Recovery from Addiction
There can be many different pathways to remission. But the mechanisms by which people change are the same. Here’s what’s needed for recovery.
By John F. Kelly Ph.D., ABPP published December 30, 2019 - last reviewed on September 15, 2020
Despite what people may tell you, changing behavior is easy. It’s maintaining change that’s hard—creating new and sustained ways of thinking and behaving. As Mark Twain quipped, “Quitting [smoking] is easy, I’ve done it dozens of times.” Many can begin a positive health behavior change, but most will run out of gas before they’re around the first bend.
The tragedy of the opioid epidemic, which has killed hundreds of thousands of individuals over the past 20 years, has thrust addiction into the spotlight, forcing a consideration of what addiction is and what helps people overcome it and recover. Not to discount the anguish caused by this epidemic, but there is some good news: Much has been learned about the nature of addiction, the processes of behavior change involved in recovery, and the active elements in the pathways that people take into remission and long-term stable recovery.
It is now well known that the repetition of rewarding behaviors produces changes in brain function and structure that facilitate habits and, for some, sustained compulsivity and addiction. Like other complex illnesses and disorders, addiction is multifactorial, resulting from a combination of genetic, social, psychological, and environmental forces.
Genetics plays an important role in conferring vulnerability to addiction. Genetic factors influence how substances are metabolized and experienced. Such biological differences can influence whether substance use continues and increases, remains “social” and occasional, or does not occur at all. In the early stages, however, those more genetically vulnerable to addiction are unaware of the risky path they are on; their experience is merely of a memorable and highly desirable new discovery.
The processes of neural plasticity and neural toxicity that deeply entrench the behaviors of substance use in the brain can make those behaviors difficult to change. Nevertheless, data bear out that most people who meet the clinical criteria for an alcohol or other drug use disorder achieve full recovery. In fact, the latest figures from the National Survey on Drug Use and Health indicate that among those who had an alcohol or drug problem, the remission rate is approximately 75 percent.
In 2016, my colleagues and I surveyed another nationally representative sample. We discovered that the national prevalence of those in recovery is approximately 9.1 percent, or 22.35 million U.S. adults. Nearly one in 10 persons in the U.S. has recovered or is recovering from a substance use disorder.
The statistics are tremendously encouraging about recovery. Still, it’s important to recognize that the recovery change process itself is very difficult. The journey to remission can be bumpy, and it can take a long time.
The Stages of Change
Hundreds of studies of addictive behavior change reveal that a common process underlies all progress toward recovery. Researchers have identified and mapped out five stages of change, and they can be used as a kind of recovery GPS—a guide to determine where anyone may be in the process of recovery.
In the first stage, precontemplation, substance users are largely unaware that their alcohol or drug use is causing problems. But to others around them, it may be very clear that substance use is costing more than just money. Over time, substance users move into a contemplation stage and begin to consider the possibility that use has some negative consequences.
A decision stage follows, marked by the intention to do something about the substance use. It is followed by an action stage—actual, concrete behaviors are learned and performed to transform the decision into tangible operations. In the maintenance phase, skills are deployed and processes are engaged to sustain the initial changes over the long term.
Relapse should be considered a sixth stage, a nearly inevitable part of the process of change. After a return to old behaviors, people make a decision to resume their active strategies of coping, facilitating remission and recovery. Recovery from addiction is a developmental learning process, and people often stumble as they progress along a new and unfamiliar path. Eventually people in recovery become confident navigators.
While it is common to blame oneself for a fall, overly engaging in self-denigration is rarely helpful in recovery. The important thing is to take a look back to notice where you fell and what caused the stumble. Taking stock of the impediments enables people to learn as they go, staying more vigilant and discovering the nature of the terrain, diminishing the likelihood of making the same mistake going forward.
Change is always difficult, and the temptation is constant to fall back into old and familiar patterns of thinking and behaving. Creating a new path takes proactive effort and much repetition before it feels comfortable. Happily, you don’t have to make all the mistakes yourself to learn what to do. Learning vicariously from others’ wrong turns is smart. Their missteps, when observed or communicated, provide guidance in how to proceed.
Step by Step
The principle of equifinality states that there can be many different pathways to a common developmental endpoint. In this case, the endpoint is remission. Any and all pathways should be cause for celebration. While our cultural psyche tends to default to a clinical recovery pathway involving some kind of mix of rehab and/or AA—which can be lifesaving—in fact, many recover without using any external services. Others make use of medications, and still others recover with religious or spiritual guidance.
No matter the pathway to recovery, the mechanisms by which people change are the same. Research shows that whether people make use of formal clinical services, mutual-help organizations like SMART Recovery and AA, or find their own unique path, they engage a common set of tools.
From an extensive review of the literature, Mary Leamy and colleagues at King’s College London synthesized information about people’s experience of recovery and identified key features of the recovery process. The ingredients of successful recovery can be summarized by the acronym CHIME: connection, hope and optimism, identity, meaning and purpose, and empowerment.
Connecting with others also in recovery can be key to staying on the path, traversing rough terrain, and simply being able to tolerate and even enjoy the journey. Carl Jung described such social connections in addiction recovery as the “protective wall of human community.”
The example set by others who have successfully traversed the recovery terrain can instill hope and optimism, another active recovery ingredient. Role models make recovery visible, tangible, possible. Actively seeking input from peers on the path to recovery, a clinician, or both can be invaluable early on. Intensive support is often needed for staying on track.
When the going gets tough—as it often does early in recovery—a coach can help you keep to your goals. Frequent feedback, encouragement, and support are vital, because physical and psychological resilience are still low, and the temptation is to give up and give in.
As people move along the recovery path, they not only gain new skills, they also begin to view themselves differently. A shift toward a new positive identity occurs as they encounter themselves in a new light. Frequent intoxication and, more broadly, the addictive process often mean that people have violated their own values, morals, and standards. They feel intense remorse, guilt, and regret, and have a poor self-image. Through the recovery process, behavior again begins to align with their values and goals. Integrity, self-confidence, and self-esteem grow, laying the foundation for a more positive identity.
New meaning and purpose compose another active ingredient of recovery. Sometimes the renewed sense of purpose is framed as spirituality. In my own research, investigating a nationally representative sample of recovering persons, I have found that the sense of spiritual connection is particularly true among African-American and Hispanic individuals.
But new meaning and purpose can come from many sources— family, social connections, work, or renewed recreational interests. The point is that there is value placed on these new sources of activity, and that value confers new rewards that can compete with and overtake the desire to return to substance use, supporting sustained remission. Recovery community centers have emerged around the country, and through the employment linkages they offer, they can facilitate future orientation and new enthusiasm for life.
Empowerment is another necessary mechanism of change; in psychological parlance it’s known as self-efficacy. It stems from the ability to consistently cope with the demands of recovery and a new life.
The Nitty-Gritty Skills of Recovery
Yet one more acronym captures the skills people actually deploy to successfully navigate the tricky terrain of early recovery. It’s DEADS, for delay, escape, avoid, distract, and substitute. When, for example, cravings hit, a helpful strategy is to self-negotiate a delay of use. This is a cognitive maneuver that doesn’t deny the possibility of future use, but rather, seeks to delay it. It relies on the fact that most cravings dissipate within 10 to 15 minutes and that waiting it out (or better, getting busy with something else) will result in a happier 15-minutes-from-now experience rather than a capitulation.
Escape is fairly self-explanatory. A lot can be at stake in a relapse, including life itself; doing whatever is necessary to ensure a way out of high-risk situations is essential. Having a “parachute” ready for such eventualities takes a little preparation and knowledge that some situations (such as a social event or party) will in fact be high risk. Strategically avoiding an event, a person, or a situation with a polite excuse can yield lifesaving dividends, especially early in recovery.
Distraction can also help interrupt craving-induced thoughts of using, which can gather momentum. Rapid interventions—cognitive, such as calling to mind a particular recovery idea or reciting a mantra or saying a prayer, or behavioral, such as reaching out to a recovering friend or reading something recovery-related—can derail that locomotive before it leaves the station.
Finally, the S is for substitute. For many with an alcohol problem, drinking a different kind of beverage can keep recovery on track. Such a simple maneuver maintains all the behavioral actions of drinking—while eliminating the active drug (ethyl alcohol)—and that can be enough to at least partially mollify the brain’s reward pathway.
Today, this very minute, there are tens of millions of Americans successfully in recovery. The principle of equifinality rings true: There are many pathways to liberation and a happier ending. Find one that fits and begin the journey sooner rather than later.
From Crisis To Solution
It’s a call anyone might dread but that has become only too commonplace in the opioid crisis. Someone you love is in the emergency room with a substance use problem, their release is imminent, and you have to quickly act to leverage the situation into a long-term solution. How do you find a high-quality addiction treatment program, one that you can afford?
Here are 12 things to look for:
- Whether it’s an inpatient or outpatient facility, does it screen patients comprehensively for a range of substance use disorders as well as physical and mental health conditions?
- Does the program address substance use and other existing problems in an integrated way?
- What kinds of recovery support services and continuing care are provided for patients after they complete the first phase of care?
- Does the treatment program provide as dignified and respectful an environment as would be found in other medical settings?
- Does the program involve the patient’s significant others in the treatment, which increases the odds of sustained recovery?
- Does the program engage specific strategies to enhance and maintain patient retention during the first weeks of treatment, when the dropout rate is highest?
- Are the program’s services based on scientific research and principles? Such evidence-based care is linked to better outcomes.
- Is there a credentialed staff representing diverse disciplines—such as addiction, medicine, psychiatry, spirituality? This is a generally reliable indicator of quality.
- Is the program attuned to the potentially distinctive needs of men and women, LGBTQ+ populations, and persons of other cultural backgrounds?
- Does the program collect data on patient outcomes and provide that information to prospective patients and their families?
- Has the program met the standards of and been accredited by an external regulatory organization?
- Will insurance cover the cost of treatment? Coverage for addiction treatment is complex and varies from plan to plan. You’ll need to call the member services department of your insurance provider; make sure to have your insurance card and membership identification number at the ready.
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