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

I’ll start this article with a quote from one of my favorite intellectual figures from the 20th century, which is actually the title of a book he published in 1970:

“I Seem to be a Verb”

-R. Buckminster Fuller

I’ll explain what I think this odd little sentence has to do with addiction recovery at the end of this article. For the moment, I propose you think about how it might relate to recovery, and why I’d lead an article about recovery with it.

I bet you’ll figure it out before I get to the end.

Now, let’s get to the topic.

How Do You Define Addiction Recovery?

I sat down to write this article and had an idea.

Since I have a personal, working definition of recovery that’s informed by my experience as a physician and consonant with the latest research in addiction treatment, I decided to see what my friends and acquaintances on social media thought about the subject.

So I posted an open question:

Friends, what do you think? Does recovery from an alcohol or substance use disorder (i.e. addiction) require abstinence from alcohol or substances?

I have a diverse group of friends, some medical professionals, most not. Their answers were almost universally, uniformly divided between the two groups: the medical professionals chose one answer, while the non-professionals chose another.

Can you guess who chose which?

I’ll answer that question at the end of the article, too.

How Experts Define Recovery

I’ll start with a definition from one of the most well-known names in recovery: Betty Ford. In 2013, The Hazelden Betty Ford Foundation defined recovery as:

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

They do not mention abstinence. But is sobriety a synonym for abstinence?

That’s a third item I owe you an answer for — but later.

Next, here’s a definition of recovery offered by the Substance Abuse and Health Services Administration (SAMHSA):

“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.”

Again — no mention of abstinence. And no mention of sobriety, either.

Are these definitions aligning with how you might define recovery?

Maybe, maybe not.

Let’s look at one more definition, formulated by another group of experts. This is how the American Society of Addiction Medicine (ASAM) defines the term:

“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.”

Four definitions in, and we finally have mention of abstinence — but perhaps not in the way one might expect.

Surprised?

How to Define Recovery in the 21st Century

One thing to understand about these definitions of recovery is that they’re part of a relatively new trend in healthcare overall: the move toward treating the whole person rather than focusing on treating only the symptoms of a disease or only treating the disease itself.

This trend — think of it as the integrated or holistic approach to treatment — has found the most traction in treating chronic medical conditions such as diabetes, hypertension, cancer, and obesity. Doctors and patients learned that when treatment goes past a diagnosis and a prescription, and includes lifestyle changes, social and emotional elements, and an awareness of family and relationship dynamics, outcomes improve for patients.

It’s also part of a sea-change we see in the way we view health and healthcare worldwide, articulated clearly by the World Health Organization:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

One thing we see in all these new definitions of recovery — and in the WHO definition of health — is that recovery is not defined solely by the absence of symptoms of addiction or by maintaining total abstinence from alcohol or substances: it includes biological, psychological, emotional, and social elements as well. I’m a proponent and active agent of this change in the way we view treatment, especially the treatment of chronic diseases, and in particular the way we treat people with alcohol or substance use disorders — which are, by the way, chronic diseases by definition.

That’s why I have an affinity for a new definition of recovery proposed in a paper published this year in the journal Addiction Research and Theory. It’s called “Defining and operationalizing the phenomena of recovery: a working definition from the recovery science research collaborative.” It incorporates most of the elements of recovery mentioned in the definitions above. It also synthesizes and simplifies those elements — without dumbing them down — into a workable definition that has meaning for both patients and providers.

The Working Definition

This paper attracted my attention for several reasons, the primary one being the presence of the word operationalize in the title. The word implies action. And one thing I know from my years in medicine: theories often fall flat when they meet the real world, i.e. when they’re operationalized. There’s nothing wrong with theories, but they’re not worth much to me — or my patients — unless you can put them into action.

Meaning, unless you can operationalize them.

So, with optimism, I read the paper. The authors analyzed the various definitions of recovery most accepted by mental health professionals, including those I mention above, and crafted the following working definition:

“Recovery is an individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness.”

I think this is a solid way to understand both what recovery is and the process of recovery for the individuals who go through it.

Why?

I’ll answer that by answering the three questions I promised I’d answer above, in reverse order, ending with an explanation of why I opened with a quirky quote from an eccentric philosopher.

That means first I need to answer the question of whether abstinence and sobriety are synonyms: in my mind, they are not at all synonymous. A person can be abstinent from alcohol or drugs yet remain enmeshed in the psychological and emotional patterns that characterize addiction. These patterns can disrupt their professional lives, damage relationships, and perpetuate cycles of behavior that may not involve drinking or doing drugs, but cause just as much harm.

I would not characterize these people as sober, despite their abstinence.

Next, I’ll let you in on the results of my informal social media poll. Remember I told you the medical professionals almost all answered one way, while the others almost all answered another way? It’s not what I expected, but it’s what happened. The professionals, said no, abstinence not required, while the rest — my friends from various walks of life — were crystal clear: obviously abstinence is required for someone in recovery — and most were adamant about it. Interesting.

My Definition of Recovery

I define recovery as a combination of all the definitions presented above: it’s individualized, it’s a process, and it’s related to improving our emotional, psychological, and emotional health. It’s complex, and cannot be reduced to yes/no questions such as “Am I or am I not abstinent?” or “Am I or am I not sober?”

I do believe in working toward abstinence — but in my practice, I do not use abstinence as an absolute metric for defining recovery, because recovery is far more complex than that. It can’t be reduced to a yes/no question. That’s how computers work: simple binaries. Ones and zeros. Human beings are not computers. Human answers to human problems — the good ones, at least — are rarely, if ever, simple, binary, yes/no answers. Human answers to human questions are nuanced and dynamic. They consider the picture, and expand, rather than limit, our understanding of the topic, and always leave open the possibility of change.

The best answers — the fundamentally human answers — always include the potential to evolve.

Just like humans.

At this moment you might be thinking:

“Okay, boomer. Make your point.”

I’m ready to. And I’ll do it by stealing a technique — the mashup — perfected by the generation who loves to say that, while answering the question I opened with:

Recovery appears to be a verb.

Christopher Johnston, MD, ABAM, is the Chief Medical Officer for Pinnacle Treatment Centers, a leading drug and alcohol addiction treatment provider. Dr. Johnston has practiced addiction medicine for the past 15 years, initially in a family practice setting primarily for opioid dependent patients and for the past eight years at Pinnacle working with individuals in residential and outpatient programs with all types of substance use disorders. He is double boarded in both Addiction Medicine and Family Medicine. Dr. Johnston attended UMDNJ — New Jersey Medical School in Newark and completed his residency at Virtua Health in Camden County, NJ, where he was in private practice for 25 years.

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Christopher Johnston, MD, ABPM-ADM

Christopher Johnston, MD, ABPM-ADM, is the Chief Medical Officer for Pinnacle Treatment Centers and has practiced addiction medicine for the past 15 years