Recently I was asked to give a presentation through the RICARES lecture series on Recovery Science. The topic was the measurement of recovery. I want to offer a bit more on the subject here, as I see a need for specific recommendations and rationale for those working in the field, particularly at the programming level.
The Meaningful Measure of Recovery
In the early 2000s, Laudet and others began to highlight a disparity between what clinicians and researchers measured in recovery and the qualitative desires of those seeking recovery. Specifically, quality of life, purpose, restoration of the family, reconnection with significant others, employment, and education are outcomes that those seeking recovery are wanting to achieve by entering into recovery.
In short, and succinctly: people seek recovery because they want a better life for themselves and those they care about.
Many treatment outcomes are reductive and operationalized to be objective. While objective measures are important, both addiction and recovery science truly lack the objectivity sought through measures of biomarkers, urinalysis, treatment retention, and the use/non-use paradigm. Our fetishization of abstinence or non-abstinence has caused us to overlook some of the most important means by which we can determine success or failure of recovery. In contrast, abstinence is essential for many, if not most people seeking recovery, scientifically it tells us very little about the recovery process. It is perhaps one variable we should capture, but not the central variable upon which we should determine efficacy. Mortality, often used in the “evidence-based” rhetoric of public health, is also equally uninformative about what initiates, stabilizes, and sustains long term recovery. Obviously, mortality is a prerequisite to all recovery and equally evident for many, so is abstinence. So what are we capturing by measuring mortality and abstinence? More often than not, these two variables are the lowest common denominator that can thus be viewed objectively and in generalizable terms of efficacy.
So what should we capture and how? I will approach this question in stages. The first of which will be to explain why the recovery experience should be the substrate from which our science of recovery should be derived.
The Ruin to Redemption Story
While there are many valid critiques about how we moralize and criminalize drug use and people who use drugs, it is perhaps not the job of scientists to play advocacy roles in this sense. We must deal with recovery as phenomena that occur in the real world, with all the structural, discursive, and ideological limitations that are placed on drug use. This is not to say that we should accept the social status quo of drug use criminalization; however, there is a point where scientists should stay in their lane and let the advocates work the political levers. Our job is to provide meaningful science for those endeavors.
As such, the Ruin to Redemption narrative (Ruhm, Nelson, and others) is central to recovery. Twelve-step recovery, in particular, is a storytelling praxis whereby the story of both “ruin” and “redemption” are the central pillars upon which the community rests. Bill W and Dr. Bob knew well that those in the throes of addiction were wary, if not wholly unable to hear the voices of concern by those without lived experience. This suspicion and inability to hear outsiders with no lived-experience is precisely what the A.A. responsibility declaration is all about. The declaration makes clear that those who have recovered have something unique to offer those still suffering, and have a responsibility to share that story when someone asks for help.
In more modern usage, we see the role of personal experience being leveraged within the peer-based support networks as well. Furthermore, while there are criticisms there too of capitalizing on the recovery story, we also must recognize that peer-based recovery support services, deployed within medical, judicial, and mental health systems, is, in fact, an institutional acknowledgment to the sheer power of personal recovery narratives and the lived experience. In summary, even the institutions in our society recognize the necessity for recovery narratives to play a central role in helping to heal others.
There are critics of such ruin to redemption narratives; however, for the sake of brevity, we will acknowledge that fact and leave it to the reader to explore such criticisms. For now, let us say that lived experience, and the recovery narrative, is a central practice of recovery.
Why People Seek Recovery
Anyone with experience in addiction knows the absolute misery that accompanies such behavior. This misery is mainly related to social consequences, the loss of personal connections, fading physical and mental health, and the absolute brutality with which society views those with addiction, especially here in the U.S. People in active addiction see their life as wasted, empty, and painful, particularly in the latter stages of decline.
For such people, the idea that a new life is possible can spark a tremendous amount of hope. Hope is the central catalyst for recovery transcendence. Without hope, little change seems possible. When people in active addiction feel entirely unable to change their lives, to be approached by compassionate, living proof, that emancipation from addiction is possible- this is perhaps one of the single most therapeutically meaningful events that can occur for the sufferer. The moment where those who have recovered meet those still suffering is the precise event whereby the hope collides with and displaces the impossibility and hopelessness of addiction.
What is offered at these revolutionary moments in time is a glimpse of an entirely new life for the sufferer. When one who has recovered tells their story to one still suffering, there is a rupture whereby something new suddenly becomes tangible and new space opens, whereby possibilities for a meaningful future emerge. Dreams, long believed to be dead and withered, stir again with life. The voices of loved ones who turned away suddenly re-emerge. The esteem and respect of society seem within reach. Comfort, peace, and stability abandoned long ago, once again seem possible, and deeply desired amid the chaos. Recovery narratives hold all of this power and much more.
Does this not make the recovery experience and the narrative of recovery the single most scientifically valuable materiel from whence to begun our study? Is not the therapeutic effect of lived experience one of the single most essential tools in the recovery toolbox? Why is this not the source from which we derive our scientific understanding? Did not Dr. Silkworth foreshadow this in the Doctor’s Opinion? That medical science is not well equipped to make use of the powers of good that lay outside of the ultra-modern standard?
So, where do we begin? I believe that at this stage in the evolution of recovery science that there is a paucity of recovery narrative studies. However, this is not because we never hear the story of recovery. Those of us who work in and around recovery hear the narrative of recovery often, so much so, that the narrative itself becomes almost white noise. Nevertheless, there is a minimal record in the ethnographic sense of these stories. We have not faithfully, and scientifically studied these narratives. We have no vast catalog of these voices. And we should. I believe that the science of recovery requires an enormous library of ethnographic records of recovery stories and how they are articulated in the lives of those who have recovered.
How else are we supposed to know what a meaningful outcome of the recovery process might be? What better way to study the motivations, emotions, contextual factors, and systemic barriers to recovery than to hear it from the mouths of survivors themselves? How are we supposed to measure recovery if we do not know what recovery means to those who have recovered? How can we design programs that respect autonomy, self-directed care, and agency without knowing what people are seeking when they enter into a treatment program?
Definition of Ethnography
Ethnography is defined in a few different ways depending on how the method is used to collect data. Two particular areas of research provide particularly salient use of ethnography: Educational Research and Cultural Anthropology. Education, much like recovery, is a process or set of processes prompted by externalities, structure, institutions, that also relies on intrapersonal strengths and interpersonal relationships. Cultural anthropology offers a way to use ethnography to understand beliefs, practices, and storytelling as a form of cultural continuance and transmission.
Here is a definition from Reeves et al. (2013),
Ethnography: “Ethnography is a type of qualitative research that gathers observations, interviews, and documentary data to produce detailed and comprehensive accounts of different social phenomena.”
There are many good books and excellent courses one may take to learn how to do ethnographic research. I recommend that everyone who studies recovery phenomena be familiar with how to do such research. However, now I will turn to our core recovery scientists and practitioners in recovery. Those of us in recovery have rights and admissions into recovery culture. As such, we are often insiders. Ethically, we must consider the line between science and the community. At the same time, we are also presented with multiple opportunities where we can collect recovery narratives in empirical and ethical ways. For those of us in recovery, it will be necessary for each of us to outline within our research goals as to when we might be able to consider participant observation as a research method. It will not be appropriate for us to charge right into our personal recovery communities and begin taking notes. We should not consider our status as scientists in recovery as carte blanche to study recovery communities. Nothing more could damage our standings in the recovery community AND the research community than the misuse or exploitation of our social position. In future posts, we will discuss strategies for deploying ethnographic methods in ethical and rigorous ways for recovery insiders, and non-insiders who may lack personal connections to recovery communities.
Laudet, A. B., Morgen, K., & White, W. L. (2006). The role of social supports, spirituality, religiousness, life meaning, and affiliation with 12-step fellowships in quality of life satisfaction among individuals in recovery from alcohol and drug problems. Alcoholism treatment quarterly, 24(1-2), 33-73.
Laudet, A. B. (2007). What does recovery mean to you? Lessons from the recovery experience for research and practice. Journal of substance abuse treatment, 33(3), 243-256.
Reeves, S., Peller, J., Goldman, J., & Kitto, S. (2013). Ethnography in qualitative educational research: AMEE Guide No. 80. Medical teacher, 35(8), e1365-e1379.