Ernie Kurtz and William White
In 2006, Ernie Kurtz and I collaborated on our first paper explicating multiple pathways and styles of addiction recovery. The article was later included in the first recovery management monograph and published in the International Journal of Self Help and Self Care. Included within the paper was a discussion of the variations in depth of addiction recovery, including descriptions of partial, full and enriched recovery.
Partial recovery, which will be described in more detail below, reflects decreased severity and frequency of alcohol and other drug (AOD) problems amidst persistent efforts to achieve recovery stability. Full recovery, while not implying the notions of perfection or completeness and as depicted in the professional literature (See HERE and HERE), most often refers to 1) positive and sustained change in the person-drug relationship (most often measured by sustained abstinence/sobriety or diagnostic remission), 2) improved global health and functioning, and 3) repair of the person-community relationship (sometimes characterized as citizenship). Enriched recovery refers to a state of optimal health, functioning, and community service rising, not in spite of addiction, but because of the strengths of character developed through the addiction recovery process. The latter two states have been elaborated on in subsequent papers and blogs (See HERE and HERE). The present blog seeks amplification of the concept of partial recovery from a substance use disorder (SUD).
Before proceeding, it is important to distinguish between two terms commonly used interchangeably. Remission is a medical term indicating that a person who once met diagnostic criterial for a medical disorder has ceased meeting such criteria for a specified period of time. In the case of SUDs, the American Psychiatric Association designates two categories: early remission—at least 3 but less than 12 months without meeting criteria for a substance use disorder (except craving), and sustained remission—at least 12 months not meeting SUD criteria (except craving). Remission can be characterized as a process of symptom or illness subtraction from what might otherwise be an unchanged life.
Recovery, a term first used to characterize the lived experience of resolving severe and persistent alcohol and other drug problems, is widely described as more than the deceleration or removal of drugs from one’s life. Within the concept of recovery we find the broader three-part definition noted above. It encompasses processes of subtraction (reduction and cessation of drug use) and addition (incremental improvements in physical, emotional, social, and spiritual/ontological (e.g., life meaning and purpose) health. Enriched recovery is distinct in its multiplication effect—dramatic transformations of personal character, identity, and levels of social functioning and community service beyond what would have been likely without strengths drawn from the recovery experience.
The concept of partial recovery is commonly applied to other medical conditions, particularly chronic conditions. This means that the condition has not been permanently cured or its symptoms permanently suppressed but that the severity and frequency of symptom manifestations and their consequences on role functioning and quality of life have been reduced to a more manageable level. The mental health field has long extolled the potential and goal of partial recovery, but until recently denied the probability and even possibility of full recovery from the most severe mental illnesses. In contrast, the addictions field, has long reified the concept of full recovery but has lacked any functional understanding of the potential for partial recovery as a transitional or terminal achievement and valued outcome of clinical intervention.
Partial SUD recovery can apply to diverse circumstances, including the following:
1. Criteria for SUD continue to be met but at lower levels of severity, e.g., declining frequency, severity, and consequences of AOD use, and related risk behaviors.
2. Substance use has ceased or decelerated to the point of diagnostic remission without evidence of larger improvements in global health and functioning, quality of life, or community integration. (The early months/years of recovery efforts are often marked by continued impairment of physical health and emotional and social functioning–symptoms that continue to improve and remit over the first ten years of recovery for most but not all persons.
3. Patterns of substance use remain unchanged with evidence of improvements in global health, social functioning, quality of life, or community integration (reversing the normally expected sequence).
4. Substance use has ceased or decelerated to the point of diagnostic remission with some but limited improvements in broader areas of health and functioning due to one or more commonly occurring conditions (developmental trauma, psychiatric illness, medical/legal/occupational burdens arising from addiction history) or environmental obstacles to recovery.
Partial recovery is a state of limbo in which addiction has been destabilized (as evidenced by repeated recovery attempts) but recovery has yet to be fully stabilized. Some in this state of limbo are trapped in the space between recovery initiation and recovery maintenance—knowing how to stop use but not yet fully mastering how to avoid restarting use or how to live and cope as a person in recovery. Needed at this point are the right combination and sequence of experiences and supports to serve as a catalyst or tipping point of recovery stability.
Several service implications flow from the concept of partial recovery.
First, partial can constitute a permanent state, a developmental stage of recovery (e.g., precovery), or a time-limited hiatus in drug use with eventual reversion to a previous or greater level of AOD problem severity. Individuals and their families considering addiction treatment and recovery support options should be informed of the spectrum of possible post-service trajectories: 1) no effect (continuation or acceleration of AOD use and its consequences), 2) limited effect (partial recovery), 3) optimal effect (full recovery), and 4) supra-optimal effect (enriched recovery). These same communications should include the factors known to influence these potential outcomes and what the individual and family can do to write the future chapters of their story.
Second, if partial recovery is sustainable without the burden of escalating clinical deterioration and is an individual choice, we should be asking ourselves what we might do by way of service designs to support such achievement given the benefits to self, family, and society that could accrue from problem deceleration. People who are constitutionally incapable of permanent abstinence from AOD use but who may choose or only be able to achieve partial recovery at particular points in their lives have not historically been viewed as legitimate service candidates within the addictions field. The emergence of a separate harm reduction field and calls to integrate harm reduction, clinical treatment, and recovery support services may change that. The good news to be shared is that recovery, like addiction, exists on a spectrum, and that considerable improvement in health, social functioning, and quality of life can be achieved on the path to full recovery. Each increment of positive change has value in its own right and incubates positive future changes. People achieve partial recovery with or without embracing a recovery identity, with or without recovery mutual aid involvement, and with or without participation in addiction treatment.
Third, alternative service designs are needed for people who achieve time-limited partial recovery but whose periodic escalation in drug use brings them repeatedly through the revolving doors of addiction treatment programs. Recycling these persons through acute care models of addiction treatment offers little more than respite care and needs to be replaced with models of assertive and sustained recovery management and potentially new or clinically adapted recovery support institutions. Recovery mutual aid organizations have long made room for such individuals; adding new sources of support might facilitate the journey from partial to full recovery.
Fourth, we need a clearer understanding of the differences between those who achieve partial versus full SUD recovery. This is both a research and clinical agenda. My observation is that recovery, like addiction, is a spectrum process. This means that just as AOD problems exist on a broad spectrum of problem severity, complexity, and chronicity, recovery similarly exists on a broad spectrum of resolution patterns. A further observation is that those achieving partial recovery often exist within this middle spectrum of problem severity, complexity, and chronicity. They may need recovery support models different than those at the least and most extreme ends of this continuum, and their long-term styles of problem resolution may differ markedly from these other two groups. The needs of those in this middle spectrum constitute a potential zone of future innovations in harm reduction, addiction treatment, and recovery support services.
Photo: Bill White interviewing Ernie Kurtz at his home in Ann Arbor, Michigan, for video series Reflections: Ernie Kurtz on the History of A.A., Spirituality, Shame, and Storytelling. Chicago: Great Lakes Addiction Technology Transfer Center.
References: White, W., & Kurtz, E. (2006). The varieties of recovery experience. International Journal of Self Help and Self Care, 3(1-2), 21-61.