This page is intended to be an overview of key ideas & the addiction recovery process, to compliment the understanding & guide readers through the Recovery 101 Tab. The individual pages of the Recovery 101 Tab summarize strategies mentioned on this page in greater detail.
Substance use disorder recovery is a process that often takes individuals several years to achieve & involves multiple change attempts.
A prominent model of behavioral change that cuts across theories – the transtheoretical stages of change – serves as a useful way to understand this change process.
Different Stages Of Change Necessitate Different Recovery Management Strategies:
As illustrated by the hatching chick diagram above, before starting the change process toward recovery individuals with substance use disorder (SUD) are in the “precontemplative” stage. While they do not yet recognize having a substance-related problem, other people around them often do notice a potential problem.
Typically with an accumulation of negative consequences and feedback from people in their lives, they begin to consider that problems arising in their life could be related to substance use – the “contemplative stage.” During this time, individuals wonder if it might help to reduce or quit using.
The goals of these interventions range from strategies aiming to help keep people safe and address the broader public health consequences of substance use (“harm reduction”; e.g., spread of infectious diseases like hepatitis C and HIV) to strategies aiming to enhance their motivation to change (e.g., motivational interviewing).
Only 11% of individuals that meet substance use disorder (SUD) criteria receive specialty addiction treatment each year, and most of these people do not feel they have a problem or that they need formal addiction services to help them change. So these “precovery” approaches often cast a wide net, and are appropriate to use in general (i.e., non-specialty) health care and community settings, such as county hospitals and community health programs.
Although often separated traditionally from substance use disorder (SUD) treatment and recovery systems, these services are without question integral pieces of a public health approach to addressing SUD, and, by association, are ideally included in an overall model of recovery management.
PREPARATION & ACTION
As individuals decide to take active steps to change their substance use – during “preparation” and “action” stages – the focus shifts to clinical and non-clinical interventions. Pages in the Recovery 101 section highlight several different types of clinical interventions, including both psychosocial strategies and medications, and the scientific evidence for these treatment approaches. While scientific evaluations of these interventions occur in particular clinical settings, for the most part programs can deliver these clinical interventions at any level of care, ranging from standard outpatient to long-term residential treatment.Click here for more on Levels of Care
Even for people who initiate and sustain recovery, it can take many recovery attempts over the course of several years 9+ years. Once individuals make that initial change and establish a period of early remission (i.e., 3 months), how well they can maintain and build on that change is key – during the “maintenance” stage.
Given that there are dozens of psychosocial treatments and medications that can help people reduce or quit using over the short-term, many have argued that how well treatment programs and public health systems support the continuation of change (continuing care (also called “aftercare”), just after an acute treatment episode, and recovery monitoring, over the course of the following several years) is among the field’s greatest challenges.
To paraphrase recovery scientist and scholar Keith Humphreys:
Given the long-term propensity of problem recurrence during substance use disorder remission – at least for the first several years – developing & testing ways to extend treatment models, rather than how to intensify them, is likely to produce a more fitting approach to addressing addiction & its myriad consequences.
State-of-the-art approaches to help extend benefits can range from targeting the maintenance of substance use disorder (SUD) remission and recovery as early as 3 months, through multiple years, and in some cases, for the remainder of an individual’s life.
Toward a More Thorough Understanding of the Course of Substance Use Disorder Recovery
How People Benefit From Substance Use Disorder Therapies: The Factors Involved
There have been literally hundreds of studies investigating the effectiveness of psychosocial approaches, where active treatment ingredients are delivered, usually by a clinician, to the patient via talk therapy (these strategies are sometimes packaged in technology-based interventions as well).
Click here for more on Recovery Technology
Overall, when two or more treatments compared to each other are designed based on a sound theory about how people change, and treatment sessions are structured to target those theoretical change processes (i.e., active treatments), there are typically very few differences in patient outcomes. Put another way, there are many “empirically-supported” active substance use disorder (SUD) interventions that are certainly better than no treatment or an intervention where the patient simply receives perhaps some general education or support (i.e., inactive intervention).
When compared to each other, however, these active substance use disorder (SUD) interventions typically produce very similar levels of benefit. Thus, recovery research experts surmise the bulk of why treatment is helpful has less to do with the specific “ingredients” of the treatment, and more to do with common factors present in high-quality therapy – which is supported by evidence when it comes to alcohol use disorder interventions.
These common & relational factors include:
- having a coherent theory of how people change
- the empathy and support provided by the therapist
- whether the therapist and patient are on the same page in terms of treatment targets and goals (“alliance”)
- the extent to which the patient believes the treatment will be helpful, and how well the therapist can help adjust the treatment to the patient’s particular clinical needs.
The predominant influence of common factors on outcome versus specific factors is sometimes also referred to as the contextual versus medical (or “technology”) models, respectively. This is not to say whether therapists deliver an empirically supported treatment is unimportant, but rather, generally speaking, it does not matter what type of empirically supported treatment they choose to provide in the short-term.
This greater influence of common versus specific factors in what explains patients’ substance use disorder (SUD) treatment outcomes is consistent with the breakdown of patient outcome influences in other psychotherapies as well.
Two Developmental Models of Recovery
1) The Life Course Perspective
As outlined by addiction scientists Yih-Ing Hser and M. Douglas Anglin, substance use disorder (SUD) recovery is not a “one-size-fits-all” proposition. Different factors influence the onset of SUD (i.e., that lead to the development of problems), as well as SUD remission and recovery. The life course perspective – suggesting the factors affecting SUD onset and recovery depend on age and other developmental considerations – is one useful model to understand how different approaches are needed to help different people achieve and sustain SUD remission.
For example, compared to older adults, younger adults have higher rates of substance use disorder (SUD) and other hazardous drinking. Therefore, for younger individuals in, or seeking, SUD recovery, they have less access to recovery-supportive people and environments. In fact, the most common precursor to relapse for young people are social situations where alcohol and other drugs are present. The salience of drinking and other drug use in their social ethos, and the more modest accumulation of substance-related consequences compared to older adults, on average, also explains why they are likely to begin a recovery attempt with more ambivalence about change.
In terms of their substance use disorder (SUD) recovery needs, therefore, young people may need greater attention to developing skills that help them access recovery support. In parallel, compared to older individuals beginning a recovery attempt, they might need more ongoing attention to their motivation for reducing or quitting substance use because abstinence and recovery is not being naturally reinforced as much by people in their social networks.
2) The “Hierarchy of Needs” Perspective
Just as individuals’ substance use disorder (SUD) recovery needs might be different depending on their life course stage, so too might they be different depending on their recovery stage. What someone in SUD recovery needs to help them sustain SUD recovery will be different if they have 3 weeks versus 3 months versus 3 years, and so on.
Based on his work with addiction treatment patients, substance use disorder (SUD) recovery expert Terence Gorski outlined six recovery stages each with distinct goals:
Indeed, there are emerging qualitative data based on retrospective interviews with people in long-term recovery (i.e., they report on their past experiences) in support of this theoretically-grounded model of recovery over time.
Similarly, from the more general perspective of psychologist Abraham Maslow’s Hierarchy of Needs, for example, early on, the recovery process may necessarily focus on strategies to remain abstinent, consistent with Maslow’s model goals of attending to physiological needs and safety. As individuals are able to meet those needs, they may be able to focus more on expanding their social life and enhanced personal growth – attending to “love and belonging” and “self-esteem”, and ultimately toward becoming their best selves and achieve “self-actualization.”
While longitudinal studies that measure outcomes over time are needed to test these hypotheses about recovery trajectories, these models explicating how recovery goals might change over time may already provide utility in understanding and applying addiction treatment and recovery science.
Gorski, Terence T. “Recovery: A developmental model.” Addiction and Recovery 11.2 (1991): 10-15.
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47(9), 1102-1114. doi: 10.1037/0003-066X.47.9.1102