Reflections on Current Debates Regarding Recovery Definitions

April 3, 2021
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Science evolves through collaboration, debates, support, and refutations between scientists. This fact is no less true in the science of recovery. Recent discussions regarding new boundaries in the definition of “recovery” illuminate the mechanics of what scientists, clinicians, and people in recovery feel are essential characteristics of recovery. As one of the authors regarding the Recovery Science Research Collaborative definition of recovery, this article will enter into the fray that Dr. Coon has done such a good job narrating and challenging here at Recovery Review. In doing so, I hope to offer some guidance to this process while also allowing this public debate to continue unabated and uncontested in so far as my own opinion is concerned.

Andreas Vesalius (Flemish, Brussels 1514–1564 Zakynthos, Greece)
De humani corporis fabrica (Of the Structure of the Human Body), 1555
Woodcut; Overall: 15 9/16 x 10 1/2 x 3 1/4 in. (39.5 x 26.7 x 8.3 cm) page: 15 1/4 x 10 1/4 in. (38.7 x 26 cm)
The Metropolitan Museum of Art, New York, Gift of Dr. Alfred E. Cohn, in honor of William M. Ivins Jr., 1953 (53.682)

I want to highlight that the recent debates between Kelly & Bergman and Witkiewitz et al. regarding the definition of recovery mark an official epoch in recovery science development. I would say that this current debate signals an official departure of recovery science; we are emerging out from underneath the shadow of addiction science. In this sense, we should pause and celebrate. It’s happening y’all!

In our 2017 paper on the definition of recovery, one of our main hopes involved shifting the impetus for defining recovery back to the independent scientific community, away from government agencies and the treatment industry. For too long, the scientific study of recovery was hindered by these forces. In the past, meaningful research on recovery required vast amounts of energy to escape the gravitational pull of private industry, non-profit treatment monoliths, and government authority of organizations like the NIH and SAMHSA. This was particularly true if scientists wanted to access funding for research. Millions of dollars were available to study addiction as a social problem, but to study recovery meant one had to take on articulations of recovery that were either reductive, too diffuse, or one-dimensional.

What’s important to consider is that while we are creating and debating a definition to be used for scientific purposes, such definitions should inform, reflect, and compel us toward the lived experience of survivors and the ways in which they themselves would define recovery.

Scientists with lived experience in recovery were indispensable to this effort. What’s important to remember about the RSRC definition is that the collaboration itself was composed of an interdisciplinary partnership whereby most of the contributors to the definition have personal recovery experience, either as people in recovery or with family ties to those with addiction and recovery experiences. Those without personal experiences had long time experience working within organic, clinical, and community recovery spaces. Their authority stems from a fusion between their scientific careers, professional practice, and lived experience. And the message of their 2017 paper is clear: any definition of recovery must be accompanied with data that is holistically informed and crosses multiple life spheres.

The current debate notwithstanding, the general equation for accurate capture of recovery should include personal variables, social variables, ecological improvements, ideally captured over longitudinal time. In short, improvements in the relationship with the self, improvements with the relationships with others, and the subsequent positive alterations to one’s life conditions, all captured longitudinally, offer the ideal framework for research design.

Recovery is a relational event; we must understand that how we define recovery also defines those relationships. Functional improvements are essential, as are long-term health outcomes. Still, neither is more important than how the individual senses their own healing and how that healing is perceived by those whose lives revolve around such an individual. And, as a scientist, whether we can measure this relational space is our methodological challenge. However, this challenge does not give us the right to define things that are easily manageable and intellectually satisfying to ourselves, our institutions, or our funders. The experience of recovery (ie., what we are trying to study) is felt at the kitchen table, in playing catch with one’s children, in showing up to a previous commitment, being emotionally available to support a partner or friend. Recovery experience involves feeling good about these events, in seeing life around oneself improve due to intentionally seeking to improve one’s health as a way of life.

White (2007) noted the tremendous amount of vested interests reliant on the definition of recovery. From treatment to enormously influential governmental and non-governmental organizations, how scientists define recovery affects treatment design, funding, insurance reimbursement, outcome benchmarks, and a whole host of other systems. Given these stakes, in recent years, scientists have noted two key facts. The first is the importance of utilizing lived experience in recovery conceptualization, definition, and measurement. The second is the emerging necessity for the study of recovery to evolve into a branch of science that separates the analysis of recovery from the science of addiction pathology.

Elementary to the justification of recovery science as a distinct branch separate from addiction science is the fact that while addiction itself is a pathology denoted by biological, psychological, and social forms of dysfunction. Recovery, on the other hand, is highly relational, social, and cultural. And while physical and psychological improvements occur (or assisted with therapy and medication), such improvements are often secondary “side effects” to intentional social, relational, and participatory community actions. It is important to understand that social involvement, social health, a sense of connection and meaning are all primary goals for those seeking recovery.

To put it another way, while it is essential to understand the manner and means by which an individual is stricken by addiction, such information is not necessarily a requirement for recovery to occur. This feature of recovery is unique. This uniqueness is because recovery occurs in the real world entirely outside of the clinical and scientific space as a cultural and community effect. People recover all the time without knowing the precise nature of their problem. And yet, if we want to inform the world as to what recovery entails, we must not look for answers stemming from our own understanding of addiction per se. Furthermore, when theories and definitions keep us from seriously considering the experience of recovery in-situ, we must consider the value of such concepts and what our motives may be for using them. Often, this reflexivity has to be an intentional part of the methodological process.

Recovery is enacted, embodied, and lived. Recovery is not a benchmark or an outcome, but rather, recovery is a verb, a state, and a way of being.

Even when recovery is assisted through clinical or medical intervention, recovery manifestation predominantly occurs outside of these spaces. Recovery support occurs through informal social networks, non-professional recovery communities, and public, non-profit organizations. Recovery is not reliant on clinical, medical, or even scientific understanding of recovery itself for healing to occur. To summarize precisely: recovery is defined, enacted, facilitated, and sustained by many forces outside of academic, clinical, and medical space. As such, scientists, medical researchers, and clinicians have been obliged to create fusions with social institutions outside their zones.

However, at times in the past, scientists and medical practitioners have taken this as a license to validate or invalidate forms of recovery experience, to define recovery for their own purposes. This encroachment is a fundamental ethical concern that recovery science must closely monitor. This monitoring and policing of our propensity to encroach on recovery community and culture is our principal ethical obligation.

With the rising opioid crisis, we saw a renewed influx of money and interest into the recovery space. We saw medical professionals for the first time taking seriously the needs of people who struggle with addiction. And while these are significant developments, they do not supplant the existing institutions, communities, definitions, and conceptualizations that have classically defined recovery– any changes in such descriptions and conceptualization must ultimately come from those who have survived addiction disorders (i.e., lived experience). And more precisely, medical professionals and clinicians seeking to address the issues wrought by the pathology of addiction should not be confused or conflated with the lived experience of recovery. This is particularly true of medical specialists- meeting the medical needs of an at-risk population in the midst of a wave of overdose wrought by a tainted drug supply have little experience or authority to weigh in on what qualifies recovery more broadly. Specialization should not be mistaken for generalization.

No matter how well-intentioned scientists may be, and no matter how intimately they may be familiar with recovery, they should be cautious about straying too far from how the people they study define their sense of healing and how these survivors have achieved that healing. This scientific humility will go a long way in the future. The science of recovery requires a de-colonial mindset for the researcher. In this way, recovery science itself requires an ethical reliance on recovery values themselves. We must be honest, self-reflexive, open-minded and we must be concerned and committed to those we study in greater proportion than our own desires for research success. We cannot impose artificial constructs on a community that would disavow such constructs. Why? Because it is a form of oppression and erasure of which western science has a long and tragic history. Let’s not make the same mistake here.

In closing, I would offer a helpful consideration. First and foremost the challenges of capturing lived experience, cultural practices, and social healing are not without precedent. Rather than asking how we can study recovery in ways that may be acceptable to science, journals, funders, and the like, we should instead ask ourselves how we can study recovery in ways that are acceptable to those who are living the experience itself. There is a tremendous amount of scholarship around this, but many of us will have to step outside the rigid structures of our disciplinary fields in order to do this. As an example of broadening our repertoire, it may be time to polish off the ideas of moral psychological realism that posit theory and definitions should come from real-world experience and daily life, and event sampling techniques.

At any rate, as always, I am reinvigorated by these recent debates and I look forward to watching this unfold among my esteemed colleagues and peers.

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