Articulating Meaningful Measures of Recovery, Part II

Last week I highlighted the recovery story as the chief substrate by which recovery scientists can define, operationalize, and create meaningful measures for the recovery process. We discussed the rationale for placing the recovery experience, as told by those who have recovered, as the primary source from which we can extract pertinent information that can be operationalized into recovery sensitive instruments to study healing. I spoke briefly of ethnography as one possible qualitative methodology for collecting data on the recovery experience. This week we will examine another way to collect meaningful, raw material that can be utilized in cataloging the recovery processes. This week will discuss the Case Study, and in particular, Interpretive Phenomenological Analysis of qualitative case studies.

A History of Clinical Case Studies

Early addiction researchers pioneered clinical case study methodology as a means of studying both addiction and recovery processes. Much of the initial theory for recovery and addiction came from clinical case studies published by clinicians and analysts working with people seeking to overcome addiction issues. Clinical case studies provide a rich contextual depth of lived human experience, and clinical case study methodology offers theory at the intersection of clinical interpretation and the lived experience of analysands and patients.

The clinicians’ interpretation of lived experience provides a useful filter for researchers, as clinicians will often link their clients’ experiences to well-established theories and clinical practices. For recovery scientists, the clinical interpretation of recovery can direct and inform the paradigms that touch upon human psychosocial healing.

Going Even Further than Clinical Interpretation

Even more useful methods for analyzing case study data can be found in Grounded Theory (GT) and Interpretive Phenomenological Analysis (IPA). For the second part of this series, we will discuss an excellent example of the latter, an Interpretive Phenomenological Analysis (IPA) of early recovery. This method allows for the lived experience of the individual to speak directly to the researcher without clinical filtration through existing theory, thereby rendering the raw material of recovery in nearly pure form. I came across the following article while working on a literature review for another article, and this particular piece stood out as a prime example for IPA.

A copy of Rodriguez-Morales (2017) can be found here https://drive.google.com/open?id=1qwqdb9mvBkf8IQSM7_dO3wOLtwCtKdaQ

From the Abstract:

“A longitudinal, qualitative study was carried out with semistructured interviews taking place at intervals of 3 months. The transcripts were subjected to interpretative phenomenological analysis. During the participant’s 2 months of recovery, a series of intrapersonal changes were reported concerning issues of self-care and emotional development. Following 6 months in recovery, the participant’s recovery focus then centered on the interpersonal issues related to changes in his social network and ways of relating. By 10 months, the participant’s recovery emphasized aspects of self-actualization, including a sense of spirituality. The findings illustrate how issues of authenticity, emotional expression, and identity transformation are intertwined in the participant’s early recovery.”

Interpretive Phenomenological Analysis

IPA is one method of capturing complex phenomena that are elusive to existing theories. Smith & Osborn (2015) state, “IPA is a particularly useful methodology for examining topics which are complex, ambiguous and emotionally laden.” IPA is a qualitative analysis method, similar in intention to Grounded Theory, whereby the researcher allows for the data to present lived experience as viewed by the individual, rather than approaching such data with pre-conceived notions of theory. IPA lets the voice of the lived experience present itself, rather than the researcher imposing hypotheses upon the data apriori. This feature of IPA makes such interpretive analysis uniquely suited from complex experiences within broad areas such as pain, grief, illness, addiction, and recovery. By allowing the data to reflect the lived experience, IPA offers an inroad to meaning specific and sensitive to the experiences at hand.

The author highlights why IPA is useful, particularly in the study of those in 12-Step recovery:

Retrospective studies depend on participants recalling memorable or significant experiences of their early days in recovery -such accounts will by then have necessarily already been accommodated as part of their current recovering narratives. This is particularly the case for participants of Alcoholics Anonymous (AA) and 12-Step fellowships, whose long-term members tend to internalize the rhetoric employed within AA’s stories of recovery and successful self-transformation (Denzin, 1993). This is part of how the recovery model works, as these stories facilitate the installation of hope for the newcomer; however, the nuances and individual processes of early recovery can either be overlooked or not portrayed in detail. Prospective studies facilitate a “natural” examination of how processes of change develop in real-time, and which experiences are lived as significant events that define early recovery as a developmentally differentiated recovery period.”

The author makes a salient point for qualitative researchers on recovery. I believe it is quite essential: Since 12-Step recovery in particular centers around storytelling as a central recovery praxis, the recovery experience is often re-conceptualized into the narrative framework of 12-Step paradigms. One key for qualitative researchers is to capture lived experience before it is reconfigured within the narrative frameworks of 12-Step storytelling. Since the bulk of recovery experience involves 12-step recovery, researchers need to develop strategies to approach recovery experience that takes into account the narrative practices of 12-Step members. IPA is a useful strategy for mitigating this fact.

Highlights from the Findings

The author studied the longitudinal experience of a young male, pseudonymized as “James.” Interviews were conducted at intervals of three months and capture very early recovery processes.

First Interview

The first interview captures James’ sense of self-care:

“James experiences his initial transformation as self-care. Self-care is primordially manifested as care for the body and is the primary reflection that attests to his transformation. Care is also starting to be lived through developing routines, keeping up with daily normal living, but most importantly, through being actively engaged and concerned with the world around him. James’ self-care also involves taking care of his emotional life through being honest about what is going on for him and sharing it in the AA meetings…Hence James’ early days in recovery manifest a new sense of authenticity. James’ gradual cultivation of emotional authenticity is centred on the disclosure of suppressed emotions, including particularly negative feelings that give rise to a sense of not being worthy in the eyes of others. AA meetings seem to provide a safe space where James can disclose difficult emotions.”

What could a recovery scientists take from this excerpt? First and foremost, we see that honesty is a form of self-care, mainly related to opening up one’s internal emotional world to trusted others in a community. This early experience highlights that community connections that embrace and honor authenticity are essential in the tallying of early recovery contextual factors and that intrapersonal means of engaging such experiences relate then to degrees of authenticity and self-esteem. Both items can be measured in empirical research.

Second Interview

In the second interview, James is transitioning into more self-sustaining life roles, and his participation in 12-Step groups is less than before. James is beginning to develop a more complex sense of identity, while still navigating his recovery identity and the concepts offered within his 12-Step experience. Social fears emerge at this phase, such as the fear of rejection and the emotional burden of resentments towards others. James is recognizing that his capacity for resolving conflict, both within himself and with others, produces anxiety. However, James does feel he has the tools for a reappraisal of himself as a process itself. Whereas the first months were devoted to developing trust an authenticity with his recovery community, James is now enlarging that process into the larger world, while navigating identity and the self in flux.

“He experiences an enhanced self-awareness regarding his relationships after being abstinent for 6 months; as James’ emotional awareness increases, his capacity to consciously experience his relational engagements facilitates a reappraisal of his way of relating and of being with others…At this second session, after 6 months of his recovery process, James is still negotiating an acceptable framework of self-understanding that resonates with his own experience and with which he can feel at ease.”

For recovery researchers, this offers clues that identity, self-efficacy, and an inventory of contextual factors, such as stable housing and employment, could render a well-detailed snapshot of the stage in the recovery trajectory.

Interview Three

In the third interview, as James is developing new understandings of intimacy. James is tentatively reaching out into the world, through his anxiety and finding himself through that process. His emotional life is the leading site of both his connection to others, but also to himself. Personal awareness comes through a hopeful trial and error; in doing so, James learns more about the interactions between trust, intimacy, and anxiety in his daily life.

“His main concern is self-actualizing possibilities; as he feels more secure in his recovering journey, he starts projecting his thoughts toward future goals. He projects himself toward the future with eagerness, yet anxiety remains around the challenges ahead, which he foresees as a process of growing. In quickly establishing the temporality of the present, he reassures himself that growing, as an expansion of self, is coming into existence. James has developed a sense of basic trust that allows positive engagement and companionship, experiencing the world with others as reliably trustworthy. Nonetheless, James still recognizes a recurrent difficulty in managing his emotional life… James’ recovering journey is one of preparation, as he must establish great trust in himself to achieve more genuine and loving coexistence with others. He also needs this great trust to confidently let go of a huge part of his old self; he knows this old part of his self has no place within his new emerging selfhood, but it is difficult nonetheless to leave it behind.”

For recovery researchers, this account may offer new insights into intimacy as a social measure, and how to conceptualize and capture data related to trust. Emotional self-efficacy and an interpersonal capture of social networks may be useful for a snapshot of this phase of recovery.

Conclusion

We see in this IPA case study that such methodology yields useful insights that can promote further research of recovery in ways that are unique to the recovery experience. Imagine, if you will, that recovery science had thousands of such studies, using this method. What could we come to understand about the early months of recovery? Would such a collection not go a long way in helping recovery scientists to create theory, instruments, and capture data that was explicitly meaningful and directly related to recovery processes and trajectories?

One of the reasons that research such as this is so important is that it presents recovery as it moves through time, and as it is experienced at the personal level. For too long, scientists and clinicians have imposed what they believe recovery to be about, rather than allowing the recovery experience to speak for itself. Using such methods as IPA, we are given threads of insight about the experience of recovery. With enough of this knowledge, we may one day be able to precisely map the topography of early recovery, and chart the obstacles, features, highs, and lows with a quantitative precision that we sorely lack today. The first step in achieving that goal will involve a significant amount of recovery scientists dedicating themselves to qualitative methods such as IPA.

In part three of our series, we will discuss the value of Grounded Theory (GT) as a useful method for qualitative analysis, and discuss how GT can offer researchers novel conceptualizations of how and why recovery operates and manifests in certain commonalities we associate with it.

References

Rodriguez-Morales, L. (2017). In your own skin: The experience of early recovery from alcohol-use disorder in 12-Step fellowships. Alcoholism Treatment Quarterly, 35(4), 372-394.

Smith, J. A., & Osborn, M. (2015). Interpretative phenomenological analysis as a useful methodology for research on the lived experience of pain. British journal of pain, 9(1), 41-42.

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