1. Hope matters in recovery
I’ve been musing a bit recently on the place of hope in addiction treatment and in recovery journeys. Researchers from the USA[1] identified that hope, although recognised as essential for recovery, was not well researched in terms of how it helps recovery progress. They used validated tools (questionnaires) to assess hope and recovery in 412 people. They found that progressing in recovery reduced relapse risk and that hope had a positive mediating effect.
Behavioural change or life transformation?
The researchers suggest that professionals “Consider adopting a holistic approach to addiction recovery that includes factors associated with wellbeing and human flourishing, as opposed to focusing solely on the managing of behaviours. By helping individuals develop a sense of self efficacy (i.e. mastering my illness), clarifying their values, and fostering feelings of connection and belonging, treatment professionals help individuals reduce the likelihood of relapse.”
They go on to stress how important these elements (self efficacy, values, connectedness) are to people who are new to recovery and how by highlighting these, professionals can strengthen their clients’ journeys toward recovery. Key to this is helping to frame recovery as a whole life transformation and not just a behavioural change. (My emphasis)
That feels like a quantum shift from how we come at things currently.
2. Abstinence goals may be more reliable than moderation goals
People asking for help for their drinking problems have a range of problem severities and a range of goals. Both things can be dynamic. Some folk want to reduce their drinking and others want to stop. Some, with severe physical or mental health consequences related to drinking will die if they continue to drink. When we research outcomes from treatment, we tend to look at outcomes that clinicians think are important and less at whether individuals reach their own goals.
In health terms, there’s a consensus emerging that no level of alcohol intake is completely safe, but for most modest drinkers, the risks are felt to be minimal. However, this is evidently not true for people with severe alcohol use disorders. Research has shown that the best treatment outcomes are achieved when people have set abstinence as an end goal, even if moderating drinking was the goal at the start of treatment. My experience from general practice for those with the most severe alcohol use disorders was that initially some – perhaps most – set moderation as a goal, but over a long period, even with maximum support, they moved towards believing abstinence would be safer.
For the kinds of patients I see seeking residential rehab who are at the far end of the severity scale, all have come to the conclusion that stopping drinking represents the best kind of reduction of harms. Many have tried to reduce or control their drinking over years and found that they could not do it in a sustained fashion.
In research[2] from the United States involving 153 people with alcohol use disorder, researchers explored what was going on in terms of the drinking goals the subjects set themselves daily – whether these varied and whether they were able to reach them. They found that complete abstinence was the commonest goal and the one most likely to be reached compared to those aiming for moderation. Paradoxically, they also found that when a daily goal of not drinking couldn’t be reached, those individuals drank more than those setting moderation goals. Nevertheless, the researchers point out:
Abstinence-based daily goals appear to lead to the greatest reduction in at-risk drinking and quantity of alcohol consumption overall.
Pavadano et al, 2022
They say their findings ‘support the clinical benefit of mapping daily goal setting and strategising for specific circumstances’. Of course, this is something mutual aid groups have been practising for decades.
3. Recovery – pulling is better than pushing
Recently I was asked whether getting bad test results (e.g. evidence of poor liver function from blood tests) could act as a motivator to help cut down drinking in someone with alcohol use disorder. I had to be honest and say that in the patient group I see, almost all of whom have biochemical evidence of livers under attack, this was not the case. I said that motivation for recovery generally has to come from hope that things can get better rather than fears that they will get worse.
It was interesting then to have my own observations bolstered by qualitative research[3] from Derby. David Patton, David Best and Lorna Brown explored the part the pains of recovery (push factors) and the gains of recovery (pull factors) play in recovery progress in 30 people with lived experience. Painful things identified included discovering unresolved trauma, difficult housing transitions, moving away from using friends, navigating a new self/world, hopelessness, family difficulties, relapse and stigma.
Pull factors in early recovery related to making new friends in recovery and gaining tools for recovery – mostly in the settings of mutual aid groups. In sustained recovery those ‘pull factors’ were things like: exceeding expectation of what life might be like, supportive romantic relationships, social networks, stable housing, family reconciliation, finding purpose and making progress in employment.
The researchers found that ‘the pains of recovery rarely led to positive changes’ and that those changes were promoted instead by ‘pull factors’.
Their bottom line:
As recovery is neither a linear pathway nor a journey without residual challenges for many people, there is much to be learned about effective ongoing management strategies in preventing a return to problematic use that utilize a push and pull framework
This confirms my impression that when it come to positive change that carrots are generally better than sticks.
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References
[1] Gutierrez D, Dorais S, Goshorn JR. Recovery as Life Transformation: Examining the Relationships between Recovery, Hope, and Relapse. Substance Use & Misuse. 2020;55(12):1949-1957.
[2] Hayley Treloar Padovano, Svetlana Levak, Nehal P. Vadhan, Alexis Kuerbis, Jon Morgenstern, The Role of Daily Goal Setting Among Individuals with Alcohol Use Disorder, Drug and Alcohol Dependence Reports, 2022,
[3] David Patton, David Best & Lorna Brown (2022) Overcoming the pains of recovery: the management of negative recovery capital during addiction recovery pathways, Addiction Research & Theory,