Can science give up on defining recovery and maintain a recovery orientation?

Justin Bell’s recent post on the scientific dilemma of whether to drop or keep recovery sparked a lot of discussion.

One takeaway from the discussion is the confirmation that people really struggle to hold space for one definition in scientific spaces while holding space for other definitions in personal, community, and professional service spaces. There is a strong sense, maybe instinctive rather than cognitive, that changing or establishing a definition in one space changes it in other spaces.

This fits my impressions over the years that research definitions inevitably bleed into other spaces, often framed with scientific authority. This scientific authority is appealing on funding requests, public education, and professional education.

Anecdotally, all of this also highlights the disconnect between online recovery spheres and offline community spheres. In my limited experience, people in offline recovery communities have little awareness of or interest in these discussions about the conceptual boundaries of recovery.

Definition quagmire

We’ve spent the last 20 years struggling to settle on a measurable definition of recovery, and it often feels like we haven’t made much progress.

Several definitions have emerged, but they often emerged from specific spaces, for specific uses, and they get promulgated more broadly by people who find it validating (or invalidating) for specific populations, pathways, or models.

The matter has gotten significantly more complicated as recovery is discussed as both an endpoint and a process. The process model has gotten more complicated due to an emphasis on multiple pathways giving way to multiple starting points (addiction, SUD, self-identified problem) and multiple endpoints (which may include abstinence, harm reduction, moderation, heavy drinking, etc.).

The case of recovery capital

Interestingly, the use of recovery capital in research and community practice has exploded over the last 20 years without much controversy.

Recovery capital isn’t recovery. Many people without Substance Use Disorders may have very high or very low levels of recovery capital, and there is no assumption that their recovery capital status confers recovery or addiction to them. BUT, recovery capital is associated with recovery. It’s more like a set of factors that influence the initiation and maintenance of recovery.

For people with an SUD, it’s uncontroversial that increased recovery capital is associated with a greater likelihood of initiating and maintaining recovery. It’s also not controversial that a loss of recovery capital is associated with an increased risk of relapse.

So… recovery capital isn’t recovery and it doesn’t attempt to define recovery. Does that mean its use isn’t recovery-oriented? Absolutely not.

It provides a framework for conceptualizing factors that can influence substance use problems and recovery/remission/resolution. And, importantly, it’s not in tension with any pathways or models of recovery, and it is not limited to any particular type of problem.

Would “Quality of Life” or “Stages of Healing” represent an abandonment of recovery?

Recovery was introduced as a paradigm because historical metrics set the bar too low for patients, providers, and systems. Those historical metrics focused on the following categories:

• symptom reduction (less substance use),
• social harm reduction (fewer arrests and lower rates of disease transmission), and
• remission (problem reduction below diagnostic threshold)

Bill White summarized the argument well here:

Recovery from opioid addiction is also more than remission, with remission defined as the sustained cessation or deceleration of opioid and other drug use/problems to a subclinical level—no longer meeting diagnostic criteria for opioid dependence or another substance use disorder. Remission is about the subtraction of pathology; recovery is ultimately about the achievement of global (physical, emotional, relational, spiritual) health, social functioning, and quality of life in the community.

White, W. & Torres, L. (2010). Recovery-oriented methadone maintenance. Chicago, IL: Great Lakes Addiction Technology Transfer Center.

So… maintaining a recovery orientation is critically important, in part because one face of stigma is lowered expectations for patients, providers, and systems. There’s a long history of harm through low expectations.

There’s a reasonable fear that “dropping” recovery would represent an abandonment of recovery. I think the example of recovery capital gives us reason to question that.

In other areas of behavioral or medical healthcare, if we want information that looks beyond remission, we might look to quality of life (QoL) measures. Brian Coon proposed Stages of Healing as a framework for evaluating care and growing knowledge about SUDs, addiction, remission, recovery, and treatment over the lifespan.

Using these frameworks to evaluate interventions and better understand which subpopulations achieve the highest QoL with which intervention might actually result in a more robust orientation.

Aligning research priorities with calls to action like “recovery by any means necessary” is vulnerable to getting bogged down with questions about the meaning of recovery.

A focus on maximizing quality of life is uncontroversial and avoids questions about starting points, pathways, and endpoints. It could give researchers the freedom to focus on questions like:

• If some people can resolve their problem and achieve high quality of life while continuing to use substances, what are the characteristics of those people and what pathways get them to that endpoint?
• If others can only resolve their problem and achieve high quality of life with abstinence, what are the characteristics of those people and what pathways get them to that endpoint?
• If some people resolve their problems but experience limited gains in quality of life, what are the characteristics of those people and what pathways get them to that endpoint?

Is that less recovery-oriented because the word “recovery” doesn’t appear in those questions? I don’t think so.

Is this a call to drop recovery? No. But I don’t fear the possibility as I did 10 years ago.

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[image credit: “True North” by Conal Gallagher is licensed under CC BY 2.0]