Landmark life in recovery surveys have been recently conducted in the United States (Laudet; Kaskutas, Borkman, Laudet, et al.; Witbrodt, Kaskutas, & Grella), Canada (McQuaid, Malik, Moussouini, et al.), Australia (Best & Savic), and the UK (Best, Albertson, Irving, et al.). These surveys provide retrospective confirmation of the improvements in physical/emotional/relational health and quality of life that accrue with duration of addiction recovery. They confirm that increased time in recovery is linked to enhancement of housing stability, improvements in family engagement and support, educational/occupational achievement, debt resolution, and increased community participation and contribution, as well as reductions in domestic disturbance, arrests/imprisonment, and health care costs.
A just-published U.S. population study by Kelly, Greene, and Bergman confirm many of these findings, noting that quality of life (e.g., happiness, self-esteem, and recovery capital) increases exponentially over the first five years of recovery and continues to increase in smaller increments in subsequent years. Their study also noted three other findings not captured in earlier studies.
First, quality of life in recovery ratings varied across gender, racial groups, and primary drug choices. Facing lower quality of life ratings in early recovery compared to other groups were women, mixed racial groups, and former opioid and stimulant users.
Second, in their U.S. recovery sample, happiness and self-esteem actually declined in the first six months following problem resolution and was then followed by progressive improvements in these areas. This finding from a community study is consistent with an early clinical study by Dennis, Foss, and Scott noting a peak period of emotional distress (at three-year follow-up) well after the early stage of recovery initiation. The differences in timing of peak negative affect between the two studies may reflect the far greater problem severity in the clinical sample. (Greater problem severity may entail a longer period of disentangling the baggage of addiction before a process of emotional thawing and healing ensues.) What is of great clinical import in both the Kelly and Dennis studies is that the period of greatest negative affect—a condition long-associated with addiction recurrence—appears long after helping professionals have discharged patients and families from active service support.
Third, Kelly and colleagues report that it took a substantial period of time (15 years) for people in recovery to reach the normative quality of life ratings of those persons in the U.S. who had never experienced significant alcohol and other drug (AOD) problems. It is not enough to say that people in recovery have a quality of life better than those actively addicted. The issue is their ability to achieve a quality of life on par with non-affected individuals and families. Providing support to achieve such parity of emotional and relational health would require a sustained recovery support menu far beyond the current range of clinical services offered within addiction treatment programs.
So what does this all mean? I would suggest the following prescriptions for addiction treatment and recovery support organizations.
Educate affected individuals, family members, and service professionals on the long-term stages of recovery and stage-specific recovery management strategies.
Provide written material, videos, and podcasts to all patients and families on the stages of recovery and tips on managing periods of physical/emotional/spiritual distress across the stages of recovery. Bibliotherapy may help normalize stage-specific recovery experiences (particularly for individuals who choose not to be involved in recovery mutual aid groups) and provide a guide for managing periods of heightened vulnerability that is not dependent upon professional care or participation in peer recovery support activities.
Cease the practice of patient “graduation” from addiction treatment—a ritual that conveys that one’s problems have been fixed and one can now expect to live happily ever after.
Provide assertive linkages between addiction treatment and indigenous recovery support resources—both face-to-face and online resources.
Provide intensive post-treatment recovery check-ups and support during the first 90 days following discharge from treatment, with at least quarterly checkups over the first two years and at least annual recovery checkups for the first five years following recovery initiation.
Titrate the intensity and duration of post-treatment recovery support services based on degree of problem severity/complexity/chronicity and level of recovery capital, with special attention to those who may be at highest emotional and social vulnerability in early recovery, e.g., women, youth, and those who have experienced the greatest degree of social marginalization.
Offer clinical services as an option across the stages of recovery. The best use of traditional counseling skills may not be during the period of recovery initiation but in the emotional crises that often come far after the “pink cloud” of recovery initiation.
Integrate the clinical care of addiction treatment and long-term recovery support services via expansion of service menus that focus on enhanced quality of personal and family life in long-term recovery.
The bigger issue remains shifting addiction treatment from models of acute care focusing on biopsychosocial stabilization to models of sustained recovery management (RM) nested within larger recovery-oriented systems of care (ROSC). RM models will assure sustained, person/family-focused support across the stages of recovery; ROSC models will assure creating the physical, psychological and social space within local communities in which recovery and quality of personal and family life in recovery can flourish over time. Achieving this shift will require a fundamental reorientation within the addictions field—a process that is now underway in many states and local communities.
Kelly, J. F., Greene, M. C., & Bergman, B. G. (2018). Beyond abstinence: Changes in indices of quality of life with time in recovery in a nationally representative sample of U.S. adults. Alcoholism: Clinical & Experimental Research, 42(4), 770-780.
William (“Bill”) White
Emeritus Senior Research Consultant at Chestnut Health System
Read all of Bill White's Blog Posts on his website here www.williamwhitepapers.com