Abstract
Purpose: The purpose of this paper is to advise recovery protection, a novel and contrasting conceptual proposition to relapse prevention. Recovery protection advocates that in addiction recovery, instead of people working to a level of preventing what they do not want, they elevate this toward acting to protect what they do. This translates to living an effective recovery lifestyle where ongoing personal growth can continue to make it a more valuable prospect. It is argued that this altered perspective would help promote addiction recovery as a positive and beneficial lifestyle choice, challenging some of the barriers that people with SUD face when accessing professional services. Research Limitations: This paper commentates on recovery protection, drawing knowledge from the recovery model as applied to mental health generally and work exploring recovery from SUD as a positive process involving change and life improvement. As a theoretical position, it is in its infancy, requiring greater study to establish it as a valid prospect in drug and alcohol treatment services. Originality/Value: Recovery protection is a novel proposition that seeks to align recovery from SUD with the recovery model in mental health generally. It recognizes recovery from SUD as a process of growth and positive change.
Introduction
Globally, harmful drug and alcohol use is responsible for an estimated three million deaths annually (Volkow & Blanco, 2023). The morbidity burden of this, and its associated deaths, make this higher however, with alcohol alone being identified as a risk factor in over 200 diseases (World Health Organization, 2022). Substance use disorder (SUD), a chronic condition that results from harmful drug and alcohol use, sees those affected unable to control their substance use (Witkiewitz et al., 2020). It is understandable therefore that as a mental health disorder, it has a high cost. It impairs personal function, impacts families, and adversely affects local communities and larger society. In some situations, this is fiscally evident, for example, in the disproportionate healthcare expenditure afforded to those suffering from SUD or the costs linked to criminal justice and social welfare (Santangelo et al., 2022; Volkow & Blanco, 2023). In others, it is more apparent in the suffering it brings to families, where the layers of distress can be many and complex, for example, relationship breakdown, mental health decline, isolation, discrimination, stigmatization, and codependency (Avery & Avery, 2019; Conyers, 2021; Santangelo et al., 2022). The pervasive and devasting effect that SUD has means it is considered a large scale problem that severely affects public health (Santangelo et al., 2022; World Health Organization, 2022). Given that it is estimated between 40% and 60% of people who enter recovery from SUD go on to relapse (National Institute on Drug Abuse, 2023), supporting people to maintain their abstinence is vital to reducing this public health burden.
Recovery and the recovery model
The concept of “being in recovery” can be linked with Alcoholics Anonymous (AA), a prevalent peer led recovery organization founded in 1935 (Alcoholics Anonymous, 1997; Borkman, 2008) that advocates a 12-step program that guides people toward an effective life beyond alcohol use disorder (AUD) (Kelly et al., 2020). AA considers life after AUD to be recovery, and participation in the 12-step program requires no professional input and is free to all its members. This has understandably drawn interest from mental health specialists, including practitioners and researchers, who have studied and applied its principles in settings outside of AA (Borkman, 2008; Leamy et al., 2011; Wnuk, 2022). Ultimately, this has led to the term recovery being adopted for more general use to describe people living a self-directed and effective life not withstanding a mental health diagnosis (Dell et al., 2021; Leamy et al., 2011; SAMSHA, 2012).
The operationalization of this has been referred to as the recovery movement or recovery model (Best et al., 2017; Davidson, 2016; Davidson et al., 2021; Jacob, 2015). This has seen knowledge grounded in the field of addiction become the bedrock of what is now widely accepted as the recovery model for mental health (Davidson et al., 2021; McCranie, 2011; Witkiewitz et al., 2020). Recovery in the present day is generally understood to be empowering and “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” (SAMSHA, 2012, p. 3). The recovery model has undeniably changed how mental health services engage with people, moving focus from pathology based correction to the individual and their own capabilities, needs, and wishes (Jacob, 2015). Policy and funding decisions, modes of treatment, and treatment accessibility are all testament to this, having seen focus shift from recovering from illness toward recovering a life (Perkins & Slade, 2012). Resultantly, guidelines that support this model have originated; for example, in the UK, the National Institute for Health and Clinical Excellence (NICE) offers clinical guidance on providing person-driven care pathways within community settings that empower people with a mental health diagnosis to live the best quality of life they can, recognizing their autonomy and treatment preferences in the process (NICE, 2024), and in Australia, the Australian government have funded an extensive set of research backed guidelines on the management of co-occurring mental health conditions (Marel et al., 2022). Guidelines such as these that are cognizant of recovery and acknowledge the importance of collaborative treatment have seen mental health services become a more hospitable and less stigmatized area of healthcare where people are given a voice, have their capabilities recognized, and are encouraged to reach their full potential (Marel et al., 2022; NICE, 2024; SAMSHA, 2012; Stylianidis, 2016).
Recovery and substance use disorder
When compared to other areas of mental health, addiction remains subject to outmoded views when it comes to recovery. This is perhaps an unexpected observation given the early link with AA and the conceptualization of recovery (Alcoholics Anonymous, 1997; Borkman, 2008). Yet, in clinical settings, abstinence is persistently viewed as a successful outcome where the issue that caused the decline in health, which in the case of SUD is drug and alcohol use, has been removed (Dell et al., 2021; van Weeghel et al., 2019). It is not a measure of the quality of life a person has or how this affects their protracted recovery (Ellison et al., 2018). This is the remit of personal recovery and the recovery model (Leamy et al., 2011). It has been suggested that the incongruity between what is considered a successful outcome in mental health generally and SUD as a specific disorder is a consequence of continued alliance with the 12-step program (Watson, 2012), where its success in mutual aid settings has seen it remain a preferred treatment option in drug and alcohol services (Borkman, 2008; Kelly et al., 2020; Mendola & Gibson, 2016). It is reasonable to suggest therefore that the transforming effect the recovery model has had on mental health care has somewhat bypassed SUD (Avery & Avery, 2019; Watson, 2012). This, and the unpopular symptomology that accompanies SUD, could go some way to explaining why it obdurately remains an area of mental health that is highly judged and stigmatized (Frank & Nagel, 2017; Goodrick et al., 2022).
The body of work that seeks to promote recovery from SUD as a positive process involving change and life improvement is underdeveloped when compared to mental health in general (Dell et al., 2021; Ogilvie & Carson, 2022; Watson, 2012). Positive interventions have primarily focused on distinct topics, for example, hope and resilience (Ujhelyi et al., 2021), gratitude (Krentzman et al., 2015), and mindfulness-based relapse prevention (Grant et al., 2017). Literature discussing addiction recovery as a process is limited, and research investigating mental health recovery in general often omits SUD as a single disorder, despite it being formally recognized as a mental health condition (First et al., 2021; van Weeghel et al., 2019).
Recent work has begun to address this by studying recovery as a process in specificity to addiction, taking CHIME a prevalent recovery framework that classifies connectedness, hope, identity, meaning in life, and empowerment as necessary components to an efficacious recovery (Leamy et al., 2011) and developing interventions that attend to them holistically for SUD to help support successful long term outcomes (Ogilvie & Carson, 2023). This work has seen an adaptation to CHIME to include a component for growth, offering the G-CHIME model for addiction recovery (Ogilvie & Carson, 2023). The addition of growth denotes how important positive function, adaptability, and striving to reach potential (SAMSHA, 2012) are to addiction recovery (Ogilvie & Carson, 2022). G-CHIME as an applied model has been used with effect in a comprehensive recovery program known as positive addiction recovery therapy (PART) (Ogilvie & Carson, 2023a) and in the exploration of the lived experience of addiction recovery (Ogilvie & Carson, 2023).
Relapse prevention
As has been previously mentioned, it is estimated up to 60% of people who enter recovery from SUD will relapse (National Institute on Drug Abuse, 2023). It is understandable therefore that relapse prevention has been a mainstay in the treatment of addiction for nearly forty years (Marlatt & George, 1984). Relapse prevention sets the precedent that there is more to recovery than achieving abstinence. This in itself is a positive message, as it advocates for change as well as maintaining abstinence (Marlatt & George, 1984; Witkiewitz et al., 2020), where the practices involved in relapse prevention are intended to promote self-efficacy, often through cognitive behavioral intervention in response to a perceived risk to an individual’s enduring recovery (Hendershot et al., 2011; Marlatt & George, 1984; Melemis, 2015; Menon & Kandasamy, 2018).
It could be argued, however, that relapse prevention projects an unhelpful vision of what recovery from SUD looks like (Miller, 2015; Ogilvie, 2023): a vision that does not coalesce with the recovery model in its forward looking stance, but rather one that recommends caution over relapse so as not to return to past ways (Menon & Kandasamy, 2018; Miller, 2015). In other areas of mental health, exempting an indefinite period of caution over possible prodromal symptoms would likely be considered as detrimental to mental wellbeing (Grupe & Nitschke, 2013); however, for SUD, it is packaged as relapse prevention, where people are expected to anticipate triggering situations, as well as recognize the early behavioral and psychological warning signs of relapse, so they may take corrective action to prevent it (Melemis, 2015; Menon & Kandasamy, 2018). This self-imposed limitation has been recognized in a call to retire the concept of relapse in treatment services (Miller, 2015); however, to date, there have been no new developments to supplant the concept of relapse prevention.
Recovery protection
A novel and contrasting conceptual proposition to relapse prevention is recovery protection, which advocates that instead of people working to the level of preventing what they do not want, they elevate this toward acting to protect what they do. This translates to living an effective recovery lifestyle where ongoing personal growth can continue to make it a more valuable prospect (Ogilvie & Carson, 2022, 2023). This is one that reinforces recovery from SUD as a positive and beneficial lifestyle choice worthy of abstinence and more. This concept better aligns recovery from SUD with other mental health conditions, so it may to benefit from the reformation seen through the recovery model (NICE, 2024; Perkins & Slade, 2012). Furthermore, recovery protection could provide a clearer message of how an individual can function at an enhanced level, through vital health related change, the wisdom of lived experience, and having the personal agency to continue to master recovery as a process (Ogilvie & Carson, 2022).
Discussion
Recovery protection does not question the validity or efficacy of relapse prevention interventions, but it does question the limitation of using a value-laden term oriented toward relapse, not recovery. It also disputes its hermetic focus on corrective intervention, especially in response to perceived risk and the incongruence with the recovery model, which looks forward and is very much concerned with encouraging what we do want, not preventing what we do not (Leamy et al., 2011; Ogilvie, 2023; SAMSHA, 2012). Unfortunately, the use of value-laden terminology is commonplace in addiction, perpetuated by the social disapproval that surrounds substance misuse (Miller, 2015), where discourse is prone to moralization and stigmatization (Frank & Nagel, 2017; Goodrick et al., 2022). The repercussions of this can be observed in the diminished self-esteem and degraded facility to engage with support services that is seen in individuals with SUD, both of which present significant barriers to recovery (Snoek et al., 2021). Compounding this further, moralization can extend beyond public opinion to include healthcare professionals, where evidence has shown the use of value-laden language in healthcare settings detrimentally impacts the care and empathy afforded by professionals to those who suffer from SUD (Frank & Nagel, 2017). Given that relapse prevention, and addiction treatment provision in general, is inclined to focus on corrective intervention (Hendershot et al., 2011; Miller, 2015; Snoek et al., 2021), this serves to propagate the negative view of addiction and what is expected from those who suffer from it, where relapse is typically viewed negatively (Avery & Avery, 2019; Collins & Witkiewitz, 2013; Miller, 2015). Moreover, the prevalence of SUD as a mental health disorder; the nature of the symptomology exhibited; and the cost it places on communities, services, and larger society mean this is a discrimination particular to SUD (Avery & Avery, 2019; Frank & Nagel, 2017; Goodrick et al., 2022; Ogilvie, 2023; Volkow & Blanco, 2023).
The recovery model as applied to disorders other than SUD does not have to contend with such strong moralizing in respect of symptomology or relapse (Avery & Avery, 2019; Miller, 2015; Volkow & Blanco, 2023). In these cases, it is more widely accepted that the path to better mental health can include setbacks that may see symptoms return; however, this is considered to be part of an evolving process of recovery, which encompasses respect of the individual and appreciation of their resilience growth (SAMSHA, 2012; Witkiewitz et al., 2020). The importance of this has been highlighted in previous work but in specificity to mental illness as a separate construct to SUD, so a return to substance use and the judgment this introduces to the recovery process are not involved (Avery & Avery, 2019; Frank & Nagel, 2017; Goodrick et al., 2022; Slade, 2015). It could be reasoned therefore that the applied use of the recovery model for people with SUD is impacted by the notion of relapse prevention. This introduces the expectation that relapse is not only likely but that life must be adjusted to avoid the possibility of relapse. This is instead of fully embracing the ethos of the recovery model and striving forward positively toward recovery through improved personal function (Leamy et al., 2011; SAMSHA, 2012; Slade, 2015).
Recovery protection as an alternative philosophy to relapse prevention suggests the need for a paradigm shift in the field of addiction, where recovery from SUD is discussed in terms of it being synonymous with making a positive lifestyle choice and having a more optimistic view of the future (Ogilvie, 2023). As a phrase, it is more empowering and could help alleviate some of psychological barriers that value-laden terminology contribute to (Frank & Nagel, 2017; Goodrick et al., 2022; Miller, 2015; Slade, 2015), as well as easing the anxiety people feel when considering a life void of substances (Menon & Kandasamy, 2018). Research such as that conducted on the G-CHIME model and positive addiction recovery therapy help elevate addiction recovery through positive interventions and reformed understanding, offering a complementary and positive basis to challenge the traditional stereotypes applied to SUD.
Future directions
SUD remains a highly moralized and stigmatized condition (Volkow & Blanco, 2023; Witkiewitz et al., 2020), which affects policy decisions, healthcare provision, and self-efficacy in the recovery process (Avery & Avery, 2019; Hendershot et al., 2011). It is modestly suggested that moving forward, service professionals consider adopting a more forward thinking stance on recovery from SUD, favoring the axiom of recovery protection over relapse prevention. Furthermore, where feasible, existing relapse prevention interventions could be reworked as recovery protection, and new and existing modes of treatment could disseminate the applied use of a more suitable model such as G-CHIME to further develop thinking around recovery protection (Ogilvie & Carson, 2023).
Conclusions
This paper recommends a change in how recovery from SUD is viewed and discussed. It proposes that recovery protection is a more empowering concept than relapse prevention, suggesting that instead of people working to the level of preventing what they do not want, they elevate this toward protecting what they do. It is argued that this altered perspective would help promote addiction recovery to be a more positive and beneficial lifestyle choice that could challenge some of the barriers people with SUD face when they require support from professional services.