Alcoholism Treatment Quarterly An Interpretive ...

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An Interpretive Phenomenological Analysis of Secular, Spiritual, and Religious Pathways of Long-Term Addiction Recovery a

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c

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Michael T. Flaherty , Ernest Kurtz , William L. White & Ariel Larson a

Clinical Practice, Pittsburgh, Pennsylvania, USA

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Department of Psychiatry, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA c

Chestnut Health Systems, Bloomington, Illinois, USA

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Duquesne University, Pittsburgh, Pennsylvania, USA Published online: 06 Oct 2014.

To cite this article: Michael T. Flaherty, Ernest Kurtz, William L. White & Ariel Larson (2014) An Interpretive Phenomenological Analysis of Secular, Spiritual, and Religious Pathways of Long-Term Addiction Recovery, Alcoholism Treatment Quarterly, 32:4, 337-356 To link to this article: http://dx.doi.org/10.1080/07347324.2014.949098

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Alcoholism Treatment Quarterly, 32:337–356, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0734-7324 print/1544-4538 online DOI: 10.1080/07347324.2014.949098

An Interpretive Phenomenological Analysis of Secular, Spiritual, and Religious Pathways of Long-Term Addiction Recovery MICHAEL T. FLAHERTY, PhD Clinical Practice, Pittsburgh, Pennsylvania, USA


ERNEST KURTZ, PhD Department of Psychiatry, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA

WILLIAM L. WHITE, MA Chestnut Health Systems, Bloomington, Illinois, USA

ARIEL LARSON, MA Duquesne University, Pittsburgh, Pennsylvania, USA

The emergence of recovery as an organizing construct has sparked interest in mapping the varieties of addiction recovery experience. This study uses interpretive (qualitative) phenomenological analysis (IPA) to examine six-diverse pathways of long-term addiction recovery. Semistructured interviews were conducted with six respondents representing natural recovery, Twelve-Step (Alcoholics Anonymous/Narcotics Anonymous) recovery (separate), secular recovery, faith-based recovery, and medication-assisted recovery. Common and distinct features of these pathways of addiction recovery are discussed with noted implications for the design of addiction treatment, recovery support services, and an understanding of recovery itself. Qualitative research can be a valuable tool in the elucidation of addiction recovery pathways. KEYWORDS Addiction recovery, qualitative research, recovery pathways, Alcoholics Anonymous, Narcotics Anonymous, Secular Organizations for Sobriety, natural recovery, medication-assisted recovery, faith-based recovery The authors express gratitude to Mark Godley, PhD, and the Chestnut Health Systems for their guidance and Institutional Review Board oversight. Address correspondence to Michael T. Flaherty, PhD, Clinical Psychologist, 4407 Old William Penn Highway, Ste. 5, Murrysville, PA 15668. E-mail: [email protected] 337

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M. T. Flaherty et al.

INTRODUCTION


Recovery as an Organizing Construct The addiction treatment field and the larger alcohol and drug problems arena have historically drawn from two foundational sources of knowledge: (1) the study of drugs and their personal, biological, and social consequences and (2) the study of alcohol- and other drug-related clinical and social interventions (El-Guebaly, 2012; Vaillant, 1995; White, 2005, 2008). These pathology and intervention paradigms are now being extended at a policy level in the United States, the United Kingdom, and elsewhere to encompass knowledge drawn from the lived experience of people in long-term addiction recovery (Berridge, 2012; Laudet & Humphreys, 2013; Wardle, 2012). At a clinical level, the recovery construct is being used to restructure acute and palliative care models of addiction treatment into evolved models of sustained recovery management nested within larger recovery-oriented systems of care (Clark, 2008; Kelly & White, 2011; White, 2008). This has sparked growing interest in defining recovery and mapping recovery pathways, stages, and processes (Humphreys, 2000; Kaskutas, n.d.; Klingemann, 2012; Laudet, Savage, & Mahmood, 2002; Weegmann & Piwowoz-Hjort, 2009) and exploring the clinical implications of such variations for the immediate and long-term resolution of severe alcohol and other drug problems (Beck & Grant, 2012; Boyle, Loveland, & George, 2011; Flaherty, 2012a, 2014). The emergence of recovery as an organizing construct is being further stimulated by (1) the growth and diversification of addiction recovery mutual aid organizations (Greenfield & Tonigan, 2013; White, 2004), (2) the emergence of a grassroots recovery advocacy movement (White, Kelly, & Roth, 2012), (3) the rise of new recovery support institutions (Humphreys, 2004; White, 2007b; Yates & Malloch, 2010), and (4) the reconceptualization of addiction as a chronic disorder (Dennis & Scott, 2007; Flaherty, 2006; McLellan, Lewis, O’Brien, & Kleber, 2000; White & McLellan, 2008). Consensus panels in the United States and United Kingdom have defined three core dimensions of recovery: (1) resolution of alcohol and other drug (AOD) problems (abstinence or disorder remission), (2) progress toward global (physical, mental, emotional, relational, spiritual) health, and (3) community reintegration (Betty Ford Institute Consensus Panel, 2007; Laudet, 2007; Substance Abuse and Mental Health Services Administration, 2013). There have also been calls to formulate recovery-focused research that can illumine the prevalence, pathways, styles, and stages of long-term personal and family recovery (Laudet, Flaherty, & Langer, 2009; McKay, 2011; White & Kurtz, 2006a).

Qualitative Research on Addiction Recovery Ethnographic studies, historical research, and thematic analyses shed light

Interpretive Phenomenological Analysis of Addiction Recovery

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on the varying ways in which recovery occurs. Most of these studies have focused on a particular stage of addiction recovery (Dawson et al., 2005; Frykholm, 1985; White & Kurtz, 2006b) or a particular pathway of problem resolution within unique populations (Brown, Whitney, Schneider, & Vega, 2006; Hänninen & Koski-Jännes, 1999; Kaskutas, 1992; Laudet et al., 2002; Miller & Kurtz, 1994; Waldorf, 1983; Yeh, Che, & Wu, 2009). Few studies have compared the shared and distinctive features of secular, spiritual, and religious pathways of long-term addiction recovery. Studies to date have not explored the potential existence of a common structure and shared themes within what would appear to be quite different frameworks of addiction recovery.

METHOD AND STUDY AIM This study seeks a structure of recovery as evidenced by the similarities and differences among secular, spiritual, and religious pathways of addiction recovery. Qualitative research is uniquely suited for such an investigation because it can elucidate the subjective experience of each recovery pathway (Larkin & Griffiths, 2002; Ricoeur, 2005; Taieb, Revah-Levy, Moro, & Baubet, 2008). The study team included two clinicians/researchers (M.F. & A.L.) trained in qualitative methods and two researchers (E.K. & W.W.) with broad experience collaborating with spiritual, religious, and secular recovery mutual aid groups.

Study Participants Following approval of the study protocol by the Institutional Review Board of Chestnut Health Systems, six participants were recruited, each representing a different framework of long-term addiction recovery. The first five participants were recruited within five well-known pathways to recovery: Alcoholics Anonymous (White female), Narcotics Anonymous (African American, male), faith-based (White male), Secular Organizations for Sobriety (White male), and medication-assisted recovery (White male). The sixth participant (White male) was chosen as someone who met the criterion of at least 5 years of self-identified recovery attained through ‘‘natural recovery,’’ here defined as a process of resolving an AOD problem in the context of broader life changes without the use of a supportive mutual aid fellowship or treatment. Each participant identified as being a person in recovery or who sees not drinking as the basis for their quality of life while sustaining abstinence and related life changes to support recovery. Each had an identity of such for at least five consecutive years at the time of the interview. The mean length of recovery for all participants was 15.8 years. All participants volunteered, signed informed consents to participate, and were assured com-

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plete anonymity. Each received a $200 honorarium upon completion of the interviews and their approval of the interview transcript.


Data Collection and Analysis The research team used direct (recorded) interviews following the methodology of interpretative phenomenological analysis (IPA) as described by Ricoeur (2005), Giorgi (1970, 2009), and Smith (1996, 2004). Each interview consisted of 18 questions (see Table 1) about the participant’s experience of recovery. The questions were submitted to each participant 24 hours before the actual interview to provide time for reflection. Additionally, each participant was afforded the opportunity to add any thoughts about the nature of his or her personal recovery or recovery in general that were not addressed by the questions. Each interview was then transcribed and presented back to the participant for confirmation of accuracy and for any desired revisions. These ‘‘approved’’ transcriptions became the raw data for theme identification. After identifying key themes, the researchers further compared their individual IPA analyses with an analysis of themes as gathered by ATLAS.ti, a computerized program that codes responses for easier qualitative analysis. IPA and ATLAS.ti.5 provided a frequency of identified themes. The two sets

TABLE 1 Interview Questions for All Subjects 1. Please briefly share the story of your personal recovery from alcohol or other drug dependence. 2. Based on your own experience, how would you define recovery? 3. For you, when did recovery begin? 4. Were their specific moments, factors or acts that for you were the beginning of your recovery? 5. What role, if any, did professional treatment or support play in your attaining recovery? 6. What has been most difficult for you in your recovery process? 7. What was most helpful to your beginning recovery? 8. What has been most helpful to you in maintaining your recovery? 9. Have there been recognizable stages within your recovery? If so, please describe them. 10. What role have others played in your recovery—positive or negative? 11. What things do you tell yourself that help you stay on track with your recovery? 12. What has been the response of other people (family, friends, coworkers, etc.) to your recovery and what have those responses meant to you? 13. What do you think everyone should know about recovery? 14. How have the relationships in your life changed as a result of your recovery? 15. What role, if any, has helping others played in your recovery? 16. Have there been changes in the (kind or) frequency of your recovery support activities over the course of your recovery? 17. Did ‘‘spirituality’’ play a role or importance in your recovery? If so, please share how or in what way. 18. Did mandates or participation in supervised treatment assist you in attaining recovery? If so, please share how or in what way.


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of themes were then compared and consolidated for each participant and pathway by each researcher individually and then collectively. Throughout, researchers noted similarities and differences (tensions) in their analyses of each participant to capture nuances and the varied perspectives of each researcher (Walsh & Koelsch, 2012).


FINDINGS Table 2 reports all themes identified and their frequency across each pathway. Summarized below are the major themes with that emerged, with selected excerpts illustrating each. We present first the commonalities experienced, then explore distinct elements within particular pathways, and finally note identified gender and cultural variations.

DISCUSSION OF FINDINGS Multiple Pathways of Recovery The study was able to confirm the existence of secular, spiritual, and religious pathways (organizing frameworks) as three broad but viable pathways to recovery that possessed shared and distinct features. STAGES

OF RECOVERY

Each narrative revealed three progressive stages of recovery: a transition from prerecovery to recovery initiation, where heightened receptiveness and an increased motivation for change served as a catalyst for change; a subsequent stage of initial recovery stabilization, where abstinence and health and wellness began and participants’ social environment changed; and the transition to long-term recovery maintenance, marked by a redefined positive identity, a reconstruction of social supports, and continually improving quality of one’s personal, family, and community life. I would say for me there were three [stages of recovery]. There was the initial one, sort of a struggling stage : : : where I realized the path I was on was going to lead to bad consequences, but I wasn’t sure how to define a successful way to address the problem. Then after I talked with the doc [primary care physician], there were six months which were challenging: : : : At the beginning of every day, I would come in the office, pull out a little calendar sheet and put a red sticky dot on the day before to represent the fact that I hadn’t had anything to drink. After the month was up, I had this sheet of red dots. I still have the 6 months of calendars with red dots on every day. That exercise allowed me to measure and

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TABLE 2 Themes of Recovery across Pathways

Prerecovery to recovery initiation Begins amidst hopelessness or pressure Heightened ambivalence about drug life Increased awareness of consequences Failed attempts at abstinence Involves transformative experience w/hope and help seeking Initial recovery and recovery stabilization Begins with synergy of pain and hope Transcendence of self for change or help Self-transcendence to external help Self-assertion for internal change Plan begun to achieve positive change Plan includes needed medical support specialized addiction treatment mutual aid medication identification with similar others support of family support of friends offers a change of one’s identity or self-narrative benefits self benefits others involves enmeshment with others in recovery gender specificity cultural support character reconstruction (better person) improved quality of life improved physical health improved peace of mind involves distinct life changes/new social supports Long-term recovery maintenance Identifies as a person in recovery cycles of recovery renewal continued improvement of physical health emotional health relationships spirituality/life purpose/meaning service to others sustained by: spirituality secular spirituality sense of self as a better person in recovery

AA

NA

SOS

Natural

Medication

x x x x x

x x x x x

x x x

x x

x x

x

x

x

x x x x x

x x x

x x x

x x

x x x

x x x

x

x

x x

x

x

x x x

x x

x x x x x x x x

x

x

x x x x x x x x

x x x x x x x x

x x x

x x x

x

x x

x

x x x

x x x

x x x

x x

x

x

x x

x

x x x x

x x

x x

x x x x

x x x x

x x x x

x x

x x

x x

x

x x

x x

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

x x x x x

x

x x x

x x x

x

x x

x

x

x

x

x x

x x

Religious

x (continued)

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Interpretive Phenomenological Analysis of Addiction Recovery TABLE 2 (Continued)


AA facilitated by: continued medical care and/or medications defining one’s past as illness vs. addict/alcoholic understanding of AOD use on self understanding of addiction as brain disease seeing life improvements does not have to have intermittent relapses may have emotional relapses w/o chemical strengthened by: sustained abstinence positive identity as person in recovery neutral identity as person in recovery reinforcing clarity and purpose in life continued transformation and self-development helping others or giving back sees recovery as shared goal whatever pathway reduction in peer enmeshment/more individualized

NA

SOS

Natural

Medication

Religious

x

x

x

x

x

x

x

x

x

x

x x

x

x x

x

x x

x x

x x

x x

x

x x

x x

x x x

x x

x x

x x x

x x

x x

x x

x x

x

x x

x x

x x

x

x x

x x

x

x

x

x

x

x

AA D Alcoholics Anonymous; NA D Narcotics Anonymous; SOS D Secular Organizations for Sobriety; AOD D alcohol and other drugs.

record each day, and gave me something tangible to show for it. That six-month period was kind of the sort of ramp-up to this new way I was going to live. Then for probably, I don’t know, three to five years, there was a getting used to this new life and building a new way of living, and a new identity without the alcohol. After that, it’s been: ‘‘I just live a life without drinking alcohol; it’s no longer even an issue.’’ (Natural recovery)

Initial Stage: Prerecovery and Recovery Initiation The prerecovery stage, sometimes begun amid hopelessness and pressure from others, most often involved heightened ambivalence, discontent, and even futility in the person–drug relationship, a painful or humiliating event, a sudden transformative experience, a turning point and insight, and then a sense of hope that triggered help-seeking. Putting the baby up for adoption caused me to snap in one way and hit a bottom in another way: : : : I pretty devastated in the parking lot of that hospital. You know, when I drank that last beer before I went inside—

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my thought was, ‘‘either this is going to work or I’m going to kill myself.’’ I was really at the end of my rope. (AA female recovery) Recovery initiation was often a synergistic blend of pain and hope. So my recovery and really attempting to not drink and live a sober lifestyle and do something different with my life began August the 4th of 1989 on a deathbed in an emergency room being told there was nothing they could do to save my life. That point was when I asked the Lord for help and into my life and that’s when my recovery began : : : at that point when everybody else had given up on me, I’d basically given up on myself and I’d basically said, ‘‘if there is a God, now is the time. If you want to prove to me that you are God, you do something about my situation, you save my life. And if you do that and you can prove that you’re real then I’m going to serve you.’’: : : I believe with all my heart that had I not received Jesus Christ as my Lord and Savior and asked him for help that I’d have been dead in 1989 : : : nothing but a miracle saved my life. (Faith-based recovery)

Recovery initiation is aided by but not dependent upon medical treatment, specialized addiction treatment, and/or participation in a recovery mutual aid organization. Treatment seemed most important for the medicationassisted pathway and most effective when engineered in alignment with an individual’s recovery intention, plan, and progress. For medication-assisted recovery, understanding addiction as a medical (e.g., brain) disease with physical underpinnings seemed critical, especially in countering historical stigma attached to this pathway and the use of medications. And then after about twenty years of this [relapsing after going off methadone], I eventually ran into J— and the National Alliance of Methadone Advocates : : : they told me that I had a brain disorder and [asked] why am I beating myself to death and being so ashamed of myself. [I figured out that] I was living a good life and that I had a chronic brain disorder, and I’m taking a medication for it. All of a sudden, all the shame and guilt went away and I started to feel good about myself. But the next thing is I got angry. I got angry because I thought, what about all the other patients? Why should everybody else have to wait twenty years like I did? I wanted people not to waste twenty years. You know, people go into methadone treatment or any kind of medication-assisted treatment and we look upon it as if we’re still getting high—we’re still using. In my own heart, I felt like I was still using because I was taking a medication. It wasn’t until I was able to put that behind and me and say ‘‘no, I’m not using, this medication is for a brain disorder, it doesn’t make me high’’— then I could get on with my recovery. (Medication-assisted recovery)

Recovery initiation can be sparked and strengthened by exposure to a recovery carrier, that is, a person in recovery whose quality of character makes recovery virtually contagious.


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He [12-Stepping AA member] took me to my first AA meeting even though I went in there with all of this resistance and this reluctance and was convinced that I wasn’t an alcoholic—that if you had my problems, you would have to drink too. But I went to that meeting and as I sat there, people went around the room and commented and I had what I call my ‘‘me-too experience.’’ Every person that commented had something that I could say, ‘‘me too.’’ At that first meeting of Alcoholics Anonymous, I fell in love with AA and I knew I was home: : : : I knew I could put the sword down. I’m not saying I put the sword down, but I knew I could. You know like, there was hope: : : : The love was so seductive that I’ve never been able to really leave Alcoholics Anonymous even though I’ve had periods of time where I’ve stayed away. (AA female recovery)

This process of identification was a pervasive theme in the interviews even when this identification transcended traditional boundaries: I hate to make race an issue here but if it weren’t for some White and/or gay members of the fellowship, I wouldn’t be clean. And remember when I got here, my two least favorite people in the world were White people and gay people. There were a significantly large number of White, gay people who loved me and supported me during my recovery. So not only were they going to go and help me and support me in my recovery, but they were going to help me overcome two barriers in my life that were prejudices in my life. They were going to be helping me change. They taught me how not to judge people based on race and how not to judge people based on sexual orientation or sexual preference. So those relationships were important. (NA recovery)

Recovery initiation can involve a transcendence of self, an assertion of self, or a mixture of the two. While all pathways relied on a heightened awareness and related cognitive-emotional shift, spiritual and religious pathways relied primarily on self-transcendence, and secular (and natural) pathways relied primarily on acts of self-assertion. God wanted me to help others. NA taught me not to judge others. A small group of fellow African Americans charged me with the responsibility to overcome my own addiction and stay clean long enough to bring other African Americans into the Fellowship. These dynamics were beyond anything I had planned but were what God wanted me to be. (NA recovery) After the third month of abstinence, I got it. I understood that this is the way I need to live my life in order to be effective, and that allows me to be proud of how I live. Living this life, there is far less depression and I feel considerable accomplishment that I’ve done this. I’m now on month 400 or so. (Natural recovery)

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But my hatred at that point, for my mother and brothers, sustained me. It kept me sober for a long time. I would think about drinking and I would immediately see their faces and think—I’m going to win! And the only way I’m going to win is to not pick up a drink. (AA recovery)


Our female participant revealed gender-specific themes not evident in our male participants. She reported sabotaging attempts by family members and described struggles with safety and intimacy during the recovery process. I saw this pattern of not being able to sustain connections with people : : : it frightened me to think that if I couldn’t sustain my connection to AA, eventually I was going to get drunk, but AA is so enormous that all I did was move on into new groups, new friends, new meetings, you know, new connections, and I never stopped working the steps and I always had new friends coming in, and people I was leaving behind and so, the attachment disorder was the thing that frightened me the most. And part of me attracted abusive relationships, although nobody ever hit me from the time I walked into Alcoholics Anonymous, I still attracted narcissistic, controlling men and women. But I was disengaging from them faster but still having a hard time getting close to people. That really frightened me. (AA female recovery)

She had needs best met by other females and presented a mix of selfsurrender and self-assertion in differentiating herself from past identities. Recovery for me was getting and staying on the path of recovery and that being embracing all of the recovery rituals that I was learning in Alcoholics Anonymous. But it was also personal growth because I had a lot of self-discovery that had to be done. I was clearly suffering from a lot of post-traumatic stress but didn’t know it and I was battling the prevailing myth back then that women should not address these issues until they were sober a year. And I was defiant. It was another one of those—we could call it a flaw that served as a gift—I was so defiant I noticed that when I was able to talk freely about things that I had gone through, when I talked freely about those things with other women, we were all staying sober, and the women who had these issues and didn’t have anybody to talk to about them were relapsing. (AA female recovery)

The one African American situated his individual recovery within a broader cultural context of recovery for African Americans. There was also that small group of African Americans who charged me with the responsibility not just so I could overcome my own addictions, but that we had a bigger goal. And that was to stay clean long enough that we could attract thousands of other African Americans to the fellowship who we believed could benefit from this program : : : I needed to stop using drugs, to stop using chemicals in order to be the person that


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God wanted me to become so that I could help others : : : So for me to have witnessed this miraculous growth from ten or eleven to three thousand African Americans involved in Narcotics Anonymous [in CITY] : : : is nothing short of a miracle. (NA recovery)

Stage 2: Initial Recovery Stabilization


Five participants emphasized that initial recovery stabilization involved more than mere cessation of AOD use, mentioning as critical their identification with others in recovery, experiencing support from family and friends, and their own character/identity/narrative reconstruction. : : : a major role in my life is keeping my heart clean and keeping the shame and guilt and self-condemnation from driving me back down into a place where I’m hopeless again and the only solution is to go drink: : : : You have to realize that other people are a little bit more important than you are. And that the world doesn’t revolve around you. And that everybody’s not there to serve you but that you play a role in helping to serve other people: : : : I began to heal on the inside from the emotional scarring and the damage that had been done emotionally as a child by learning to forgive and to let go and put those people into God’s hands and not my own. (Faith-based recovery)

The exception to the need for character reconstruction was the participant representing Secular Organizations for Sobriety: I’ve known some real sober bastards : : : they know how to do sobriety but they are real pricks : : : and there are some real sweethearts who are still drunk : : : there’s nothing wrong with getting good. If you stole hubcaps when you were drunk, we hope you stop doing that. But if you don’t, you might be able to stay sober : : : I am thrilled by staying sober with other unresolved issues raging. I think that’s a very hopeful, helpful thing : : : mafia chieftains can stop drinking and continue being mafia chieftains I suppose. I’m not advocating that; I’m just saying it’s a separate issue from recovery. (Secular sobriety)

For most, initial recovery stabilization involved an enmeshment with others in recovery. All but the person in natural recovery reconstructed their social world. The participant in faith-based recovery illustrated such enmeshment over time: I don’t go to 12 Step groups anymore. I’ve helped found several such groups that I go to and touch base with people I’ve worked with over the years. I have a support group, but it’s my peer group around me today. I think more than anything on the planet, a peer group is a source of accountability. I don’t seek out the AA, the NA, the CA type groups

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anymore. I stick with people that believe as I believe, in Jesus Christ as Savior : : : we have a right to speak the truth to one another if [we are] struggling or we see one another not doing the right thing: : : : I have friends around me today who step up today and say, man I see that you’re struggling and you haven’t said anything and I’m wondering why? I give them the right to do that. We have a close enough relationship they can do that. And I have a close enough relationship with them that I can do that with them too. We’re a safety net for one another. We have group every day [laughter]. You know what I mean? (Faith-based recovery)

The natural recovery participant at first distanced himself from his social world but then later re-engaged it once he had attained abstinence and a confidence in his identity as someone who no longer wanted to drink either on his own or when with others. All participants viewed recovery as a lifelong process, often depicting that process as involving cycles of personal renewal, continued spiritual or personal growth with improved health, relationships, self-respect, honesty, self-knowledge, and self-regard. For most, a ‘‘belief’’ system or form of spirituality played an integral part in recovery. [Recovery is] taking responsibility for your life, for the hurt that you’ve caused. [It’s] surrendering your life, in my case, surrendering my life to Jesus Christ and beginning to build relationships with healthy people and moving away from that type of lifestyle. It’s a lifelong process. It was taking ownership for the people that I’d hurt in my life. It was also seeking : : : peace in my life for the harm that had been caused me because I’d been abused terribly as a child, living in an alcoholic home : : : all played a role in my recovery. And my physical health—you know, getting healthy again. My mental state, my spiritual state, my emotional state—they all played a role : : : just staying sober is not recovery. (Faithbased recovery) Recovery is a process of change that allows the person or promotes the person to better health, to better self-respect, to better control over their own life and destiny and allows them to have much better quality of life and peace of mind. (Natural recovery) It [spiritualty] had nothing to do with it really. I mean I don’t know the answers. I’m more of an agnostic than an atheist but I think that [I have] more a scientific view—that’s actually the most reasonable view. (Secular sobriety)

For all but the natural recovery subject, recovery involved embracing a recovery-positive identity. I’m pretty open now about the fact that I’m in recovery. Sometimes people do have a negative reaction to it but it doesn’t bother me anymore.


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Some people can’t risk sharing that they are in recovery. My whole life, my whole world, my career, everything I am, my soul’s journey is all about recovery—so I’m not at risk: : : : I have come to see that the answers for me lie within. (AA female recovery)


The way I feel about myself and the way I feel about my place in the world is dependent on lots of things, but one of them is not using alcohol or drugs. A return to drug or alcohol use would create a big deficit in how I view myself and the way I hope other people see me, but I’ve never done a lot of public discussion [about this]. I mean, talking to you is the first time I’ve ever really talked in any depth about it [decision to stop drinking]. (Natural recovery)

Stage 3: Long-Term Recovery Maintenance Long-term recovery maintenance is sustained abstinence in recovery over cycles of renewal and numerous life events or issues. In this phase, a clearer purpose to life emerges while one continues to develop personally and to transform oneself in recovery. Often helping others or giving back to society becomes a form of practicing recovery even as previous enmeshment with recovery activities, fellowships, and supports diminishes. Recurrence of AOD use, often portrayed as common or even part of long-term recovery, did not occur in our subjects. It seemed that after prolonged (3C year) period of initial recovery stabilization (Phase 2) each participant moved into a strengthened identity and role where life challenges became more the focus than just sustaining recovery. Some did refer to emotional relapse that, when self-identified, helped prevent chemical relapse. I define an emotional relapse by a period in my life where I’m not using chemicals but my behavior, characteristics, and thoughts and interaction with people are based in total self-centeredness. Somehow or another even after being clean for 28 years and being a part of my faith-community and living out the spiritual principles in my program, occasionally I find myself reverting back to selfish behaviors where I don’t care how I might hurt somebody else or I might have offended somebody else or what happened to somebody else. And that’s a total contradiction to what my twelve-step and faith-based recovery have taught me—both have taught me to take care of myself so that I can always be in a position to help others. (NA recovery)

Helping others or giving back was a central theme in maintaining longterm recovery, with four of the participants embarking on public advocacy for recovery. So the fact that I know there are people out there who will die because they’ll never find recovery or end up in prison because they would never

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have access to recovery : : : that’s motivation : : : it’s a self-motivation that I give myself [and that] keeps me involved in this movement. And I call it a movement, the recovery movement. The movement that’s designed to make recovery as accessible to as many people as possible: : : : So this is not about me : : : It’s really about those who might live as a result of the work that I might do. (NA recovery)


DISCUSSION Recovery from addiction has an observable trajectory, shared themes, and an emerging common structure. That structure reveals three progressive stages. In the first prerecovery to initiation stage, personal suffering and growing disillusionment with drug use leads to an acceptance of one’s need for help and a transformative awakening to the possibility of and initial attempt to change. In the second initial recovery stabilization stage, cessation of AOD use is strengthened by increased support from others and improvements in the quality of one’s life, for example, personal health, new relationships, and life circumstances. This phase involves a transformed identity and selfimage, a newly emerging self-narrative, character reconstruction, and a reconstruction of daily lifestyle and social relationships. The third stage of long-term recovery maintenance involves not only sustained abstinence but also a continued improvement in one’s life, health, and character. In this phase one identifies positively as being a person in long-term recovery that involves continued self-insight, a sense of being a better person, sharing and giving back, and a deepening sense of spirituality and/or life meaning and purpose. Although enmeshment with peers in recovery may diminish, family and personal relationships are strengthened as one’s emotional and relational health improves. In addition to the common themes and structure that begins to emerge, internal themes within each of the six pathways and narratives pointed to unique challenges, opportunities, and adaptations reflecting the highly personal nature of recovery. Beyond the core common themes of recovery, some unique needs must be addressed for recovery to remain personally relevant, such as addressing medical, trauma, or abuse issues that could sabotage the ongoing recovery process.

Limitations and Recommendations for Future Research LIMITATIONS This initial study is based on a rigorous, qualitative analysis of a six-participant sample. Further exploration of additional participants is now needed to enhance or refine the general structure and science of recovery and the



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potentially distinguishing nuances of recovery relevant for particular populations such as women, trauma victims, adolescents, men, elderly, veterans, Native Americans, African Americans, sexual minorities, and others sharing distinct personal or cultural experiences. The study did not measure prevalence of the pathways studied, nor was our sample representative of all recovery pathways. Although this study focused on those in recovery, recovery itself occurs over time and often over numerous attempts in many cultural settings, within varying ideological frameworks. In this regard future research will need to further refine the structure of attaining or seeking recovery by exploring such attempts as moderated recovery (remission achieved through decelerated AOD use), failed recovery, and recovery attained through clinical interventions such as psychotherapy, recovery supported by various types of medication, and the elements of natural recovery itself (Vigilant, 2008; Waldorf, 1983; White & Mojer-Torres, 2010). Additionally, often used clinical constructs such as selftransformation, personal empowerment, self-actualization, characterological change, or just turning points (Koski-Jannes, 1998; Yeh, Che, Lee, & Horng, 2008), gender distinctions (Kelly & Hoeppner, 2013) and recovery within the context of other illness (Tangenberg, 2001), or within physical or mental limits, merit further exploration. The obvious need for continuing care seen herein also opens the question of how to best provide recovery support and treatment for a chronic illness (Dennis, Scott, Funk, & Foss, 2005; McLellan et al., 2000; White, 2007a). FUTURE

RESEARCH AND DEVELOPMENT

Each of the study limitations points to an area for future research. Further studies are needed to strengthen or reject the finding that a structure of recovery exists across recovery pathways and to illumine additional themes across the pathways and stages of recovery. As a common structure is expanded, it should be refined for population variances. All pathways to recovery must be included, examining their distinctive and shared elements and variations in personal styles as well as their related cultural context. Additionally, each stage of recovery needs further analysis to understand better the transition steps and processes. Much could also be learned by studying those who fail to make the transition from ‘‘prerecovery’’ to recovery stabilization or across stages and by further comparing professional and peer supported pathways of recovery with natural recovery (reported to be account for up to 78% of those in recovery; Dawson, 2005; Sobell, Cunningham, & Sobell, 1996; Vaillant, 1995). Such studies would shed additional light on components critical to attaining recovery while elucidating the treatment and recovery support services needed to better accommodate the varieties of recovery experience and stages of recovery (White & Kurtz, 2006b). Transcending the pathology paradigm requires a new organizing philosophy of care—‘‘recovery management’’ (Skipper & DuPont, 2011; White


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& Kurtz, 2006b; White, Kurtz, & Sanders, 2006)—that connects a broadened clinical understanding and practice with the lived experience of long-term recovery. Abstinence remains foundational in this view, but it is connected to a larger process of personal healing, growth, and purpose rather than being an end in itself. This broader understanding of addiction and recovery can open new ways and measures to enhance prerecovery engagement, recovery initiation, recovery maintenance, long-term recovery—and ultimately the quality of life for the individual, family, and community. Lastly, the identification of shared themes across varied pathways to recovery and the emerging general structure therein promises an enhanced paradigm of understanding requiring a broadened research agenda and national policy that truly unites individual, family and community participation and wellness with best science and practice for the measureable health, wellness, and quality of life of all (Flaherty, 2012a, 2012b).

CONCLUSION An analysis of six differing pathways to personal recovery from addiction reveals that a general structure of recovery exists and needs to be elaborated upon to improve clinical treatment and long-term recovery support. An emerging science of recovery based on both quantitative and qualitative studies would make a significant paradigmatic advancement within the alcohol and other drug problems arena.

FUNDING The authors express gratitude to the Institute for Research, Education and Training in the Addictions in Pittsburgh, Pennsylvania, for its partial financial support of this study.

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