Recovery is something done by the person with the substance use problem, not by a treatment practitioner or anyone else. Whilst there are a multitude of pathways to recovery, there are a number of key factors that facilitate recovery from serious substance use problems. (9,586 words) *
There have been various definitions of recovery proposed over the years. For the purpose of this article, I use a definition proposed by a leading addiction recovery advocate, historian and researcher, William (Bill) L White:
‘Recovery is the experience (a process and a sustained status) through which individuals, families, and communities impacted by severe alcohol and other drug (AOD) problems utilize internal and external resources to voluntarily resolve these problems, heal the wounds inflicted by AOD-related problems, actively manage their continued vulnerability to such problems, and develop a healthy, productive, and meaningful life.’
There are a number of features about addiction recovery that need to be understood. Recovery is something done by the person with the substance use problem, not by a treatment practitioner or anyone else. Professional treatment or engagement in mutual aid groups may facilitate recovery, but they do so by catalysing and supporting natural processes of recovery in the individual.
The second feature of recovery from serious substance use problems is that it does not occur in isolation. The maxim ‘I alone can do it, but I can’t do it alone’ is particularly pertinent to recovery. As I will discuss later, connection to other people is a key element facilitating recovery.
Although formal treatment may help people, recovery occurs in the community rather than in the clinic. Treatment is generally the start of a recovery journey and is not needed by everyone. For those people who access local treatment services, the vast majority spend far more time in their community than in the treatment service. For those who attend a residential rehab, they continue their recovery journey upon returning to their community, where all they have learnt will be put to the test.
Recovery is a process that generally takes a long period of time and requires sustained effort. Recovery initiation and recovery maintenance are qualitatively different processes. Recovery is not a linear process. The person may make small gains followed by a major step forward. The person may falter, slide back, re-group and move forward again. Relapse is not a failure; it is part of the recovery process. It can be followed by a major move forward in the recovery journey.
Recovery is much more than just stopping use of drugs and alcohol. It is about repairing the damage caused by drug and alcohol-related problems, including problems which may have arisen as a result of poor treatment practices. It is about actively managing the person’s continued vulnerability to the problems that arose from drug and alcohol use, and the initial problems (e.g. childhood trauma) that may have been a causal factor in the person’s descent into problematic substance use.
Ultimately, recovery is about gaining and maintaining a healthy, productive, and meaningful life. It should be pointed that not everyone who finds recovery gives up all drug and alcohol use.
Recovery is better predicted by someone’s assets and strengths, rather than their deficits and weaknesses. People can make progress by identifying and building on their personal assets and strengths. Successful interventions to facilitate recovery focus on helping individuals to build recovery strengths, more often referred to as ‘recovery capital’. Recovery capital is the quantity and quality of internal and external resources that one can bring to bear on the initiation and maintenance of recovery (please see below).
Recovery from addiction is holistic. It encompasses a person’s whole life, including mind, body, spirit, family, community, culture and wider society. Treatment and support services need to address the multi-faceted needs of the recovering person. As addiction is generally a symptom of a deeper underlying problem, such as trauma, recovery is greatly facilitated by addressing such an underlying problem.
Everyone’s recovery is different and deeply personal. However, whilst there are a multitude of pathways to recovery, there are a number of key factors that facilitate recovery from serious substance use problems. The importance of these factors has been illustrated in the narratives of recovering people about their journeys into and out of addiction.
Here, I describe a number these factors, illustrating their importance using primarily quotes from the Stories in my eBook Our Recovery Stories: Journeys from Drug and Alcohol Addiction. It should be noted that many of these factors are inter-related, so there will be some degree of repetition. Many of these factors facilitating recovery are also relevant to family members and other loved ones who have been indirectly affected by such problems.
1. Hope
The first essential factor for a person to be able to recover is hope. This hope is based on a sense that life can hold more for one than it currently does, and it inspires a desire and motivation to improve one’s lot in life and pursue recovery. Hope is the catalyst of the recovery process. Without hope, there is no real possibility of positive action.
Hope is gradually diminished in people with serious substance use problems, as the problems themselves increase in number and intensity, and repeated efforts to abstain are unsuccessful. Social isolation, which often occurs when someone has a serious substance use problem, erodes hope. Not knowing anyone who has overcome similar problems leaves one feeling trapped in a world from which there is no escape.
‘You have to realise my state of thinking prior to that first group meeting in the treatment agency. Once I had become addicted to heroin, I did not see that there was any alternative to the life I was living. I didn’t know anyone who had overcome heroin addiction. I had never heard of anyone who had done so. I could find no information on the internet on how to give up using the drug. That was it! I just had to carry on doing what I was doing.’ Natalie
People in recovery from addiction describe the importance of having hope and believing in the possibility of a renewed sense of self (or identity) and purpose in the process of recovery. Hope is created by seeing other people find recovery from addiction, and knowing that recovery is possible, not just for others, but also for oneself. Hope grows over time. However, hope can also be squashed by poor treatment practices.
‘It was the first time in my life that I’d heard anyone speak about using drugs like I’d used drugs. It was also the first time I’d seen anyone who’d stopped using—actually chosen to stop, and who was at peace with their decision. I’d stopped using a lot, but always because I either had no money or no access to drugs.
The results of that first meeting, and the effect on my life, were immense. I’m certain that there is a small element of hope—or faith or some kind of spiritual flame—that burns inside us all. I believe it’s never completely extinguished, but can become so dim that it’s almost invisible to us. It was rather like that flame was fanned by my experiences at my first meetings, and I became aware again of hope.’ Simon
Hope can be fostered by recovering people, family members and friends, people working for treatment providers and other support services, and a wide range of other people.
‘I was sitting in a mutual aid meeting, it was the Doctors and Dentists Group, and one of the members was talking about his experiences. He was a GP like me and he had drunk in a similar way to me and he had the same kind of consequences as me and he felt the same as me. He was a few years into his recovery and I identified and connected with him to the degree that I suddenly thought, “Oh my God, if he can do it, maybe I can do it.”
I probably must have felt a mustard seed worth of hope. It was the first time I felt anything like that. I’d already tried for the best part of two years going down the medical route to try and find some sort of sobriety and this guy’s experience spoke to me in such a way that it created hope.’ David
A sense of hope is generated by focusing on a person’s strengths and assets, by using language that reflects a belief in potential and possibility, and by encouraging a person to take risks.
2. Empowerment
Recovery is something done by the person with the substance use problem, not by a treatment practitioner or other person. The major sources of power driving the recovery process are the person’s own efforts, energies, strengths, interests and hope. Treatment practitioners, and others involved in the person’s recovery journey, can facilitate the recovery process by encouraging and supporting the person’s own hopes, strengths, interests, energies and efforts.
Given the above, self-determination and empowerment are key foundations underlying recovery. To move forward, recovering people need to have a sense of their own capability, their own power. They need to regain a sense of agency, which is so often lost in the isolation and chaos of addiction. Their hope needs to be focused on things they can do for themselves, rather than on new ‘cures’ or fixes that someone else will discover or give them. The person must be the author and arbiter of their own recovery.
‘I understand that whatever the help that is offered, ultimately the movement from addiction into recovery has to come from deep within the individual. If I hadn’t embraced treatment and opened myself up to a painful process, it would have had little impact. Nobody could make me recover from my addiction. I had to take certain opportunities as they occurred.’ Paul
Those people trying to help a person on their recovery journey must respect and facilitate the person’s autonomy, as well as their right to make choices about the services and supports they believe will assist their recovery. People trying to help should not be controlling and coercive.
After being prescribed a low dose of methadone which failed to stop her experiencing withdrawal symptoms at work, Sapphire was seen by a more understanding and better-informed GP. She was listened to and her wishes were met.
‘It felt great to freely talk about what was really going on in my life. My new GP listened to what I had to say and treated me like any other (non-addict) person. She also did not repeat ad nauseam that, “Everything in my life would be rosy if I was abstinent”, which was the party line of the CDT. [ Community Drug Team]
My GP increased my methadone dose and I was able to function totally normally without having to buy any methadone on top, or without feeling like I wanted to use any other drugs. I felt like any other person…’ Sapphire
Sadly, this GP later passed away and Sapphire faced new problems with her treatment service.
‘As I was testing negative for all drugs other than those I was being prescribed—that is, I was not taking anything on top of my prescription—the CDT kept insisting they reduce my methadone dose. They believed that I didn’t need the same dose of methadone, as I wasn’t now using illicit or unprescribed drugs. They were ignoring the fact that it was because of this dose of methadone that I was able to abstain from other drugs and alcohol. “As the medicine is working, she needs less of it!”’ Sapphire
3. Self-responsibility
The flip side of the fact that ‘recovery is something done by the person with the substance use problem’, is that the person has to take charge of their own recovery. Although people generally need to be supported in their recovery, they can’t be care-taken or protected into recovery. Setting one’s own goals and pathways, taking one’s own risks, and learning from one’s own successes and failures, are essential parts of a recovery journey. No one else can do the work.
Being responsible for one’s own recovery means that a person has a lot to learn in order to facilitate the process, not least that recovery takes time and a great deal of effort. The person must generally learn a good deal about the recovery process, and a great deal about oneself; some of the latter might be confronting. The support of others plays an important role in these matters.
‘Group therapy is very helpful at giving you a new pair of spectacles through which to see the world, and very quickly I gained insight into the repetitive and self-destructive patterns of thinking and acting that had tripped me up so many times in the past.
One of the first lessons I learned was that I was responsible for my own feelings. Although now that sounds very self-evident, for much of my life I had believed that what was happening around me would determine the way I felt; as if I was passive and had no choice in how to respond to circumstances. There was a scared little kid in me who was still dictating the way I would deal with difficult life circumstances and difficult people.
Discovering that how I responded was actually down to me, and not to the circumstances I found myself in, was an eye-opener and very empowering. Treatment helped me to move away from being a perpetual victim to life’s challenges and to develop a bit more self-assurance and confidence.’ Tim
4. A sense of belonging
Recovery cannot be achieved in isolation. In fact, many people with serious substance problems have become isolated and alienated and this has a further debilitating effect on their already vulnerable psychological state. People who have had such problems need to belong and feel part of something. They need to feel the acceptance, care and love of other people, and to be considered a person of value and worth.
‘In the rehab, I began to feel hope and a sense of belonging. I began to believe that I could and would have a new life. I started to interact with people and make new friends, which reduced my isolation. I discovered that people cared about me and wanted to help me. I also started to learn how to live without using drugs and drinking as a coping mechanism.’ Adam
‘The nurses in the rehab were also a powerful positive influence, as they made us feel important. As alcoholics, we had so little self-esteem—I felt really crap about myself—and the nurses helped us to start to feel good about ourselves. Looking back, the empathy and compassion the staff showed to me was the single most important factor that helped me on my journey to recovery. People in the rehab, clients and staff, saved my life.’ Michael
Gaining a sense of belonging and acceptance can come from various sources, including a peer support group, treatment agency, workplace or volunteer group, sports club, or the church. Interacting with animals—be it with a beloved pet, during voluntary work at an animal sanctuary, or engaging in equine therapy—can also provide a sense of belonging and acceptance, and facilitate recovery.
The power of gaining a sense of belonging is emphasised by Guardian reporter John Crace in an article he wrote about his heroin addiction.
‘If it was rehab that got me clean, it was Narcotics Anonymous that kept me clean. Without meetings, I would have been back on drugs within days. NA gave me meaning and hope… I felt an intense sense of belonging. Like a family I had never known, who understood my life, my shame, my darkness. Anyone who had been clean for more than a couple of years was like a god to me.’
In a qualitative research project Lucie James and I conducted focused on the RAPt treatment programme in a male and female prison, we found that ‘Belonging’ was a key element identified by interviewees in changing their thinking, emotions and behaviours.
5. Being supported by, and helping others
Acceptance is just one aspect of the fifth key factor underlying recovery, being supported by others. People in recovery stress the importance of having someone believe in them, particularly when they don’t believe in themselves. They also stress the importance of having a person in recovery as a mentor or role model as they travel their journey.
‘I would not have been able to tackle my addiction without the treatment agency. They gave me a structure to my life. They taught me how to live again. After engaging with the treatment agency, I felt like I belonged somewhere for the first time. There was just something about the place. I loved the people, and most importantly they weren’t judging me and they were treating me like a human being. I was being supported in what I wanted to do and I was being treated like a decent person. They believed in me, when I didn’t.’ Natalie
Other recovering people, or role models, help people know what recovery looks like, give them something to which they can aspire, and provide ideas on how to overcome stumbling blocks in the recovery process.
People who are trying to overcome a serious substance use problem can more easily relate to and trust someone who has been there. Recovering people can help alleviate some of the stresses and strains the person may feel on their journey to recovery. They can also help the person find connections in the community they need to facilitate their recovery.
‘Ian was an important role model for me, someone I could look up to. He gave me confidence and hope, and I was able to ask him questions knowing he would give me sensible answers, providing information I could use in my life. He’s ‘been there’ and come back from a life of hell, so as far as I was concerned, I could relate to, and trust, him.’ Adam
‘Tom is a recovering alcoholic, so he understood what I’d been through, which meant that I could respond to him more. I was not thinking, “Oh, what a wanker, go look it up in a book.” It was important to me to know that he wasn’t looking down on me. Tom would show that he was no different to me, by telling stories of his alcohol use and then showing how he is now. He made recovery seem achievable.’ Kevin
The power of a support group, such as AA, and how its members can facilitate recovery in a variety of ways, is described by one of our interviewees.
‘So, a week later I went to my first official AA meeting. Scared, confused and shaking, I was greeted with nothing but warmth and empathy. As I listened to these other alcoholics talking, I realised that these people were just like me. They understood what I was going through in a way that no one really ever had before. They had fallen into the same traps as I had and suffered from the same screwy thoughts.
I actually didn’t get my recovery through traditional AA methods. I didn’t do the steps and I don’t have a sponsor. However, attending AA gave me the understanding and connection that I had been missing. It gave me the support network of people who have been there that I had never had before. It gave me wisdom through listening to others sharing their experiences. It helped me to understand a lot more about addiction. It impressed upon me the importance of gratitude and putting my recovery first. In short, it gave me a good deal of guidance and a whole lot of hope.
AA also gave me respite when in my renewed sobriety, I thought I might fall apart and drink. It gave me a safety net. And if I ever think it’s a good idea to drink again, I know exactly where to head in a moment of desperation to be talked out of it.’ Beth
The role of support and belonging emphasises that recovery is a social process and stresses the importance of relationships. It is important that these relationships are not one-sided, like the professional-patient situation in the medical model, but are reciprocal in nature, with the recovering person both giving and receiving. The practitioner-client relationship must be one of equals. Practitioners must show empathy, an ability to see the world through someone else’s eyes. The person visiting a practitioner must be able to feel safe.
In describing the importance of safety and social support in facilitating recovery from trauma, Bessel van der Kolk wrote [1]:
‘Being able to feel safe with other people is probably the single most important aspect of mental health; safe connections are fundamental to meaningful and satisfying lives….
… Social support is not the same as merely being in the presence of others. The critical issue is reciprocity: being truly heard and seen by people around us, feeling that we are held in someone else’s heart and mind. For our physiology to calm down, heal, and grow we need a visceral feeling of safety. No doctor can write a prescription for friendship and love: These are complex and hard-earned capacities.’
Interactions between peers, especially in the group setting, are particularly important as a recovering person can give, as well as receive, feedback. Participation in such mutual relationships gives the recovering person a feeling of worth—they have something of value to offer to others—and allows them to see aspects of themselves they may not have seen for some time due to their substance use problem. They learn more about what they are capable of and aspects of who they are, that ultimately contribute to a change in identity, from an addict to a worthwhile person. Supporting others can become a key element that facilitates one’s own recovery. It helps create a ripple effect of recovery.
‘Group therapy is very helpful at giving you a new pair of spectacles through which to see the world, and very quickly I gained insight into the repetitive and self-destructive patterns of thinking and acting that had tripped me up so many times in the past.’ Tim
Interacting with, and helping others, can serve other purposes that facilitate recovery.
‘I had spent many years without any real hope or passion in my life. The broad horizon of my youth had narrowed to a point where my life had become a place of struggle, with no real pleasure, just relief from a gnawing, constant, self-centred fear. Where everything and everybody was an obstacle to overcome, by myself, and with little energy.
I was becoming much more aware of other people, their feelings and their responses to me, and I realised that I gained real pleasure and satisfaction from helping and being useful. A key feature of the NA programme is the principle of service to others, as a way out of self-centredness. This growing awareness was described to me as spiritual in nature. I liked this idea, as I did the idea that I was enjoying a spiritual awakening. It was becoming clear to me that this 12-Step programme, whilst appearing from the outside to be rather religious in tone and language, was a series of exercises that enabled the ‘awakening of my spirit’.’ Simon
Family members are an important source of support for someone on a recovery journey. At the same time, however, family members may have been negatively affected by their loved one’s addiction and related problems, and may need their own supports.
6. Involvement in meaningful activities
Another important factor facilitating recovery involves the development of valued social roles through involvement in meaningful activities, such as described above. Through these activities, recovering people gain a sense a purpose and direction in their life—they find a niche in the community.
These meaningful activities may involve employment or volunteering, engagement in hobbies or other leisure activities, or connecting with other organisations or groups. Employment is a central way in which people can achieve more meaning and purpose in their lives and is therefore a key pathway to recovery. As described in the previous section, impacting on the lives of other people in a positive manner, ‘giving back’ as it is often called, is also important for personal recovery.
Ian and Irene decided to set up a support group for parents and carers and this initiative not only helped other people, but facilitated their own recovery journey.
‘… it occurred to us one night that what we could do would be to provide what we had wanted when we first discovered Robin’s addiction to heroin. Quite simply, someone to talk to, understand what we were going through, be non-judgemental, have a knowledge of drugs and addiction, and be able to act as a signpost to further help.
And so, on another cold November night, CPSG (Carer and Parent Support Gloucestershire) was conceived….
… What our experience has given us is a great insight into, and an absorbing interest in, the substance use and recovery field. We’ve been able to translate our knowledge and understanding into a service that provides help for those people (particularly family members) who have been affected by another person’s drug or alcohol use. Our ongoing work has not only been rewarding, but has also been a major factor in our own recovery.’ Ian and Irene
Iain describes the importance of engaging in a variety of different recovery-based activities.
‘Hundreds of people came to our first annual RAFT event and the feedback was absolutely amazing. I got the same positive feelings at this event that I got with RAFT each week, but multiplied by about a thousand. I also felt like this after the Annual UK Recovery March in Glasgow in 2010.
During the early stages of RAFT, I was introduced to the Wired In To Recovery online community. I started blogging about RAFT on Wired In To Recovery every week, either at the event or at home straight afterwards. I immediately found this blogging to be a great way to air my feelings and thoughts in a safe manner, whilst receiving thoughtful comments from people around Scotland and further afield. This was all extremely helpful to me.’ Iain
Many people in recovery describe the importance of believing in something spiritual, having faith in a higher or transcendent power. Spirituality, religion, or belonging to a faith community, represents important pathways to recovery for some people. Kevin felt that God was involved in the early stages of his recovery when he visited Livingstone’s rehab:
‘When I visited, I straight away decided that I didn’t want to go. It was a Christian rehab and I wasn’t a Christian. Tom, who runs Livingstone’s, asked if I wanted to have a look around anyway, so I did.
All of a sudden, a very alien, but comforting sensation, came over me. I knew beyond all doubt that it was God showing me what my life could be like if I chose to follow him. I felt at peace. I felt happy. The weight lifted off my shoulders. I was back to how I remembered feeling as a kid. I knew this was the place for me….’ Kevin
The pleasures and rewards that come from engaging in meaningful activities help foster a sense of agency, a self-belief that the person can impact on their own life. Sense of agency is closely related to empowerment.
7. Gaining recovery capital
Recovery is better predicted by someone’s assets and strengths, rather than their ‘pathologies’, deficits and weaknesses. People can make progress by identifying and building on their personal assets and strengths. Interventions to facilitate recovery must focus on helping individuals build their recovery strengths, more often referred to as ‘recovery capital’.
Recovery capital is the quantity and quality of internal and external resources that one can bring to bear on the initiation and maintenance of recovery. It takes three main forms:
- Personal (physical health, mental health, financial assets, housing, values, knowledge, self-esteem, self-efficacy, problem-solving capacity, etc).
- Family/social (support from family and other loved ones, people in recovery, and people in the wider social network, etc).
- Community (local recovery role models, full continuum of treatment and other support services, mutual aid groups, less prejudice in community, opportunities for work and volunteering, etc).
Recovery capital, both in terms of quantity and quality, plays a major role in determining the success or failure of recovery, either natural recovery or recovery assisted by treatment and/or peer support groups. People with low levels of recovery capital, for example homeless people without a job, are likely to face much greater problems in achieving recovery than people who are seeking recovery from a position of privilege. Increases in recovery capital can spark turning points that trigger recovery initiation and strengthen the maintenance of recovery.
Most people with severely depleted family and community recovery capital gain little from individually-focused addiction treatment that fails to mobilise family and community resources. In fact, long-term recovery outcomes may have more to do with family and community recovery capital than the attributes of individuals or a particular treatment protocol.
8. Understanding
Understanding is essential for recovery. People with substance use problems and those on a recovery journey need information and education about a variety of matters, including: the nature of addiction and their own substance use problems; the range of interventions they can use to help them manage or overcome these problems; opportunities that allow them to exercise their strengths and assets; supports they can use to facilitate their recovery journey, and self-management skills that help them cope with situations that might lead to relapse.
Recovering people are a major source of information that can facilitate another person’s recovery journey.
People with substance use problems and those on a recovery journey need to understand that addiction is generally a symptom of a deeper underlying problem. The recovery process is greatly facilitated by tackling the underlying problem. World leading experts like Gabor Maté and Bessel van der Kolk see addiction arising from past traumatic experiences. Gabor Maté stresses that whilst addiction is a problem:
‘… it is also an attempt to solve a graver problem that is, unbearable psychic pain. To understand addiction we need to understand human pain and that takes us to focus on childhood experiences.’
People who have been traumatised often don’t fully understand what is going on for them and often don’t look towards other people for help.
‘Trauma builds into us feelings of worthlessness and self-destructive urges. We experience people as being inherently untrustworthy, so when we have problems, we don’t reach out for help, instead relying on the comfort of a liquid. Deep down, we feel that a lethal painkiller is all we deserve to soothe us.
The prevalence of trauma had been apparent in my experience of working with addicts. I had seen myself as an outlier. I now understand that I had just as traumatic a childhood as most addicts did. I just didn’t know it.’ Beth
Some people deal with the psychological pain caused by past traumas by going to their GP, where they may be prescribed a benzodiazepine drug such as Valium. This class of drugs is highly addictive. Other people drink alcohol excessively, while others turn to the ‘street’ to obtain and use heroin. This drug alleviates both physical and psychological pain.
A person who has been traumatised by physical, sexual or psychological abuse as a child will not only feel the powerful analgesic effects of heroin, but may also benefit from relationships and experiences within the social setting in which they take the drug. The people who they take the drug with may have experienced similar abuse in their youth, or may know others with similar problems, and are therefore more likely to be understanding and comforting.
At least three of the stories in Our Recovery Stories project refer to traumas experienced as a child. Natalie did not realise until many years into her recovery, when she attended a talk given during a session of the Sycamore Tree Project run in a local prison, that she had been traumatised by her experiences as a child. Once she started to address this trauma, and the issues that had arisen following her visit to the prison, Natalie found a ‘new level’ of recovery.
‘I now feel happier and more content when I go back and explore the past. I don’t feel the shame to the same level that I used to feel. I can look back at it and take it as it was. I can feel what it must have been like for my Dad, how awful it was for him, without being overwhelmed by negative emotions relating to this or to what I experienced. I can think clearly about the positive things my Dad did, like the advocacy work he did for fellow prisoners.’ Natalie
A variety of models of addiction have been proposed, the best known being the disease model of addiction. This model has caused controversy, the details of which I am not going to describe here. What is important in terms of a person’s recovery is for them to gain an understanding of their problem—their addiction, and the factors that have contributed to its development and maintenance—and how it can be overcome, the factors that facilitate recovery.
A person may believe in the disease model because it gives them an explanation for why they are as they are. It may help them to stop blaming themselves for their destructive behaviours, which can facilitate recovery. However, any other model, or combination of models, as an explanatory framework might be beneficial. The most important thing is that the person must understand and relate to the model—it must be believable and ‘actionable’ to them. Of course, a person may change opinions about different models at different stages of their addiction journey.
People on a recovery journey generally learn a lot about themselves during this journey, a process that is often facilitated by other recovering people.
‘I learnt in group that I am not a bad or an evil person. I learnt that I can’t be perfect and I make mistakes. I learnt that I don’t know everything and that I have a lot to learn. I learnt that I am willing to learn. I discovered that expressing my emotions was healthy, even though everything within me said otherwise…
… This was probably the first time that I realised that my addiction wasn’t about a particular substance, but was about my way of thinking or perception of reality. The substance was in fact my solution to my inability to live at peace with myself. Coming to accept that I, rather than the substance, was the problem, was the foundation to my recovery. The realisation that, ‘If I worked on myself, I wouldn’t need to keep running to chemicals’, was a revelation.’ Paul
‘I’d arrived at this point in my life with some really embedded behaviours that I was coming to understand were not just fear-based, but almost completely self-defeating. As a self-absorbed, self-centred person, I was used to the idea that I was always right, and that nothing was my fault. As a newer member of NA, I was learning that it was not possible to resolve these conditions alone. I was now responsible for the direction of my life, but I needed external guidance. There was a wealth of experience for me to draw upon, not least within my own community.’ Simon
Sometimes, a new insight or understanding can have a profound effect on someone trying to recover from addiction. Brad decided it was time to take a break from drinking. He abstained for six weeks, but found that his craving for alcohol was stronger than it had ever been. He couldn’t understand why.
‘Alan, who was 16 years in recovery, simply said to me, ‘Brad, you haven’t just got a problem with alcohol.’
When he said this, I thought to myself, ‘He’s mad. What does he mean?’
He then proceeded to tell me that if my problem was just about alcohol, then everything in my life would have been rosy and nice when I had stopped drinking. Clearly, this wasn’t the case—everything wasn’t as perfect as I had expected.
At this point, I experienced something I remember clearly like it was yesterday. My head span and I was dizzy. I had never realised that my problems involved more than just alcohol—they involved me as a person. No one had explained this to me before. Alan also said to me that if I were to listen to him, then this would ‘fuck my drinking up’. It certainly did that.’ Brad
Anna’s life became focused on her brother’s addiction to heroin. She decided to go to a psychologist.
‘In the third session, the psychologist said to me, ‘Anna, I’ve been hearing a lot about your brother and all of his problems. What about you? Do you think you might have a problem with drugs too?’
I said, ‘Yes.’ I was drinking every night to cope with what was going on, and my boyfriend at the time was also a heavy drinker. She said that I needed to accept that I couldn’t change my brother’s behaviour or anyone else’s. I could only change my own. She also said that I needed to focus on my own life, and stop focussing so much on my brother’s.
After the session finished, I went out to my car and bawled my eyes out. However, this was a different type of emotional release. I felt an overwhelming sense of relief. I knew that things would be different for me, and that I could change the way I was thinking and feeling.’ Anna
Many people with a serious substance use problem start using drugs, alcohol and solvents during their early teenage years, at a time when they are still developing emotionally. This substance use, particularly if it gets out of hand, can interrupt their emotional development, such that their emotions, thinking and behaviours are influenced in a negative manner in later life. They can act as if they are still in their teenage years and be unable to deal with situations that someone with a normal emotional development would deal with.
‘And even today, I’m puzzled a bit by what was going on in my head. But I think it comes down to the fact that I never had the emotional development that other people had as child and a teenager, because I was sniffing glue and other substances and then drinking excessively. Over the previous years of my recovery, I had been learning slowly to deal with new emotions. The more I dealt with them, the more used to them I became. However, I had never experienced anything like these feelings of love. They hit me like a ton of bricks and I had no idea how to deal with them.
Rather than work through the emotions, I told myself I couldn’t do it. I didn’t use my anaesthetic (alcohol), since I didn’t want to drink. I decided to just run from the situation. I went home, switched off and blocked everything out. I didn’t contact Emma. It was all just too hard.’ Brad
9. Overcoming stigma
Stigma can be defined as social disapproval of personal characteristics, actions or beliefs that go against the cultural norm. It can occur at a variety of levels in society, i.e. individuals, groups, organisations and systems. A person can be labelled by their problem (e.g. addiction to drugs and/or alcohol) and they are no longer seen as an individual, but as part of a stereotyped group, e.g. a ‘junkie’, ‘alkie’, etc. Negative attitudes and beliefs toward this group create prejudice which leads to negative actions and discrimination.
For example, people addicted to heroin are often considered to be carriers of hepatitis C and other blood-borne viruses, thieves who rob old ladies of their handbags, and dirty, weak-willed junkies who will never get over their problems. ‘Once a junkie, always a junkie’ is a saying I’ve even heard in discussions amongst drug treatment agency workers. Our Wired In research has not only shown the strong prejudice that exists towards heroin users, but also towards recovering heroin addicts.
Stigma can impact on a person with a substance use problem, or someone on a recovery journey, in various ways. It can create feelings of shame, blame, self-disgust, self-hatred and hopelessness, and impact badly on self-esteem and self-efficacy. The person may isolate themselves, or remain in the drug-using community for fear of being judged and treated badly by other so-called ‘normal’ people. They may decide to avoid looking for help for the same reasons. External stigma has become internal stigma—both forms of stigma are barriers to recovery.
Family members are also affected by stigma, in the sense that they are fearful of being blamed or held responsible for their family member’s addiction, or they are upset by the way that their family member is treated by other members of society.
‘The worst thing for me was the attitudes of some of my work colleagues. It’s very strange because I work in a caring profession in the health service, but some of the attitudes of workers were truly awful. Over the time that Kevin was an inpatient, I heard that the staff had been gossiping about him, not only on their ward but on other wards. They discussed Kevin and our whole family in a very derogatory manner. Much of what they said was unfounded or damn right untrue. I find it incredible that they can break confidentiality with other members of staff.
I was angry and hurt and felt dreadfully bad for Kevin. He was desperately ill and they were discussing him in such a malevolent way. Gossiping, saying, “Why hasn’t his father visited?’, or ‘His sister has cut him off?”, which was quite untrue at that time….
… People are really unaware of the deeper issues surrounding addiction. I would have thought the people I was close to at work would have understood. Yet all they could say was, ‘She should cut him out of her life.’ I actually had someone say that to me, not in a nasty way, but thinking that she was being helpful. I took it as well-intentioned, because she wasn’t malicious, but I said, ‘There’s no way I could do that, he’s my son.’ Kerry
Society needs to change in order to help more people recover from addiction. People who have recovered, or are receiving from serious substance use problems, can become advocates and contribute by helping communities transform into environments that are more accepting of people who have developed substance use problems, and ensure that treatment and other support services eradicate stigma and discrimination towards people who are trying to recover from their problems. Such advocacy can facilitate personal recovery, as well as indirectly facilitate recovery in others.
‘I believe that if there wasn’t such a massive stigma attached to addiction, then more people would be inclined to seek help. As it is, a lot of addicts wait until they hit a rock bottom or two, before they finally get so desperate that they have no choice but to ask for assistance.
As a society, we need to foster an environment of sympathy and support, rather than judgement and blame, in order that people are able to ask for help sooner. We should encourage people rather than sanction them for admitting they have a problem. Addicts should not have to wait until they have lost everything, including any self-esteem they once had, and are so desperately mired in shame that death or recovery are the only options.
We also need more role models who are prepared to stand up publicly and show that they are not ashamed of being recovering addicts, because there is nothing to be ashamed about. I only understand as much as I do about addiction because others were prepared to share their knowledge with me. I only knew that recovery was possible, and desirable, because of examples of other alcoholics who had found recovery. But we need to bring that message out of the dimly-lit church halls and into the open for everyone to see. It shouldn’t be hidden away, obscure and hard to access. The message should be loud and clear, so that it is accessible to everyone.’ Beth
In saying this, it must be recognised that some recovering people prefer less visible, direct, or explicit ways of dealing with stigma, such as ‘passing for normal’, only confessing current or past problems to people they trust. Some of these people may avoid professional treatment because they have experienced prejudice, or feel they have been judged negatively, in such services, and turn to peer support groups. Recovering addicts are far less likely to be judgemental and prejudiced.
Ultimately, each individual will find what suits them best during their recovery journey. What is important is that the person feels good about themselves and proud of what they have achieved. They must find places in the community that allow them to feel in this way. They must have role models. They must learn ways to overcome the negative attitudes of others. They must know when they deserve better and stand up for themselves when they are being mistreated.
I leave this section with the words of Gabor Maté from his book In the Realm of Hungry Ghosts [2]:
‘Addicts are locked into addiction not only by their painful past and distressing present but equally by their bleak view of the future as well. They cannot envision the real possibility of sobriety, of a life governed by values rather than by immediate survival needs and by desperation to escape physical and mental suffering. They are unable to develop compassion towards themselves and their bodies while they are regarded as outcasts, hunted as enemies, and treated like human refuse.’
10. Gaining a positive sense of self (or positive identity)
People with serious substance use problems lose a lot of the roles or personal characteristics that help define their normal identity (e.g. loving son, athlete, generosity, intelligence) as their dependence on their substance(s) increases, relationships wither and isolation increases. Eventually, their identity as viewed by others may become ‘a useless, dirty addict’. They will also have personal views of what they have become and these views can lead to lowered self-esteem or even intense hatred of oneself.
On the basis of qualitative research with over 100 heroin addicts who had recovered from their addiction without professional treatment, Patrick Biernacki argued that:
‘To change their lives successfully, addicts must fashion new identities, perspectives and social world involvements wherein the addict identity is excluded or dramatically depreciated.’ [3]
James McIntosh and Neil McKeganey (2002) came to the same conclusion, on the basis of their qualitative research with 70 people recovering from drug addiction, most of whom had received formal addiction treatment at some stage [4].
‘… at the heart of most successful decisions to exit drug misuse is the recognition by individuals that their identities have been seriously damaged by their addiction and the lifestyle that accompanies it. This, in turn, stimulates a desire to restore their identities and to establish a different kind of future for themselves.’
These Scottish researchers argued that successful decisions to stop using illegal drugs come from (1) a motivation to ‘exit’ use which is more powerful than the fear of stopping, and (2) a sense of a future that is potentially different from the present. This successful decision may come from rational decisions, arising from the person wanting to stop using on the basis of the unacceptable nature of what they have become, or from ‘rock bottom’ decisions. With the latter, the person knows they have no other viable option but to stop. They have reached the end of their tether. Often the person has contemplated, or even attempted, suicide.
The transition to non-addict status is by no means an easy one, since it generally involves a major disruption to the person’s life.
‘All of a sudden, the social networks, values, activities and relationships that had defined and structured the addict’s life are removed and a potential void is created…. it is essential that this gap is filled in an appropriate and constructive manner if the individual is to stand any chances of success in sustaining his or her recovery. In addition, of course, a new non-addict identity also has to be constructed and sustained. None of this happens on its own. It has to be managed by the addicts themselves and often at a time when they are not feeling particularly robust.’
Two main strategies that the people in this study used to achieve their goals were (1) the avoidance of their former drug-using network, and (2) the development of a set of non-drug-related activities and relationships. The alternative lifestyle which these relationships and activities provide, give the person an enhanced sense of personal value and a new meaning and purpose to their life, and imbue them with a sense of hope for the future.
‘Paid employment was especially beneficial; it occupied their time constructively, did wonders for their self-esteem and provided a network which could assist in the validation of their new identities. Relationships with non-users were also central to the recovery process; these people provided the necessary social acceptance for the recovering addicts’ new status and made it possible for them to participate in the drug-free world. They also provided companionship, which played an important part in preventing loneliness and isolation, thereby neutralising the latter’s potential to draw the recovering addicts back into the company of users.’
Patrick Biernacki discusses the transition that the recovering addict makes into the so-called ‘normal’ world, providing an indication of how ‘normal’ people can facilitate or hinder a person’s recovery journey [3].
‘Those addicts wishing to change their identities may first have to overcome the fear and suspicions of nonaddicts before they will accepted and responded to in ways that will confirm their new status. Gaining the recognition and acceptance of the nonaddict world often is a long and arduous process.
Eventually, acceptance may be gained by the exaddicts behaving in conventionally expected ways. Following “normal” pursuits, remaining gainfully employed, meeting social obligations, and possessing some material things will often enable nonaddicts to trust the abstainer and, over time, to accept him and respond to him in “ordinary” ways.
At the same time, the addict’s feelings of uncertainty and doubt will lessen as he comes more fully to accept the new, nonaddict life.’
As the process of recovery unfolds, the person starts to regain elements of their old identity and/or elements of a new identity. These changes operate at both an external level (what others perceive of you) and internal level (what you think about yourself).
Interestingly, many people in long-term recovery (and others around them) comment on their becoming a better person for having gone through the recovery process. This is not surprising, given the intense and painful journey that recovering people have taken and the great deal of self-analysis that has generally been undertaken.
11. Overcoming withdrawal symptoms
People who decide to stop taking drugs or drinking alcohol after using or drinking for long periods of time, need to be aware that they might experience withdrawal effects which can be irritating, debilitating and even life-threatening. Many of these withdrawal signs, which can be psychological and physical in nature, are generally opposite to the effects the person experienced when the drug was being taken.
For example, abrupt withdrawal from long-term use of Valium (diazepam) and other benzodiazepines, drugs which are prescribed to alleviate anxiety and insomnia, can lead to pronounced anxiety, insomnia, agitation, intrusive thoughts and panic attacks. In addition, people withdrawing from benzodiazepines can experience physical withdrawal signs, such as burning sensations, feeling of electric shocks, and full-blown seizures. The duration and strength of these withdrawal signs is dependent on the amounts of drug having been used and the duration of time the person has been using the drug.
Long-term administration of drugs and/or drinking alcohol can lead to tolerance, such that over time higher doses of the drug or alcohol are required to exert the same positive effects seen initially with the lower dose. One consequence of this tolerance is that increasing the dose over time is likely to lead to more pronounced withdrawal signs when drug or alcohol use is terminated.
People wishing to terminate use of benzodiazepines after long-term administration should seek medical advice, for example from their GP, before doing so.
‘The detox from Benzos was one of the worst things I have ever been through. I continued being reduced by 1mg a week until I got to 2mg a day of diazepam, and then my GP stopped the script. I have since found out that this wasn’t really the best thing, for my mind or body, to be stopped cold turkey still on 2mg a day. I had some seizures and terrible headaches, and I couldn’t sleep properly for months. The first time I had a seizure I was out in town and knocked myself out on a wall. I was taken to hospital where they gave me some diazepam, as they were sure that the seizures were from the doctor reducing me too quickly.
I ended up in hospital about nine times with seizures, but I would not take more benzos, since I didn’t want to go through the withdrawal again. I was worried that I would feel awful forever, and never escape from my addiction, but after about eight months it seemed that the worst of the withdrawals was over.
Once the seizures were under control, helped along by some non-addictive epilepsy medication, I tried to get back to a normal day-to-day life. However, I was so nervous about literally anything and everything. I found it difficult to learn how to deal with anxiety and stress without having benzos to help. I thought I would never lead a normal life. It took almost a year after the detox before the anxiety and sleeplessness had subsided to a manageable level, so it was difficult to plan anything for the future as my head was all over the place.’ Sapphire
People who have become heavily dependent on alcohol may need to seek medical advice before stopping drinking. Alcohol has some similar actions to benzodiazepines in the brain, and similar withdrawal symptoms, such as increased anxiety, agitation, intrusive thoughts and even seizures.
People who have become addicted to stimulant drugs like amphetamine and cocaine can feel depressed when they stop using. The expression ‘What goes up, must come down’, comes to mind. Heroin withdrawal signs include stomach cramps, vomiting and retching, muscle pains, the shakes, hot and cold spells, and headaches. The strength and impact of these withdrawal signs depends on the length of time using, doses used, and the overall physical condition of the user. Withdrawing from stimulant or opiate use is rarely life threatening.
However, a person who has stopped using heroin—from being in prison, for example—and then decides to use again must be very careful. They must inject less drug than they had generally used before terminating use, as their tolerance has been lost due to the period ‘away’ from the drug. Too my people have overdosed, due to respiratory arrest following injection of their ‘usual’ dose, by ignoring this piece of advice.
Craving, an intense or overpowering desire to engage in drug-taking or alcohol consumption, can occur for substances associated with addiction, such as opiates, stimulants, alcohol and nicotine. Craving has been suggested as a prominent feature maintaining drug/alcohol use and precipitating relapse after a period of abstinence.
Craving can be produced by external stimuli and/or internal mood states. Over a long history of drinking or drug-taking, stimuli that have been repeatedly associated with consumption of alcohol or drugs (e.g. sight of the pub, or the syringe) become conditioned stimuli that can elicit craving. For example, watching someone smoke a cigarette and the smell of the tobacco can remind an ex-smoker of the relaxing effect of smoking and trigger an intense desire to experience this effect again.
Craving can also arise from the need to relieve withdrawal or conditioned withdrawal symptoms. Thus, a person returning to an area where they have experienced withdrawal on many occasions in the past may experience conditioned withdrawal symptoms, which in turn can generate craving.
Mood states also elicit craving. Many of us have needed a drink of alcohol to alleviate the stress we have felt on a certain occasion. Imagine what it would be like for a person recovering from a serious alcohol problem who is already experiencing alcohol withdrawal signs and now become stressed because of some external stimulus, such as seriously bad news.
Positive mood states (e.g. excitement) can also generate craving when having previously been associated with the pleasurable effects of drugs and alcohol.
People on a recovery journey need to learn how to deal with the cravings they experience. Fortunately, cravings gradually disappear over time, although the time for this to occur differs from person to person.
References:
1. Bessel van der Kolk, M.D., The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma, Penguin Group, USA, 2014.
2. Gabor Maté MD, In the Realm of Hungry Ghosts: Close Encounters with Addiction, North Atlantic Books, USA, 2008.
3. Patrick Beirnacki, Pathways from heroin addiction: recovery without treatment, Temple University Press, 1986.
4. James McIntosh and Neil McKeganey, Beating the Dragon: The Recovery from Dependent Drug Use, Pearson Education Limited, UK, 2002.
> Factors That Facilitate Addiction Recovery (pdf document)
