“Being present for your life again”: Young adults’ views of recovery
In the United States, there is a large gap between the number of young adults with substance use disorder and the number who engage with specialty addiction treatment. Reasons accounting for the difficulty of engaging this population include both individual barriers (e.g., motivation) and external barriers (e.g., lack of treatment affordability or access). In this study, researchers explored perspectives of recovery among young adults with substance use disorder to better understand some potential ways to reach this population and address barriers to engaging them in treatment and recovery support services.
WHAT PROBLEM DOES THIS STUDY ADDRESS?
Engaging and retaining young adults in addiction treatment can be very difficult. In 2019 in the United States, 14% of young adults needed treatment – meaning they met criteria for substance use disorder or received specialty addiction treatment – yet only 1.7% initiated it. As well, research has demonstrated that young adults are less likely than older adults to remain engaged in treatment for the suggested duration. While addiction severity, personal motivation and readiness for treatment are strong indicators of treatment engagement, other research indicates a variety of reasons for the difficulty of engaging this population. For example, there may be internal barriers such as denying that there is a problem, less developed frontal lobes (associated with emotional and behavioral regulation) relative to adults coupled with greater independence than adolescents, interpersonal barriers such as a lack of supportive family or friends (or actively using individuals in their network who provide easy access to substances), or larger system-level barriers such as a lack of treatment affordability or availability. Other studies have indicated that dropping out of treatment is due to feelings of unmanaged cravings, not being able to cope with experiencing negative emotions, or feelings that the treatment was not supportive enough of their particular needs during the process. This study aimed to explore perspectives of recovery among young adults with substance use disorder to better understand some potential ways to reach this population and better address barriers to their engagement with treatment and recovery supports.
HOW WAS THIS STUDY CONDUCTED?
This was a cross-sectional, qualitative study. The researchers conducted in-depth individual interviews (40-70 minutes long) with 20 young adults (21-29 years old) who had current opioid use disorder. The researchers used an interview guide that included open-ended questions covering addiction and recovery, and although they only included patients with opioid use disorder, recovery was discussed as a “whole” rather than specific to their opioid use. The interviews were audio recorded and were then transcribed. The transcriptions were analyzed using an iterative categorization approach, meaning that the researchers read through the interview data several times and created a set of codes. The team used these codes to systematically describe and categorize the interview data. The researchers then further categorized these codes into four overarching themes they felt the data represented.
This sample of 20 young adults who use opioids were recruited from an urban safety net hospital in Massachusetts. The majority were male (65%), Non-Hispanic, Caucasian (75%), and all but one had current or past experience with receiving medication treatment for an opioid use disorder.
WHAT DID THIS STUDY FIND?
The Recovery Process was viewed as a holistic process.
These young adults described multiple needs that they needed addressed which would require different types of supports and programming in addition to medication treatment and substance use changes. For example, several participants reflected that they needed to engage in mental health services to learn better emotional responses and coping, as well as engage in other activities to enhance their day-to-day lives (e.g., job training, social groups).
“If you utilize everything around you…you’re going to have the most successful chance of getting out of this and making a better life. If you only utilize one, for me, I’ve always struggled. And yeah, it’ll solve one problem in my life but then I still got the other 10 problems.” (Schoenberger, p. 3).
Recovery as a way to return to normal life.
For participants, this return to “normalcy” meant achieving the developmental goals that others their age were achieving, or had already achieved: finding a purpose, pursuing hobbies, finishing school, finding employment, securing stable housing, and finding a partner. It also meant that they wanted to break out of the cycle of substance use cravings driven from their addiction and the resulting negative feelings.
In seeking to find a life outside of substance use, many wanted their identity to be defined not in relation to substances but in light of their other positive achievements. That is, once participants had completed their treatment, some anticipated that they would not want to define themselves as in recovery: that chapter of their life was closed.
“I think the conversation isn’t just about… people won’t die … It’s like people will be present for their lives again.” (Schoenberger, p. 3).
Recovery (for some) would be a lifelong pursuit.
In contrast to the theme of return to normalcy, nearly half of the participants reflected that their recovery would involve lifelong work, a journey in which they would have to remain persistent.
“My recovery…it’s a work in progress. It’s always number one as far as where my life is going. I know my recovery has to remain first in order for anything else to fall into place.” (Schoenberger, p. 4).
Owning one’s recovery.
All participants also took ownership over the process of recovery and considered themselves to be strongly motivated to succeed. For some, hearing that addition is a disease was not helpful as they felt it gave them an excuse not to engage in treatment; they rejected that view and felt they had power over their choice to use and were responsible for that decision. Along these lines, some participants were critical of what they saw as a “recovery cult” presence in some mutual-help groups. That is, they described hearing the same slogans and actions over and over that someone must do to remain in recovery. They felt that simply doing what everyone else in recovery was doing might take away their own agency in the recovery process and their ownership of their own recovery journey.
Selected quotes from study participants.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
This study of 20 young adults engaged in treatment supports findings from existing research which highlight that recovery is a multi-dimensional process, especially for this age group. Recovery for young adults is integrated with the developmental transitions taking place at this time, and so outcomes other than substance use must be considered as markers of success. Importantly, finding a sense of purpose and returning to engage in seeking the developmental achievements of their same-age peers is especially important. Notably, research suggests that this is a reciprocal process of change: as time in recovery lengthens, and milestones are achieved they may grow more committed to their recovery journey and vice versa. Focusing specifically on meeting these milestones may be its own reward for continuing to engage in care.
Along these lines, a developmentally-oriented recovery capital approach suggests that there are a variety of strengths and capacities that a person holds and these can all be used to support their recovery process. That is, there is a need to integrate a focus on identifying life goals and supporting young adults in achieving these goals outside of the addiction recovery space that will help them meet developmental milestones. Thus, any recovery-oriented system of care involved in working with this age group should take a multidimensional approach to address different types of barriers to recovery and to building recovery capital; this approach will likely need to be tailored to some extent to the individual and their unique experience.
Despite the common themes identified by the research team, each participant seemed to view their recovery process slightly differently, which is also in line with existing research. That is, some participants seemed to align strongly with the recovery narrative from 12-step groups which suggested that recovery would be a lifelong process, whereas others felt that narrative had a place for some but was less helpful in their personal process as it removed some of their own agency. This could be due in part to the local 12-step meeting environment: young adults tend to participate in these meetings when there are more similar age peers also in attendance. In some regions, this may not be possible and so to be successful in engaging young adults, there needs to be a wide variety of treatment and recovery services that can work with young adults who have different perspectives on what their recovery journey should look like. As well, these differences suggest that despite the growing body of evidence on recovery pathways and processes, there is still much research to be conducted to better understand different recovery pathways, especially among adolescents and emerging adults.
- As this was a cross-sectional study, it only captures a small snapshot of the recovery experience for these young adults; future work is needed to examine how representative these perspectives may be and how they may shift across the developmental trajectory and over time in treatment.
- The study population was already invested in treatment, yet still had very diverse responses suggesting that while these themes represent the perspectives of this sample, there may be additional missing viewpoints important to understanding recovery.
- The participants of this study were primarily white and urban-dwelling, so findings may not translate to other demographic populations or those in more rural areas.
This study of 20 young adults in treatment highlights the importance of providing holistic services to individuals struggling with their substance use. These services should attend to the various aspects of young adult development within a recovery-oriented system of care and include goals beyond stopping substances. The findings from this study emphasize that practitioners and researchers might help their young adult patients better by potentially attending to the needs of the individual from a developmental perspective and by utilizing a patient-centered approach, i.e., an approach that uses activities to help a young adult find purpose and identify goals to meet that purpose. Clinicians who work from this perspective may find that they are more likely to build greater client recovery capital and thereby improve chances of their client’s successful recovery, while researchers using this perspective may find they identify important predictors of recovery to better understand the process for specific groups of people.
- For individuals and families seeking recovery: Although one primary goal of treatment and recovery support services is to end substance use and maintain sobriety, for this goal to be successful among young adults, there is often a need to address other needs and goals. Young adults want to be viewed as more than their substance use (or more than their efforts to stop). Helping a young adult navigate these systems and identify ways to find their own purpose may increase their engagement in this process and motivation to continue in recovery. As well, helping them advocate for services to address specific unmet needs may be necessary to support their continued engagement in the recovery process.
- For treatment professionals and treatment systems: As other research has indicated, the treatment and recovery process should focus on goals and needs beyond substance use; this diversity in experience reflects a need for a patient-centered approach, where clients are invited into the treatment session to participate in their own care, identifying their goals and barriers to meeting those goals. As well, utilizing the treatment service space to identify relevant community supports for the client to explore may be one way to support them in meeting their goals while linking them up with developmentally-appropriate services.
- For scientists: While this study’s findings support previous research indicating that the recovery process should focus on activities and outcomes beyond substance use, the researchers have also demonstrated that there are many ways that young adults define their recovery journeys. Although there are common elements across these journeys, there is a need for further research to examine different types of recovery pathways and the best services to use to support someone on their chosen pathway. Future research should also attempt a more diverse sampling to identify the values, needs, and barriers to building recovery capital of other groups of young adults.
- For policy makers: From a system-level perspective, this study’s findings support a recovery-oriented systems of care approach, where treatments and services are integrated to best support an individual seeking recovery. Research and funding to address (1) which services should be closely linked, (2) how to better integrate these services, and (3) the effectiveness of these linkages will be necessary to ensure resource efficiency and positive young adult outcomes.
Schoenberger, S. F., Park, T. W., dellaBitta, V., Hadland, S. E., & Bagley, S. M. (2021). “My life isn’t defined by substance use”: Recovery perspectives among young adults with substance use disorder. Journal of General Internal Medicine, [Epub ahead of print]. doi:10.1007/s11606-021-06934-y