Brian Coon posted a reaction to the NIAAA definition yesterday. I also recently watched the NIH webinar on the definition.
“Recovery is a process through which an individual pursues both remission from AUD and cessation from heavy drinking. Recovery can also be considered an outcome such that an individual may be considered ‘recovered’ if both remission from AUD and cessation from heavy drinking are achieved and maintained over time. For those experiencing alcohol-related functional impairment and other adverse consequences, recovery is often marked by the fulfillment of basic needs, enhancements in social support and spirituality, and improvements in physical and mental health, quality of life, and other dimensions of well-being. Continued improvement in these domains may, in turn, promote sustained recovery.”
I like several elements, including ones that Brian noted:
- It frames recovery as a process and an outcome. (Other recent definitions frame recovery only as a process.)
- It provides clear criteria.
- The criteria address alcohol use.
- It looks beyond drink counting and references improvements in global health and quality of life. (Note, though, that these improvements are not required.)
All that said, it leaves me wanting something different.
As I sat with that dissonance, I decided that it is a fine definition of recovery for Alcohol Use Disorder (AUD) but I find myself troubled by the application of the concept of “recovery” to AUD.
In the webinar, John Kelly discusses (15:30) the challenge of trying to turn a cultural concept (recovery) into a scientific concept. The cultural concept of recovery is more than the reduction (or even elimination) of symptoms and focuses on an additive experience. I think it’s also fair to say that, in the cultural realm, recovery has been more than a process or outcome–it’s been an identity.
Why would something recovering from an illness become integrated into one’s identity? Because the experience of alcohol and other drug addiction is often life-threatening, traumatic, treatment can provide few guarantees, and it often erodes one’s identity. It also transforms an experience of stigma into an identity the individual feels pride in.
So, when you’re talking about recovery as a kind of identity, “recovery from what?” becomes a salient question.
People who faced and survived a life-threatening illness like lung cancer may integrate being a cancer survivor into their identity. The same might be true for groups of people who survive certain disasters. Importantly, those identities may serve as a source of connection to others who share the identity and can be powerful enough as a social adhesive that entire communities are built around them.
This definition puts the following people into the same category of “recovery” from AUD:
- While in college, Henry drank several days a week, spending most of the weekend drinking with friends. During his sophomore year, it was common for him to have as many as 8 drinks on weekend days, but that progressed to 12 during his junior year to achieve the same effect. It was common for him to be hungover on Saturday and Sunday mornings and spend half the day recovering. His drinking caused considerable tension with his parents who believed his drinking adversely affected his grades and his relationships with his family. This was true, but Henry said he wasn’t concerned. After a few rough semesters, Henry decided to cut back to a couple of drinks on Thursdays and 4 drinks on Fridays, Saturdays, and Sundays.
- Shayna started drinking in her teens and drank heavily on weekends, often drinking to the point of passing out. On a couple of occasions, friends needed to take her to the hospital for alcohol poisoning. She tried to cut back, but found herself unable to moderate with any consistency. Shayna got into a good college, but her drinking led to her being expelled due to poor grades. Several relationships ended because of her excessive drinking and her behavior when she was intoxicated. She lost jobs due to her drinking and tried to stop but was unable to, despite her best efforts. Her parents took physical custody of her children because her drinking made her an unreliable caregiver. She entered treatment several times but dropped out or never stopped drinking despite anti-craving medication. She spent time in jail due to multiple impaired driving convictions. She entered treatment for the 8th time, moved into a recovery home for 12 months, got deeply involved in a mutual aid group, stopped going to old hangouts, and developed a new social network of people in abstinent recovery. She struggled with severe cravings to drink, fortunately, these faded slowly as she did the hard work of rebuilding her life.
- Mark had a pattern of alcohol use very much like Shayna’s but also used cocaine, cannabis, and opioids. After a drunk driving accident, Mark found that using benzos helped him reduce his drinking to a few drinks a few times a week. Others have noticed that his cocaine use accelerated following the reductions in his drinking. His drug use is causing considerable functional impairment and he meets all criteria for substance use disorder.
Does it make sense to put these three people in the same category? They’re all in remission from AUD and have ceased heavy drinking.
Would Henry or Mark be likely to identify as in recovery? Might they begin to use that label if researchers, treatment providers, and advocates tell them they are in recovery? Would their loved ones think of them as in recovery? Would it make sense to an observer if we describe them as being in similar states of recovery?
To me, remission seems like a more appropriate characterization of Henry’s experience.
On the other hand, it would seem strange to characterize Mark as in recovery from AUD when he is in the throes of drug addiction.
Would Mark, Henry, and Shayna see themselves as having a shared experience or identity? Would their experiences be helpful or validating to each other? How meaningful is a category that includes such diversity in pathology and problem resolution?
Putting the three of them in the same category may make sense from the perspective of a researcher (I’m not sure that’s true.), but does it make sense from a cultural perspective? Does it make sense to develop research definitions that create discord with cultural understandings (even if their boundaries are poorly defined)? Where there is discord, how do research and cultural understandings interact and influence each other?