Mechanisms of Change in Addiction Recovery
By William L. White
High degrees of variability in the pathways and styles of addiction recovery obscure shared mechanisms of change across such healing processes.
The alcohol and drug problems arena is filled with professional claims and counterclaims, excessive marketing hype, and riveting personal testimonies of how such problems can be best resolved. The central stakeholders in these debates commonly assert that their particular ideas and methods constitute THE TRUTH, and wrap these claims in the mantle of science or personal/clinical experience. The resulting noise can leave listeners understandably bewildered about the nature of such problems and their ultimate solution.
People recover with and without the ever-expanding menu of professional treatment; with and without medication support; with and without involvement in the growing networks of religious, spiritual, and secular recovery mutual aid groups; and with and without involvement in new recovery support institutions (from recovery homes and collegiate recovery communities to recovery cafes and recovery ministries). Some find culturally indigenous pathways of resistance and recovery (e.g., The Red Road, Wellbriety Movement). For some, recovery is a transformative conversion experience, while for others it is a long-term process of incremental change. Some take on new recovery identities and recovery-based social networks, while others do not. For some, problem resolution involves a deceleration of drug use, while for others it involves complete and enduring abstinence. For some, recovery involves a complete reconstruction of one’s life; for others, changes in alcohol and drug use occur within an otherwise unchanged life. And on and on the varieties continue. So what does one make of such varieties?
As a person in long-term recovery, a treatment practitioner, a recovery historian, and a recovery research scientist, I have conducted a sustained meditation on the recovery process across diverse populations and cultural contexts for nearly half a century. Here are some of the conclusions I have drawn at this late stage of my life.
*The resolution of alcohol and other drug (AOD) problems is marked by multiple pathways and styles. All should be cause for affirmation and celebration.
*The question, “Which pathway of recovery is best or most effective?” is unanswerable without reference to “For whom?”, “At what point in time within that person’s addiction/recovery life cycle?”, and “Within what environmental and cultural context?”.
*Addiction recovery involves processes of destruction, retrieval, and creation. Destruction entails breaking entrenched patterns of acting, thinking, feeling, and relating. Retrieval involves the reacquisition of lost assets. Creation requires new recovery-nourishing daily rituals, character traits, relationships, and reformulating life meaning and purpose. These recovery processes can be thought of in terms of subtraction, addition, and multiplication.
*Secular, spiritual, and religious pathways of addiction recovery address the need to address addiction-spawned debris/baggage (i.e., harm to self and others) via such processes as acceptance, commitment, self-inventory, confession, acts of restitution, and acts of service.
*Seemingly contradictory metaphors of change (e.g., powerlessness and empowerment) may be simultaneously or sequentially integrated within the recovery process. This can be seen in patterns of dual citizenship in recovery (i.e., individuals who concurrently participate in Alcoholics Anonymous and SMART Recovery or Women for Sobriety).
*Distinct pathways of recovery (e.g., secular versus spiritual and religious, assisted versus unassisted) often share common mechanisms of change.
*While many factors (e.g., age, gender, sexual orientation, gender identity, ethnicity, etc.) may influence the saliency of particular mechanisms of change, the two most powerful of such influences appear to be problem severity/complexity/duration and personal/family/community recovery capital. Recovery pathways and styles differ markedly across these two dimensions.
*Mechanisms of change and related recovery support strategies that are effective for those with low problem severity/complexity/duration and moderate to high recovery capital cannot be indiscriminately applied to those with high problem severity/complexity/duration and low recovery capital. And vice versa!
*Mechanisms of change common across recovery pathways include breakthroughs of self-perception, mutual identification, trust, the creation and maintenance of hope (to move beyond pain of the past and forge a better life), self-efficacy (confidence in ability to adhere to AOD-related change in the face of high-risk social situations and positive/negative emotions), coping skills, termination of pro-drug relationships, acquisition of pro-recovery relationships, helping others, and spirituality. These mechanisms work simultaneously and synergistically, and combinations may vary across individuals, stages of recovery, and cultural settings.
*Recovery can be initiated at any stage in the progression of AOD problem development. Mechanisms of change and their catalytic metaphors may differ significantly by the stage of problem severity at which recovery is initiated. Some mechanisms (e.g., spirituality) are likely to have greater salience among those with greater problem severity and fewer social supports. Mild to moderate AOD problems are commonly resolved through acts of self-assertion (drawing on strength within the self) where the resolution of the most severe, complex, and chronic AOD problems are marked by a process of self-transcendence (reliance on strength outside the self).
*The factors required to sustain recovery may be different than those required to initiate recovery. While particular mechanisms of change may differ across individuals and within the same individual across the stages of recovery, some mechanisms of change seem to span stages of recovery. A change in status within any of these mechanisms may influence both quality of life in recovery and the risk of addiction recurrence.
*Combining/integrating mechanisms of change may have a catalytic effect in recovery initiation or enhancing quality of life in recovery beyond what could be predicted from the effects of the single ingredients.
*Historically, there has been more focus on conflict than commonalities within AOD problem resolution strategies. Quite promising are recent studies by Dr. John Kelly and others on shared mechanisms of change within what on the surface appear to be different recovery processes.
The mechanisms of change in addiction recovery are often nested within two very different processes: story construction and storytelling. Those experiencing addiction, affected family members and friends, and those seeking to offer help all have a need for sense-making. All, including myself, develop theories about the sources and solutions to addiction and weave these into personal and professional narratives that may or may not have anything to do with the actual processes through which such change occurs. The ultimate truth (and the best news) is that such change is possible and increasingly common.
Stages and Styles of Addiction Recovery
By William L. White
Dr. Ernie Kurtz and I, during the last years of his life, spent considerable time exploring the varieties of addiction recovery experience, including variations in the stages and styles of addiction recovery. For me, this exploration of stages and styles began in 1974 when I heard John Wallace present a paper at the Alcohol and Drug Problems Association meeting in Minnesota. The presentation stunned me with its clarity and potential clinical import. Wallace first stated that alcoholics frequently develop a preferred defense structure (PDS) (e.g., denial, minimization, projection of blame, intellectualization, etc.) to sustain excessive drinking and escape its growing consequences.
That starting position was not a new idea to most of us in the audience, but Wallace went on to say that the same PDS that supports drinking may be used as strategic coping mechanisms through the early stages of recovery and that prematurely confronting this brittle, recovery-sustaining PDS could trigger a resumption of drinking. That denial and minimization (of the problems facing the just-sobered), black-white thinking (e.g., “all of my problems are related to my drinking; all I have to do is not drink and everything else in my life will be fine”), and other defense mechanisms could be allies in the recovery process was a striking concept and one pregnant with implications for clinical practice—practices which at the time consisted primarily of verbally confronting such defensive gambits.
But then Wallace laid out the third paradox of recovery: the same PDS that supported alcoholism and that could be reframed to support early recovery must be eventually abandoned in later stages of recovery. In Wallace’s view, the latter transition was crucial to fully stabilize recovery, as well as enhance maturity and quality of life in long-term recovery.
I have been closely observing the addiction recovery process for half a century. I have been struck by two extremes: people whose fragile recovery is forever frozen at a primitive stage of development, and people who go through metamorphic changes that transform their character, values, and the quality of their interpersonal relationships. In the former, drug use has ceased or radically decelerated in frequency, intensity, and consequences, but this change remains nested within the same self-centeredness, resentfulness, dishonesty, and intolerance that often characterizes active addiction. This former pattern has been referred to as the “dry drunk” syndrome. In the latter style, the radically altered person-drug relationship is accompanied by dramatic enhancements in global health and functioning, as well as changes in character and identity—changes AA co-founder Bill Wilson characterized as “emotional sobriety.”
It is easy to cast these widely varying styles of recovery into the boxes of bad and good, but time and experience have softened that view for many of us as we have come to see how each style can exist within the same persons (and within ourselves) at different stages of the long-term recovery process. Also of note is that the executive brain functions of some people may have been severely and even permanently damaged from addiction, precluding tolerance of the ambiguity and more complex decision-making of the transformative style of recovery.
Today’s guiding mantra is “whatever it takes—recovery by any means necessary under any circumstances.” While we can deeply admire those in recovery who have used the recovery experience as a catalyst for personal transformation (via humility, gratitude, tolerance, service, etc.), we can also admire those who must tenaciously cling to those crude early defenses as a way to “keep the plug in the jug.” Both are deserving of respect and admiration.
The above articles were originally posted by William L. White on his website: