Recovery, Recovered, Recovering: New Definitions Acknowledge the Process of Recovery

What is recovery?

There is no simple answer to this question.

I address this topic in an article I published here on Medium in 2019:

What is Recovery? Abstinence, Sobriety, or Something Completely Different?

In that piece, I conclude that whatever recovery is — considering all the various definitions of recovery under debate and in light my personal experience treating patients in recovery over the past twenty years — I understand one important thing about recovery:

Recovery appears to be a verb.

When I say that, I’m not being cheeky or dismissive. Far from it. My goal is inclusion, compassion, and openness. I recognize that recovery is not a destination, a fixed thing, or a label. It takes various forms. Recovery may look different from person to person. Recovery may include abstinence, recovery may include medication, and recovery may include reductions in harm and increases in psychosocial functioning. It may include all, most, or some of these things.

In every case, however, the phrase recovery appears to be a verb means that what defines recovery is taking action to create positive change.

I’m writing this article now in response to a recent publication from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in which a leading panel of experts on alcohol use disorder (AUD) offer a new definition of recovery from alcohol use disorder.

I’ll describe that process and offer their new definition in a moment.

First, I’ll explain why the NIAA convened the panel of experts to form this new definition and review the various definitions of recovery that preceded this one. I’ll end with a brief list that may be the most important part of this article: answers to the question “What is recovery?” from people who are, themselves, in recovery.

Let’s look at why the NIAA spent the time and energy they did on defining recovery.

Bridging the Gap Between Clinical Criteria and Lived Experience

The NIAA released their new definition to the public via the NIAA website in September 2022.

Earlier, in April 2022, they published a report on the collaborative research effort behind the new definition in the paper “Defining Recovery from Alcohol Use Disorder: Development of an NIAAA Research Definition.” The research team asserts that a clear definition of recovery from AUD has been “difficult to operationalize” for a variety of reasons.

Among the current, formal definitions of recovery in use by treatment professionals and people in recovery, the research team identifies four significant limitations:

1. The current definitions and concepts require abstinence from both alcohol and substance use

2. Current definitions don’t include the Diagnostic and Statistical Manual of Mental Disorders, Firth Edition (DSM-5) diagnostic criteria for AUD as part of the recovery process, meaning that the current definitions do not recognize remission from AUD as a component of recovery

3. The current definitions and concepts don’t link cessation of heavy drinking to improvement in quality of life or other measures of biopsychosocial function

4. Current definitions don’t distinguish between alcohol and other substances of misuse/disordered use

Those limitations cause problems because they lead to inconsistency in areas we need stability and reliability. Mental health professionals working in AUD and SUD treatment need to communicate with other professionals working in AUD and SUD treatment and know that when they use certain terms, their colleagues know exactly what they mean. People in recovery from AUD and/or SUD need to know what it means to be in recovery, and if they are in active recovery, their recovery experience needs formal recognition and validation.

The expert panel believes a new definition can:

“…increase consistency in recovery measurement, stimulate research to better understand recovery, and facilitate the process of recovery.”

I agree — now let’s look at the definitions they reviewed to create their new one.

Recovery Defined: Concepts of Recovery Before 2022

While I typically don’t talk about other treatment centers in my articles, there’s one treatment center that’s exempt from any restrictions or rules on my part, because of its status and the positive contributions it has made to our understanding of recovery over the past fifty years: The Hazelden Betty Ford Foundation.

In 2007, the foundation convened an expert panel of their own to address the same problems the recent NIAA panel addressed: the experts wanted to formalize a definition of recovery that included the most recent developments in the science of addiction and recovery.

Here’s how they defined recovery in 2007:

“A voluntary maintained lifestyle characterized by sobriety, personal health, and citizenship.”

This definition identified three primary components — sobriety, personal health, and citizenship — that lay the foundation for how we view recovery today, and which the NIAA panel considered and incorporated into their new definition. We’ll unpack those components now, because they form the core of the debate around our current — and evolving — concept of recovery.

First, I’ll discuss the concept of sobriety.

Sobriety

If the debate around defining what is and isn’t recovery is brand new to you, then we need to explain something.

Traditionally speaking, sobriety meant one thing: not drinking alcohol. In terms of drug use, it meant not taking drugs. However, the advent of medication-assisted treatment (MAT) in the 1970s, and its expansion between 2000 and the present threw a monkey wrench into that concept, and created a significant rift in the treatment and recovery community. That rift continues to this day: one side thinks people on MAT are sober and in recovery, the other side thinks they aren’t.

Here’s how the Ford panel attempted to resolve that conflict:

“To be explicit, formerly opioid-dependent individuals who take naltrexone, buprenorphine, or methadone as prescribed and are abstinent from alcohol and all other nonprescribed drugs would meet this consensus definition of sobriety. Similarly, alcohol-dependent individuals who take acamprosate or naltrexone as prescribed, to reduce cravings for alcohol, but are abstinent from alcohol and all other nonprescribed drugs would also meet this consensus definition of sobriety.”

The argument is persuasive and convinced a large segment of the treatment community. There are still those who take a hardline, abstinence only position on recovery. However, that concept is slowly fading and is no longer the dominant orthodoxy in treatment. The new paradigm is harm reduction, which we’ll discuss below.

Next, we’ll discuss the concept of personal health in recovery.

Personal Health

Including this component in the broad concept of recovery was an important step. It gave weight to the idea that recovery is about more than not drinking/doing drugs and emphasized the value of taking positive steps to address the negative consequences of AUD and SUD and restore overall health. We repeat: previously, recovery simply meant not drinking or doing drugs. Including these three dimensions of personal health in the definition of recovery expanded the concept, and placed it more firmly in the 21st century:

>Physical health: recovery includes improving physical wellness, and restoring the imbalances accrued during active addiction

>Mental health: recovery includes improving the following:

· Emotional distress tolerance

· Cognitive function

· Psychological function

>Social health: recovery includes creating a pro-recovery social network and improving:

· Family life

· Personal relationships

· Vocational functioning

· Academic functioning

Now let’s look at the last component of the Ford panel definition, citizenship.

Citizenship

I include this here to acknowledge the idea, although I’m not convinced citizenship is the best way to describe this component of recovery. The panel defined citizenship in the context of recovery this way:

“…working towards the betterment of one’s community through participation, volunteer work, and efforts to improve life for all citizens.”

What I take away from this idea is the overall sense that recovery involves giving back to the community in some way. Whether that’s helping recovery peers in a 12-step group by becoming a mentor, volunteering for causes, or helping other people find treatment and support, giving back promotes recovery. It keeps people in recovery involved, active, and doing things they feel are right. While I don’t think it’s a requirement for recovery, the idea behind citizenships is consonant with my belief that helping other people is a rewarding, recovery friendly, top-line behavior.

I spent time exploring this Ford panel definition because it framed the subsequent conversation and dialogue about recovery, including the NIAA effort to create a new, formal definition that treatment professionals and people in recovery alike agree is accurate and helpful.

Now let’s move forward — like the NIAA panel wants to do with their revised and expanded concept of recovery.

Towards a Unified Concept

The introduction of the definition above changed the way people think and talk about recovery. Five years later, the Substance Abuse and Health Services Administration (SAMHSA) offered their version, which clearly incorporated elements of the Ford panel definition.

In 2012, SAMHSA described recovery as:

“A process of self-directed change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential.”

Next, in 2018, American Society of Addiction Medicine (ASAM) offered this comprehensive definition of recovery, that incorporated all the key components of the previous definitions, with the exception of the citizenship component included in the 2007 Ford panel statement:

“A process of sustained action that addresses the biological, psychological, social, and spiritual disturbances inherent in addiction. Recovery aims to improve the quality of life by seeking balance and healing in all aspects of health and wellness, while addressing an individual’s consistent pursuit of abstinence, impairment in behavioral control, dealing with cravings, recognizing problems in one’s behavior and interpersonal relationships, and dealing more effectively with emotional responses.”

All these definitions represent progress in AUD and SUD treatment. I use the definition above when we discuss medication-assisted treatment with people in recovery, since it reinforces the idea that recovery is a holistic process, and focusing on one component at the exclusion of others can be counterproductive.

Recovery in 2022: A Complete Definition

Now I’m finally ready to share the new definition of Recovery From Alcohol Use Disorder as revised by the NIAA:

“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.”

That’s a long and involved definition.

I’m okay with that, because in many cases, recovery is a long and involved process. For some people, it’s a simple as the “process of self-directed change” in the SAMHSA definition, but in other cases, it’s a complex, multi-layered, lifelong experience.

The importance of this new definition is that it recognizes recovery as both a process and an outcome and validates both process and outcome equally. In addition, reconciles a working, operationalized definition of recovery from AUD with the clinical criteria for AUD as indicated in the DSM-V, which can help clinicians track treatment progress with objective metrics. Finally, it includes the cessation of heavy drinking on the recovery continuum and accepts the idea that improved quality of life and biopsychosocial functioning — in the absence of total abstinence — are valid metrics that indicate an individual is, in fact, engaged in the process of recovery.

That final phrase is the most germane:

The process of recovery.

A person in recovery takes action and commits to a process of healing that involves all domains of their life. Abstinence and sobriety are core concepts that inform the entire recovery experience, but they are not the only components that matter: what matters is that an individual works toward abstinence, with the idea that recovery is a lifestyle and process that revolves around continuous self-improvement, rather than a fixed destination that can be reached and defined by a single metric, such as passing a lab test that screens for the presence of alcohol or substances of misuse.

What Do People in Recovery Say?

I’ve now come full circle, back to my initial idea: recovery seems to be a verb.

That scans with everything I’ve discussed here: if recovery is anything, it’s a set of actions a person takes to improve their life. It’s more than that, of course — see this whole article — but it’s also that, in a nutshell.

I’ll end this article by sharing quotations from people in recovery published in the article “Elements That Define Recovery: The Experiential Perspective.” All the definitions above come from scientists and clinicians. Some of them may be in recovery, but we can’t be sure. This article set about asking people in recovery what recovery means to them.

When you think about recovery, think about the formal definitions, but also consider these three statements from people actively involved in the process of recovery:

1. Recovery is being honest with myself.

2. Recovery is a process of growth and development.

3. Recovery is taking responsibility.

I agree. And I believe that everyone — not just people in recovery — can benefit from engaging in a process that involves honesty, growth, and personal responsibility. We live to learn. The more we live, the more we learn. And the more we learn, the better we live: that’s the recovery ethos.