Mechanisms and mediators of addiction recovery

Addiction recovery is a complex, dynamic and non-linear process of change on multiple life domains, and in substance use patterns in particular (Dekkers et al., 2020; White, 2007). While early definitions equated recovery with ‘remission’, ‘abstinence’ or absence of symptoms of dependence, later conceptualisations have also emphasised the importance of health, well-being, quality of life, citizenship and social participation, as illustrated in the Betty Ford Consensus Panel definition (Betty Ford Institute Consensus Panel, 2007, p. 222): ‘a voluntarily maintained lifestyle, characterized by sobriety, personal health, and citizenship’. Although abstinence may be an important feature, it is not a prerequisite for recovery (Laudet & White, 2010). The addiction recovery literature has grown quickly over the last few years, including a variety of recovery indicators, resources and instruments (Ashford et al., 2020; Best & Laudet, 2010; Best et al., 2021; Cano et al., 2017; Cloud & Granfield, 2008; Groshkova et al., 2013; Neale et al., 2016). Far less is known about how recovery takes place and which mechanisms and mediators are central to addiction recovery.

The role of professional treatment and other forms of structured support (e.g. peer-support, mutual aid groups) has been acknowledged in the literature. Yet, several authors have documented the phenomenon of ‘natural recovery’ or ‘self-change’ (Klingemann et al., 2010). A recent national probability-based estimate in the US indicated that around 9% of all adults have resolved an alcohol or drug problem (Kelly et al., 2017). Although ‘being in recovery’ cannot be considered synonymous with ‘resolving an alcohol or drug problem’, only half of the sample (54%) used some type of support and only 27.6% made use of professionally assisted recovery support (i.e. formal treatment). It is unclear how these US figures relate to other countries, but cumulative evidence shows that recovery is possible and not uncommon, even after lengthy addiction careers. Despite the recognition of addiction as a chronic relapsing condition, some systematic reviews show that over 50% of all persons with an alcohol or drug problem eventually recover (Sheedy & Whitter, 2009; White, 2012). As addiction recovery research has only emerged in the past decade, many issues have remained unaddressed.

This special issue has been driven by the insights and connections from the international REC-PATH (Recovery Pathways) study, funded by the European Research Area Network on Illicit Drugs (ERANID). This 3-year multi-country study in the UK, the Netherlands and Belgium aimed to identify recovery pathways of persons who use illicit drugs and assess the impact of societal responses on recovery trajectories (Best et al., 2019; Martinelli, Nagelhout, et al., 2020; Martinelli, van de Mheen, et al., 2020). Based on a multi-method research design, over 700 persons with lived experiences of drug use problems were assessed during various waves and in specific sub-studies. REC-PATH can be considered one of the first and largest cohort studies on drug addiction recovery outside the US. The background, findings and experiences from this study served as an impetus for setting up this special issue, in which we intended to collect multidisciplinary insights on addiction recovery from a range of countries through a variety of research methods. A parallel objective was to echo individuals’ lived experiences to enhance recovery-oriented policies and practices. As in the REC-PATH study, the focus was on broad mechanisms and specific mediators of addiction recovery. With recovery mediators, we refer to stable/fixed variables or characteristics (e.g. gender, ethnicity, social status, recovery stage) that affect the recovery process, but may be difficult to change. Recovery mechanisms are active interventions (like participation in treatment or mutual aid groups) or changes in individuals’ lives that influence the recovery process positively or facilitate recovery.

Mechanisms of behaviour change have been conceptualised in the work of Moos (2008) and Kelly et al. (2009) and refer to a process or series of events through which one variable leads to or causes change in another variable (Nock, 2007). Consequently, similar changes in addictive behaviours can be explained by various social, psychological, behavioural and neurobiological processes, while different mechanisms that account for behaviour change may occur simultaneously or cumulatively (Kelly et al., 2009). No single mechanism is likely to account for recovery, while the availability of mechanisms may change over time and different mechanisms may be involved in initiating and maintaining recovery. Building on these assumptions, we hypothesized in the REC-PATH study that five mechanisms of behaviour change contribute to addiction recovery: (1) 12-step mutual aid support; (2) other peer-based recovery support; (3) residential and therapeutic community treatment; (4) specialist outpatient (maintenance and abstinence-oriented) treatment; and (5) natural recovery (Best et al., 2019; Best 2019). The assumption was that most study participants would have attempted multiple mechanisms, if not all, and that this would differ according to gender and recovery stage.

The REC-PATH study constitutes a central part of this special issue, providing the model and the data for three papers:

In a first quantitative paper, Martinelli, van de Mheen, et al. (2020) looked at various mechanisms of behaviour change and its association with recovery stage, recovery capital and social inclusion. Lifetime participation in mutual aid groups was strongly associated with social network participation, greater levels of recovery capital and stronger commitment to sobriety.

The second REC-PATH paper focuses on the policy component of the study. ‘Chasing a pot of gold’ by Bellaert et al. (2021) provides an analysis of the development, implementation and evaluation of recovery policies in Belgium and the Netherlands. Findings illustrate that while recovery is proclaimed to be the ‘new gold standard’, structural implementation, dedicated funding and systematic evaluation of recovery practices are missing, as well as the participation of persons in recovery in developing recovery policies and recovery-oriented support services.

The diversity of research methods in the REC-PATH study is evidenced by the third paper, in which Van Steenberghe and colleagues (2021) used the innovative photovoice research technique to uncover women’s recovery experiences and understand what helped them to initiate and maintain recovery. The results highlight the complex interactions and positive and negative dynamics between recovery capital and gender and other social constructs.

The paucity of recovery studies that focus on gender issues is addressed in this special issue, not only by the photovoice paper (Van Steenberghe et al., 2021), but also in papers by Collinson & Hall (2021), Kougiali et al. (2021), and Andersson et al. (2020). Based on a secondary analysis of two qualitative studies of women in recovery, Collinson and Hall (2021) describe recovery as a socially mediated process that involves different recovery mechanisms and mediators for women compared to men. Its implications for community-based, gender-responsive recovery support are discussed.

Kougiali and colleagues (2021) reviewed the literature on women's pathways into alcohol dependence and towards recovery using a qualitative meta-synthesis. As in the other papers exploring gender, the negative role of shame and stigma and adverse childhood experiences is discussed, as well as recovery facilitators like belonging, participation in recovery groups, developing ‘the self' and the complex interplay of these processes.

Based on data from the first UK Life in Recovery survey, Andersson and colleagues (2020) assessed differences between female and male participants in a community sample of recovering alcohol users. They identified greater mental health needs and relational issues in women, while men experienced more physical health needs.

A second major focus of the REC-PATH study as shown in the Martinelli, van de Mheen, et al. (2020) paper examines the importance of recovery stages. This was also the focus of the paper by Von Greiff and Skogens (2021) in this special issue, which revisited a Swedish sample of persons who self-identified as ‘in recovery’ 5 years after they completed residential 12-step treatment. A multitude of recovery processes is described, underlining that recovery is a process differing from individual to individual and ranging from abstinence to moderation.

All other papers in this special issue (Anderson et al., 2021; Dekkers et al., 2021; Frings et al., 2021; Gueta et al., 2020; Jason et al., 2021) focus on diverse recovery mediators and mechanisms and their role in individuals’ recovery trajectories, reflecting the primary objective of the REC-PATH study.

In their paper ‘It’s not 9 to 5 recovery’, Anderson and colleagues (2021) studied the size and density of the social networks of persons in recovery participating in peer-support groups, using social network analysis (SNA). Recovery group membership was associated with a significant increase in the number of positive relationships and the replacement of alcohol and drug using peers by recovery peers.

Dekkers and colleagues (2021) looked for quintessential components of recovery trajectories among persons who participated in different types of recovery-oriented support in Belgium (i.e. outpatient, residential, low threshold community-based support, 12-step self-help groups and no formal or informal support). The role of ‘time’ and ‘supportive environments’ were central in recovery processes, contributing in turn to the development of a sense of self and the future.

Based on a large set of Alcoholics Anonymous (AA) participants, Frings and colleagues (2021) studied the role of social identity for preventing relapse in early and later recovery stages. Their findings suggest that social identification is particularly important when quitting substance use and starting to attend AA, emphasising the importance of recovery formation and transition.

The article by Jason and colleagues (2021) is highlighted as the editors’ choice and features a longitudinal study of 497 Oxford House residents for predicting post-departure relapse. This unique model of addiction recovery homes represents the main type of residential, post-treatment support in the US. Relapse after leaving these homes is associated with younger age, involuntary departure and less recovery capital.

One article compared individuals in recovery through self-change and treatment-induced change, using a mixed methods study design in Israel (Gueta et al., 2020). The authors found several significant differences between both groups, with self-changers displaying more intrinsic motivation, personal goals and greater self-reliance. They stress the importance of individuals’ personal and social context in shaping recovery maintenance.

Finally, the study by Jouet and colleagues (2021) focuses on the role of non-abstinence oriented residential treatment in individuals’ recovery pathways in France. In-depth follow-up interviews demonstrated the importance of a holistic well-being approach, person-centred care and support, risk and stress management, peer support and supportive family and social networks.

Overall, this special issue on addiction recovery mechanisms and mediators contributes to the growing evidence-base for providing recovery-oriented support in treatment and community settings (Ashford et al., 2020; Best, 2019) and disseminates knowledge and insights from recent research. First, several papers demonstrate that participation in self-help groups is crucial for initiating and maintaining recovery, not only through involvement in new, cohesive prosocial networks, but also through a strong commitment to sobriety (Anderson et al., 2021; Frings et al., 2021; Kougiali et al., 2021; Martinelli, van de Mheen, et al., 2020). Developing ‘the self’ and a ‘post-addiction’ identity as well as social identification appear to be crucial elements in early recovery (Frings et al., 2021; Kougiali et al., 2021; Van Steenberghe et al., 2021). Second, time in recovery and recovery stage came to the fore as important predictors of stability of behaviour change (Dekkers et al., 2021; Martinelli, van de Mheen, et al., 2020; von Greiff & Skogens, 2021). Third, Cloud and Granfield’s notion of recovery capital (Cloud and Granfield 2008) emerged in several papers, illustrating the importance of personal, social and community resources for promoting recovery and avoiding relapse. Frequently mentioned resources were supportive social and family environments (Anderson et al., 2021; Dekkers et al., 2021; Martinelli, van de Mheen, et al., 2020), recovery-supportive housing facilities (Jason et al., 2021), and personalised and holistic support services (Bellaert et al., 2021; Jouet et al., 2021; Van Steenberghe et al., 2021). Finally, several papers show that women face different challenges compared with men in recovery, as they experience more mental health and family needs (Andersson et al., 2020) and are more often confronted with adverse childhood experiences and multiple stigma (Kougiali et al., 2021), indicating the need for gender-sensitive recovery services (Collinson & Hall, 2021). One outstanding question is whether these observations can be extended to other gender identities not included in these studies. The same is true for the findings around self-change and whether similar mechanisms and mediators are at work among individuals who recover without external help (i.e. natural recovery populations). These are only two potential research questions stemming from what we can learn from the collection of papers in this special issue.

Ultimately, this special issue illustrates the growing diversity in recovery research in both the geographic areas in which it is conducted (many of the papers included are from non-Anglophone countries) and the populations studied at varying stages of their recovery journeys. One of the aims of undertaking the REC-PATH study was to build capacity for recovery research and to generate new research questions and concepts that reflect the diversity of recovery populations and philosophies, but also show the increasing (and needed) focus on the needs of specific sub-groups in a range of countries and contexts. The studies on gender are an important contribution to this research model, but we also need to understand more about recovery pathways linked to specific substances (and to behavioural addictions), as well as increasing the research corpus around culture, context, geography and demography. The papers in this collection provide us with the impetus to push forward with an evidence-based recovery debate that should elicit considerably more research undertaken by a broad range of academics and people with lived experience. We will continue to publish from the REC-PATH study and other ongoing recovery projects and our hope is that this will be matched by an international commitment to research in this area.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work is supported by European Research Area Network on Illicit Drugs (321580).