acts of citizenship.”

6. The RSRC was a group of researchers, practitioners, public health professionals, and policy advisors from institutions across the U.S.

7. The Duke philosopher and person in recovery Owen Flanagan, previous podcast guest, is a notable exception who has said quite a bit that’s useful about identity and addiction (and much more!). Sadly his chapter ”Identity and Addiction” is paywalled, but you can get some of the gist from his excellent writing on shame.

8. ''Do you know who . . . I am?'' Tyson asked in disbelief when Ayer urged him to desist: ''I'm the heavyweight champion of the world.'' ''And I am the former Wykeham professor of logic,'' Ayer answered politely. ''We are both pre-eminent in our field. I suggest that we talk about this like rational men.''