Narrative Means to Recovery Ends. Novel Psychoactive Substance Users in Early Recovery

Abstract

The relationship between trauma and subsequent substance use has been extensively studied. Substance dependence and its consequences are a source of further traumatization. This explorative qualitative study is an analysis of the recovery narratives of persons with polydrug dependence, using mainly novel psychoactive substances (NPSs). NPS use, with its unpredictability and major health risks poses a challenge to treatment systems, but only few studies are available on NPS users’ recovery processes. In this longitudinal study, authors explore processes of identity reconstruction in the emotionally valent episodes of 10 respondents’ life interviews. The interviews had been conducted with 77 patients at the beginning of their residential treatment and were repeated a year later with those in recovery and available for the study, altogether 10 persons. Narrative Oriented Inquiry was used as a framework, focusing on the key themes and changes in the narrative mode. Our results support the findings on previous and subsequent NPS use-related traumatization. In this perspective, NPS use corresponds to revictimization. Contrary to available but sporadic evidence suggesting a marked difference between the recovery processes of users of classical substances and NPS users, the respondents in this study could utilize the traditional cultural stock of recovery stories during their treatment. Changes involved more reflective and responsible attitudes and the broadening of a healing social network. Contents describing care/self-care and the emergence of hopeful attitudes were also identified. Further research, involving larger samples and cross-cultural comparisons, could deepen our understandings of NPS users’ recovery processes.

Keywords:

• Novel psychoactive substance
• trauma
• recovery
• narrative oriented inquiry
• longitudinal study

Introduction

Novel psychoactive substances (NPSs) are drugs—either in pure form or in preparation—that are not controlled by international drug control conventions. Individual and community-level risks caused by their use are commensurable with or exceed those elicited by classical substances. By 2023, NPSs have become a global concern affecting 141 countries. The several hundreds of rapidly proliferating substances are categorized by their effect or chemical composition (United Nations Office on Drugs and Crime, 2024). The main four types of these synthetic drugs are stimulants, cannabinoids, hallucinogens, and depressants (Shafi et al., 2020). Two common NPS types are synthetic cathinones (SCH, beta-ketone amphetamine analogs) and synthetic cannabinoids (SCB) (Prosser & Nelson, 2012). Early studies on NPSs focused on the puzzling multitude of these substances and the new risks associated with use, such as HIV-1 outbreak among synthetic cathinone users (Hanke et al., 2020), increased risk of Hepatitis C infection (McAuley et al., 2019), incidences of severe and sudden cardiac, neurological and psychiatric symptoms, and occurrences of death (Funada et al., 2019; Prosser & Nelson, 2012; Van Hout et al., 2018). Psychiatric symptoms include paranoia, bizarre and violent behavior, and acute psychotic episodes (Bennett et al., 2017). Further, NPS use is usually polydrug use, the concomitant use of two or more psychoactive substances multiplying the serious health risks (Higgins et al., 2021; Neicun et al., 2020; Rinaldi et al., 2020). Polydrug use entails unpredictable adverse effects and higher risks of overdose. Dependence occurs when the frequency or quantity of use leads to serious impairments in the bio-psycho-social domains (European Monitoring Centre for Drugs & Drug Addiction, 2021). Polydrug use and dependence are a feature possibly related to patient characteristics and to the addictive potentials, volatility, and unpredictability of NPSs.

In addition to the risks associated with the various NPSs, the ethnography of the different user groups, their motives and experiences, and appropriate clinical guidelines were among the researchers’ main questions (Abdulrahim & Bowden-Jones, 2015; Gittins et al., 2018; Van Hout et al., 2018; Wieczorek et al., 2022). Marginalized and nightlife users are a traditional user group. The broadband internet, smartphones, and social media established new user communities and new risks (Kaló & Felvinczi, 2017). Enhancement and expansion were associated with the contexts of use or NPS type (Wieczorek et al., 2022), whereas social and conformity motives characterized the user groups (Benschop et al., 2020). In several countries, NPS use is widespread among marginalized groups living under the poverty threshold (Felvinczi et al., 2020). In these groups, users’ preexisting poor physical and mental conditions, hopelessness, and helplessness add to the above risks. In addition, access to health services for persons with drug-related problems might be deficient in these areas. Marginalized groups use NPS to escape from their everyday reality and the pains of unsolvable problems (Csák et al., 2020). In a study, however, NPS use was found to be associated with mental health problems more than with socioeconomic vulnerability (Neicun et al., 2020).

Several studies have confirmed the strong relationship between traumatic life events and substance use disorder (SUD) (Van den Brink, 2015). The connections between post-traumatic stress disorder (PTSD) and substance use have been extensively studied (Basedow et al., 2020; Dass-Brailsford & Myrick, 2010; Najavits, 2015; Schein et al., 2021; Van den Brink, 2015). Few articles are available on the specific relationship between NPS use and psychological trauma (Gittins et al., 2018). Kassai et al. (2017) identified SCB use as a particular type of trauma.

Recovery processes from NPS dependence have also remained an under-researched area as only few subjects are available for the studies (Kassai et al., 2017). These studies are the first step to know more about the recovery processes from NPS use, which represents a new paradigm deeply challenging the treatment systems (Rácz et al., 2016).

Recovery from addictions

Recovery is a process to improve one’s health, wellness, and autonomy and develop one’s full potential in life (SAMSHA, 2012). Anthony, highlighting the relational aspects of recovery, described it as “a deeply human experience, facilitated by the deeply human responses of others.” (Anthony, 1993, p. 531). Mudry et al. (2019) explored the transformative pathways in natural recovery and the major changes in interpersonal relationships from pathologizing modes to healing relational patterns.

The recovery concept and practices of self-help groups informed the professional theories and models in addictions (Arbour & Harris, 2023; Madácsy, 2020). Twelve-step recovery communities and therapeutic communities (TCs) rely on the social support provided by the sober community as well as on the rich knowledge of those in sustained recovery as experts by experience. These communities equip the service users with SUD with rich narrative resources to facilitate therapeutic change (Harrison et al., 2020; Mudry et al., 2019). Recovering persons’ own interpretations of recovery include adopting new lifestyles, enhanced well-being, self-development, accepting what life can give, abstinence, the ability to identify problems, and adequate help-seeking behavior (Laudet, 2007). Recently, studies on the potential connections between recovery from addictions and post-traumatic growth have appeared, emphasizing the role of spirituality and community support (Haroosh & Freedman, 2017; Ogilvie & Carson, 2022; Stokes et al., 2018).

Though abstinence is not sobriety, programs that require abstinence have been proven more effective. In their survey study, Kaskutas et al. (2014) described four recovery domains: abstinence, essentials of recovery, enriched recovery, and a spiritual orientation. Essential recovery comprises honesty to oneself, an ability to manage negative emotions while maintaining abstinence and enjoying life without substance use. Enriched recovery involves growth and development, giving a balanced response to life’s ups and downs, and taking responsibility for the things one can change (Kaskutas et al., 2014). Jacob et al. (2017) found that carers’, and consumers’ perspectives on recovery differed: carers focused more on the outcomes, mainly understood as freedom from symptoms; for the consumers, recovery was a complex process comprising personal growth and transformation while finding new meaning and purpose in life. Available social support, reciprocity in one’s relationships, follow-ups, and taking personal responsibility for one’s health were identified as key elements during the personal journey from an addict identity to a sober identity marked by increased well-being.

In sum, recovery from addictions is understood as a substantial identity transformation, a second birth or redemption leading to a personally, socially, and spiritually meaningful life (James, 1902/1982). The journey with its crises, guiding the person toward a sober identity with vital improvements that permeate all areas of life, is a demanding developmental task. It is a holistic, nonlinear process involving not only deep transformations but the restructuring of daily life as well (Betty Ford Institute Consensus Panel, 2007; Costello et al., 2020). The process requires growing commitments and an ability to learn from one’s mistakes.

Stages and processes of recovery are usually determined according to the transtheoretical model by Prochaska et al. (1992). Precontemplation is characterized by denial, defensiveness, and a focus on the positive impacts of the drug. Recovery seems an irrational, meaningless, and unmanageable endeavor. The next phase, contemplation is characterized by ambivalence. The person is willing to consider drug-free ways of life. Preparation involves steps to quit and/or organize some treatment. Minor changes in personal life are possible, including temporary abstinence. The action stage is about commitment to change. In this phase, persons learn how to ask for help when needed and can identify and manage relapse. Maintenance is characterized by self-care and a sober lifestyle.

The health learning model, describing the specific recovery processes in the context of a therapeutic community (TC), comprises three main elements:

1. reacting to the program with a focus on the whats (actions, structures, etc.), but not understanding the hows and the whys yet,

2. working the program and building conscious recovery competence manifested in self-monitoring and an awareness of risks,

3. responding to the program and achieving a stage of reflective competence with deepening explorations and insights into the personal meaning of recovery (Kelemen & Erdos, 2010).

Based on these models, a constructive therapeutic change involves growing commitment to recovery, developing healthier habits, an ability to identify the risk of relapse, asking for help when needed, and the development of reflective skills. For the majority, it takes about two years to reach a stage marked by some stability. Therefore, we identified the respondents in this study as patients in early recovery, proceeding from their preparations to actions and reflections.

Narrative practice

The title of this study refers to a seminal work by two narrative therapists (White & Epston, 1990). Changes in narrative identity take place in the dual landscape of events and actions, establishing new coherence and directionality by reconstructing and expressing personal meanings. Narratives connect personal experiences to cultural meanings and social structures and establish the narrator’s position for potential actions (Hiles & Čermák, 2013). Narrative frames open the door to new possibilities for deconstructing and reconstructing disorganized, dissociated, or oppressive-dominant narratives—the silenced stories in the domain of the not-yet-said (Neimeyer, 2006; Rober, 2002). Narrative therapies highlight the importance of telling and retelling (re-authoring, restructuring) the problem-saturated life story, thereby creating new positions and prospects for the future (Tarragona, 2008). Trauma, if unexpressed and unanalyzed, often becomes insidious, leading to a variety of health problems. Studies have confirmed that speaking and writing about one’s traumatic experiences lead to enhanced well-being (Chung & Pennebaker, 2007; Pasupathi et al., 2015; Pennebaker & Smyth, 2016).

Storytelling has always been central to twelve-step practices (Arminen, 1998; Kiss et al., 2022; Madácsy, 2020). Rennick-Egglestone et al. (2019) identified several positive outcomes of using personal narratives to support the recovery process. The recipients of the stories could experience connectedness, validation, hope, empowerment, appreciation, reference shift, and stigma reduction. Negative impacts comprised feelings of inadequacy, disconnection, pessimism, and burden. Perceived authenticity facilitated positive changes, while a crisis state was conducive to negative impacts (Rennick-Egglestone et al., 2019).

Hänninen (2004) distinguished between three main narrative modes in her model on narrative circulation. The told narrative is a manifest verbal representation of events. The inner narrative is the domain of the not-yet-said that can be externalized and validated by relying on one’s cultural resources and can be transformed into a told narrative during therapy (Rober, 2002). The lived narrative is the “real-life drama” with its situational constraints (Hänninen, 2004, p. 69). In the model, the inner narrative is connected to both the told and the lived modes, and the personal stock of stories is defined by the cultural stock of stories and the person’s own experiences.

Hänninen and Koski-Jännes (1999) in a qualitative study on 51 recovery narratives have described five story types. As tools for meaning making, the different types offer personalized and culturally matching storylines for identity change.

• The AA story: excessive drinking, loss of control, and hubris—as the symptoms of a lifelong disease—lead to isolation and impairments in all areas of life. In the AA narratives, this is hitting rock bottom, the most profound crisis in the addict’s life. Repeated own attempts at recovery fail until the person has learned humility and has joined Alcoholics Anonymous, a potent community resource to master decent ways of life. In this conception, the person is a victim of a disease, and they must learn how to live with it. The only cure is one’ personal commitment to a sober community.

• The personal growth story sees addiction as the result of early oppressive relationships and neglect. Growing emancipation, autonomy, and agency are the keys to recovery. The person, a previous victim, should find their own true self instead of conforming to others’ wishes. They are like a “butterfly breaking out of a cocoon” (Hänninen & Koski-Jännes, 1999, p. 1842).

• The co-dependence story is characterized by silenced stories, a transgenerational “curse.” Addiction is the result of secrecy and the repression of own negative feelings, and recovery is that of honesty and breaking the curse of the transmission by the victim of a victim.

• The love story: addiction is a compensation for the lack of love. Recovery occurs when love is given.

• The mastery story: initially, addiction is seen as a source of autonomy and later as a threat to autonomy, self-respect, and responsibility. This insight, as the triumph of reason, leads to recovery and the construction of a strong and good self.

These storylines help the person comprehend addiction and recovery, release them from guilt, and give them hope. Each framework is related to a particular gender and type of addiction, though the respondents often integrated the elements of other stories into their narratives. The AA story as a framework was used predominantly by men with alcohol dependence, whereas women preferred the personal growth story. The co-dependence story was characteristic of polydrug users. Love story as a framework was used mainly by persons with bulimia, and the mastery story was characteristic of smokers (Hänninen & Koski-Jännes, 1999).

Current study

Kassai et al. (2017) have claimed that NPS users’ recovery processes may differ from those of the users of classical substances. Unpredictable and rapid alternations between NPS users’ positive and negative experiences result in a more fragmented user identity. Therefore, SCB users cannot successfully organize their experiences into collective structures of meaning, and the narrative resources for SCB users to construct a new, non-addict identity during recovery are limited. However, Kassai et al. (2017) could explore a small sample of patients at the beginning of their treatment.

In the TCs providing long-term residential care, the interventions are directed at the social self and facilitate the improvement of mentalizing skills (Fonagy et al., 2002), the management of emotions, and the overall reconstruction of identity. Respondents are familiar with and actively use twelve-step resources that highlight relational ethics in interpersonal relationships and the role of spirituality in the healing process.

Therefore, we would predict that progress in recovery is indicated by a more elaborate and balanced view, mirroring the overall development of reflective skills. A spiritual orientation, characteristic of post-traumatic growth, may appear. However, no specific results concerning NPS users’ use of recovery narratives are available. As this is a qualitative exploratory study, we maintain the openness of our analysis, also focusing on the emerging issues—the whats and hows.

Methods

Participants

This sample is a sub-sample of a longitudinal study conducted among 77 patients. Respondents were recruited at the beginning of their treatment. NPS use was confirmed by biological tests. A year later, 10 persons could meet the inclusion criteria of this research (1 year abstinence, and at least 3 months spent in treatment) (M_age = 28.50; SD = 9.03; Min. = 18.00; Max. = 45.00), 1 female and 9 males (M_months = 9.1; SD = 1.91; Min. = 5.00; Max. = 10). All of them were polydrug users diagnosed with substance dependence and treated in a TC. Table 1 is a summary of patient data.

Table 1. Respondents’ demography.

Pseudonym	Gender	Age	Drugs used	Therapeutic community	Months spent in treatment
Aiden	M	45	SCH, XTC, amphetamines, cocaine, THC, alcohol	TC1	10
Patrick	M	43	SCB, SCH, THC, alcohol	TC1	10
Rory	M	20	SCB, SCH, XTC, amphetamines, cocaine, THC, alcohol	TC1	10
Charles	M	29	SCH, XTC, amphetamines, cocaine, alcohol	TC2	5
Devin	M	24	SCB, SCH, XTC, amphetamines, cocaine, THC, heroine, alcohol	TC3	10
Chloe	F	26	SCB, SCH, XTC, amphetamines, cocaine, THC, heroine, crack cocaine	TC1	10
Alex	M	23	SCB, SCH, XTC, amphetamines, cocaine, THC, psilocybin, alcohol	TC1	10
Pete	M	31	SCB, SCH, XTC, amphetamines, cocaine, THC, psilocybin, heroine, alcohol	TC2	6
Zach	M	26	SCB, SCH, amphetamines, cocaine, THC, LSD, alcohol, GHB	TC1	10
Archie	M	18	SCH, XTC, amphetamines, cocaine, THC, LSD, psilocybin, ketamine, GHB	TC1	10

SCH: synthetic cathinones; SCB: synthetic cannabinoids; XTC: methylenedioxymethamphetamine (ecstasy); THC: tetrahydrocannabinol (marijuana); GHB: gamma-hydroxybutyric acid.

Note: The three different therapeutic communities are anonymized. Naming could potentially identity the patients as the number of these facilities and the number of patients in treatment are low (usually, below 20). TC 1 is a church-based community and the other two TCs are secular ones.

Considering Malterud et al. (2016) principles on information power, this sample size is adequate for our research questions. The narrow research aim, a specific sample, a hybrid analysis combining deductive and inductive directions, and a strong dialogue (the interviews were conducted by a therapist) result in high information power. The study combines case-based and cross-case analyses (Malterud et al., 2016).

Ethical approval was issued by the University of Pécs (PTE KK RIKEB, 2019.05.02). The procedures used in this study adhere to the tenets of the Declaration of Helsinki. Informed consent was obtained from all the patients before their inclusion in the study.

Measures

The Foley Life Interview (FLI) is a scheme to facilitate in-depth explorations of the life narrative (McAdams, 1993, 2007). FLI designates key scenes (nuclear episodes) as peak or nadir experiences, turning points, childhood/adult memories, major loss, and a spiritual/religious experience. In a study conducted in the US on emotionally valent episodes among persons with SUD, the occurrence of redemption sequences as positive meaning making in one’s nadir point texts, together with positive meaning making in high point texts, were indicative of enhanced well-being (Cox & McAdams, 2014).

The episodes used in this study were translated by the authors and were the responses to the following questions (the first sentences are quoted verbatim from the original):

1. High point. Please describe a scene, episode, or moment in your life that stands out as an especially positive experience. This might be the high point scene of your entire life, or else an especially happy, joyous, exciting, or wonderful moment in the story (…)

2. Low point. The second scene is the opposite of the first. Thinking back over your entire life, please identify a scene that stands out as a low point, if not the low point in your life story (…)

3. Turning point. In looking back over your life, it may be possible to identify certain key moments that stand out as turning points—episodes that marked an important change in you or your life story (…) (McAdams, 2007, p. 2); for further details, please see McAdams (2007).

Procedures

In our study, FLI was conducted when respondents entered treatment after detoxification. Basic sociodemographic data were also collected. The interview was repeated a year later. FLI was conducted in the respondents’ own language, Hungarian.

Following the phenomenological tradition by staying close to the data with a strong focus on the respondents’ unique experiences and meaning making enables the researcher to identify the potentially relevant themes and thematic connections when studying an unexplored phenomenon. For the analysis, we used Narrative Oriented Inquiry (NOI), which, with its pluralistic approach, is a flexible qualitative framework enabling case-based, idiographic approaches and cross-case comparisons (Hiles & Čermák, 2013; Kiss et al., 2022). This analysis, a combination of theoretically established and explorative directions, utilizes the fabula/sjuzet differentiation as an analytical tool. Fabula describes the events and themes (what exactly is told), and sjuzet, the way the stories are told (Hiles & Čermák, 2013). After reading the narratives, we decided to focus on the emotionally valent nuclear episodes (high point, nadir point), an approach by Cox and McAdams (2014), and on the turning point, a recurrent topic in the studies on recovery. The analysis involved parallel readings and re-readings of the episodes and repeated discussions between the authors. As a concluding step, we used ATLAS.ti 8.3, a tool for qualitative data analysis, to make our work more robust and transparent, and the results, easily comparable (For the data, please see the data availability statement).

Results

In this section, we summarize the major changes in the respondents’ perspectives. We also provide brief quotations mirroring the respondents’ lived experiences and then interpret and discuss these. Tables 2–4 are a summary of the main results, comprising the key contents and the changes in the three nuclear episodes between the first and second interviews.

Table 2. Major changes in the fabula/sjuzet in high point excerpts in the 1st and 2nd interviews.

Patient	1st interview	2nd interview
Aiden	Being clean, works, mother helps/“it (high point) is now”; “at the top”	Completing treatment, changes/chances in life, wide social network/“this gives me goosebumps”; “another chance in life”
Patrick	First son’s birth/mentioning the exact date and his attempt to reduce drinking/“a child will be given in my hands, and I cannot wabble”; “surely I drank a little as I was so excited”; “I drank more than necessary.”	A visit to his kids/self-reflection: “the elder son was a bit distancing himself from me, but it was my fault and I have to work hard to prove…”
Rory	Substance use (SU)/“bad direction”; “from my grey self into a much more colourful self”	Own accomplishments: leaving the TC and entering the halfway house/“my fellows were waiting for me (…) my happiest moment so far.”; “I was even crying”; “I stepped out of the house as, so to say, a winner.”
Charles	A pilgrimage to El Camino/absolution, catharsis “after the first whirlpool”	Returning to TC/self-reflective, committed: “has changed a thousand times since last year”; “my genuine way”; “such a good place”
Devin	SU/“the first shot gave me such, such a good feeling that, that, that, that I cannot describe it”; “the most, most, the best, the most liberating, the most joyful, the most enhanced, the warmest, the most, the best.”	Entering rehabilitation/self-reflection: “then, I did not think that it was the best thing, but I had fears”; “this is where change began, the whole thing, that is, my life.”
Chloe	Romantic love, son’s birth/“it was wonderful when I could hold him in my hands”; “I was completely out.”	Son’s birth/self-reflective: “I was using. I could not really experience that happy moment.”; “I missed it because I numbed it with drugs.”
Alex	A satisfactory life, meeting own needs, working, own home, girlfriend; controlled use/“I felt like a king. I did not need the substance.”	A satisfactory life by meeting own needs, happy moments of life; being related/more emotional and spiritual: “I have life, I have feelings, I have a meaning in life.”
Pete	Own family/speaking about the future “I do not want to see in my daughter’s eyes that Daddy is drinking again.”	Becoming a father again/responsible parenting: “not like before”; “I can become a responsible father now”; “see the world differently”
Zach	SU/reflecting on the transformation of previous self: “it gave me what I had always wanted to become”; “high-spirited, open, talkative, determined, self-assured” “easy-going with women”	SU, cool life/reflecting on the illusion: “this was just a dream, this was not real”; “I felt as if I were God. Lots of money. Always drugs. Always a drink in my hand.”
Archie	Admitted to a good school/“What else should I tell you?”	Being with the mother, a momentary relief from father’s physical and psychological abuse/more emotional and reflective: “I could see my mother and I hugged her, and this was one of my happiest moments”; “I was entirely lost when I was with my father and my life was miserable.”

Table 3. Major changes in the fabula/sjuzet in low point texts in the 1st and 2nd interviews.

Patient	1st interview	2nd interview
Aiden	SU-related accident, a broken car and hospital treatment/“this is the end” “I will never understand,” “cannot delete”	Own aggression, beating his wife while his kids were around/self-reflection: “an unarticulated beast”
Patrick	Aggression, police intervention/both an aggressor and a victim; severe injuries; prison/mentioning the contrast with his upbringing, now “a beast”	Aggression, police intervention/remorseful, reflective, and more responsible: “I did not even know where I was”; “that policewoman was a family mother of two kids”; “scary”; “nothing worse could have happened”; “proud to get out of this”
Rory	Loss of friends, blocked by them on social media/“while I was lapsing they were building their lives”; “they were distancing themselves from me and the lowest point was the why”	Father’s death, grief, suicidal, emotions as guilt, shame and sadness/a result of drug use is missed opportunities to be with his father for the last time: “I was not even here to say goodbye to him.”
Charles	Raped/“this is what I deserve, I am ashamed of coming to this, I am contemptible”; “associations of hell”; “with a complete stranger”	Bad sexual experience (same story)/“unfeeling”; “Sodoma”; “the worst thing was that it did not give me anything”
Devin	Sex worker/“the worst, the biggest, that, that I was careless enough to sell my own body that I should appreciate the most.”	Substance-related way of life/mentioning more consequences: “five of us in one room, she is pregnant, I’m using bioweed, from morning to evening, sleeping, not working, not doing anything.”
Chloe	Neglecting mother/“my little boy was taken away from me for the second time now”; “I have not visited him for two weeks.”; “that fucked bioweed”; “I hate the (nation) for making this stuff.”	The childcare service takes her son; moves to a dealer, SU, victim of sexual abuse/self-reflective: “I did not even know which planet I was on.”
Alex	Bad company, others abusing his girlfriend at a party/“17th, last week”; “must have been a different type of crystal as it made me very aggressive”;” I will either get mad or become a murderer, or dead, or a prisoner”; “you cannot believe a user”; “I do not believe myself.”	Experiencing extreme parental neglect as a teenager; homeless, starvation, isolation/reflecting on the loss of major social identity elements (education, family connections): “failed at school and failed in life.”
Pete	Major loss, grandfather’s death/“I miss him so much, we have experienced so much together, and he has suffered a lot”; “I missed him. And I bought something to drink.”	Major losses, his grandfather’s and friend’s death/“I forgot to tell you that I was his carer (…) I could stop using for six months, I think.”
Zach	Family-level child protection intervention because of his use (a threat to take his little sister); parents want a divorce; lives alone and as a homeless while an adolescent/“They made me live in the street and my mother said that she would not sacrifice two children for one”; “I was revengeful (…) wanted to execute my family” “the substance took control over me.”	A homeless, other people are ashamed of him/self-reflective, mentions many different losses; understands family reactions: “I was spending Christmas alone with a bottle of wine and some designer drugs. And I was thinking about suicide”; “Self-pity makes me tolerate all these and use.”; “no other way out of using but suicide” “always blaming others” “I had to use because I was blaming myself.”
Archie	Mother’s death, he was abroad/mentions the event but does not speak about emotions.	Mother’s death, missing leave-taking/very emotional, focussing on the loss: “she had deceased just a couple of hours before we could arrive home”; “the only person who stood by me, always” (…) I did not have the chance to hug her”; “she asked my brother where I was. She was looking for me.”; “It was very painful, and I was only 14.”

Table 4. Major changes in the fabula/sjuzet in turning points in the 1st and 2nd interviews.

Patient	1st interview	2nd interview
Aiden	Signs of mother’s, and others’ trust; work; mother bought him a car, but he also achieved a lot/“my life has changed entirely.”	Entering the TC/mentions the exact date: “this is where I got my second chance.”
Patrick	Asking for help, first therapy, able to live an ordinary life, life abroad; recreational drinking/lonely life abroad as “isolation period”	Clean or die, suicidal, first treatment was not successful, asking for help/“in the middle of a desert among the beasts”; “why should I go on like this?”
Rory	Grief, father’s death, change of workplace/impersonal style	Asks mother for help/mentions exact date/“this day began to bring me the change.”
Charles	Parents’ divorce/“endless pilgrimage between the parents”; “a week here, a week there”; “this was the time when I got mad.”	Catharsis at a psychodrama session; leaving destructive relationships; onset of recovery/self-reflection: “I was always finding faults with others.”
Devin	Entering TC/self-reflection, liberation, “like the first shot”	Entering TC/self-reflection, same as high point: “from this time on, everything has changed.”
Chloe	Others, including her father, got to know that she was a sex worker/blaming the father	Entering the TC/“thinking differently”
Alex	Onset of drug use/“I was not even interested in the stuff before”; “I was sensitive to this.”	Suicidal; then meeting his girlfriend/rich in recollections and reflections: “I started to write a suicide note”; “I listed my goals, why I should stay alive that day”; “I and my father could not even talk to each other unless we had some beer on the table.”
Pete	Physical deterioration, substance-related death of a friend, leaving behind his daughter/“my body is in ruins”; “he used a stuff (…) I think bioweed (…) this quantity of poison, he just went home and died”; “she (the little girl) is running to the grave with a bunch of flowers.”	Completing treatment/mentioning the exact date “I can be happy because the sun is shining”; “I can be a father to my daughter, and they trust me enough to leave her alone with me”; “a new life”
Zach	First treatment/change of perspective: “using was not good anymore”	Relapse, a self-destructive way of life, mother helps and trusts, own attempts fail, hitting rock bottom, asks for help/“she was hoping that it was over”; “the moment she left I bought alcohol and took the prescription drugs”; “they were shouting at me if they should call the ambulance”; “I don’t want this anymore.”
Archie	Ankle monitor/“without this, I’d be hanging around with my chums.”	From home arrest to TC/“my deeds have consequences”; “this is where all ‘me’ begins” (…) what type of person I am.”

Changes in high point episodes

Table 2 shows that initially, six speakers identified high points as identical with or closely related to substance use. Chloe and Patrick (seeing drinking “necessary” in the first episode) mentioned the birth of their own child as a peak experience, accompanied by substance use. Interestingly, both Rory’s and Zach’s initial high point texts follow the narrative organization of a recovery narrative (a personal growth story, Hänninen & Koski-Jännes, 1999), but these newly discovered, more colorful, and attractive selves are related to the use and not recovery. Positive experiences of “normie” life are also related, such as good education and having a family. However, these matter-of-fact descriptions are in contrast with the high emotional valence of Devin’s and Zach’s summaries on substance use. Religious spirituality is a core theme for Charles.

In the second excerpt, entering the TC is often seen as a high point, and the key concepts of recovery appear. Substance use is not identified as a high point experience anymore (“was not real”), and the idea of controlled use (as in Alex’s first text) is not raised either. Reflections on happy and painful moments, a broadening social network with sober fellows, and emotionally meaningful relationships are a common themes in the episodes. Aidan and Alex speak about the beginnings of a new life and experiencing recovery-related spirituality. Others refer to the end of denial and self-deception—a recognition that the “more colorful self” was a false one (Patrick, Charles, Chloe, and Zach).

Rory’s narrative is rich in the prototypical elements of a hero’s story, in which the protagonist successfully fights the difficulties, and his achievements are validated in the new environment. This finding is similar to the results of a narrative study involving experts by experience by Kiss et al. (2022).

Speakers are more reflective and self-reflective, also establishing links between past and present experiences and future anticipations. In the second high point episode, several speakers gave a more balanced and realistic evaluation, mentioning some negative aspects of a generally positive experience. Taking responsibility for others is another new theme (Patrick and Pete). When speaking about reconstructing his relationship with his elder children, Patrick noted the relational distance and interpreted it as a natural consequence of his former use. Devin mentioned his fears, and Archie reflected on his traumatizing relationship with his father. However, these negative experiences did not compromise the overall positive value and did not transform the high point story into a sequence of contamination (Cox & McAdams, 2014).

Changes in nadir point episodes

In the first nadir point episodes (Table 3), speakers usually reported problems associated with substance use or a traumatic event before the onset of use. Some respondents told a different second story; for example, Aiden mentioned a traffic accident first, but his second story was about his own role as a perpetrator in a family conflict leading to violence, with his children witnessing the event. For Rory, rejection by his former friends made him come face to face with the fact that he was no longer acceptable to his former classmates as a heavy user. The same speaker’s grief experience in the second episode—the loss of his father and the guilt he felt about it—is at a much deeper emotional level. Alex’s initial story, a chaotic report on a party experience, is also in sharp contrast with the consequences of the extreme parental neglect he experienced as a teenager. These speakers could share a deeply personal story of the losses they had suffered and the shame they had felt. The three stories seem to be the ones that the respondents were not able to relate to a year before. Others, as Patrick, Charles, Devin, Chloe, Zack, Pete, or Archie told the same or a very similar story, but this time they could share more details, also identifying and describing their own painful emotions. They took responsibility for what they had done—or had missed to do. They could reflect on their own aggression and the harm they had caused to others; and on the emotional numbness related to addiction. They could speak about their previously suppressed grief experiences and suicidal ideations accompanying their substance use.

Changes in turning point episodes

In the turning point episodes (Table 4), speakers either mentioned various events related to substance use or their first attempts at recovery, which might imply that they were at different stages in the recovery cycle when entering treatment. Initial help-seeking or previous treatment attempts often changed the user’s perspective and interfered with substance use. Confrontation with the potential consequences also appears in the excerpts, as, for example, in Pete’s recollections on a friend’s NPS-related death or the ankle monitor Archie had to use. Patrick’s hopes for controlled use, a way back to recreational drinking represents a common idea of dependent persons—one that they usually give up in the ongoing recovery process.

A year later, the turning point was entering the TC and/or progressing from an initially ambivalent phase toward a growing commitment to the therapeutic program. These second stories are often about asking for help. A deep change, a choice between life and death (“second chance,” “clean or die,” “this is when all ‘me’ begins,” etc.) is present in almost all the cases. One respondent, Pete defined change as a developing ability to experience and value everyday realities. Taking responsibility for their own lives is also a common theme for most respondents. Mentioning the exact dates (Aidan, Rory, and Pete) is telling about the emotional significance of the event. It is worth noting that Alex instinctively used the 24-h focus (a practice of twelve-step groups) to stay alive and cope with his suicidal thoughts.

Summarizing group-level changes in the three episodes

When quantifying the results, we could see that most follow-up excerpts (21 of the 30 by the 10 respondents) were about a different story in either the high, low, or turning point texts. In some cases, the storyline was essentially the same, but the narrative mode was quite different (nine of all the episodes by seven respondents). This included, among others, a marked increase in reflections, understood here as connecting one’s own or others’ emotions and behavior to life events and experiences. In the first interviews, non-reflected sequences of actions and events were related, usually in a chaotic manner. Blaming others for one’s fate, unresolved traumas, such as death and grief, and identifying oneself as a victim of substance use and of other people were characteristic of the texts. First attempts at entering treatment were also related. Contrastingly, the second excerpts were about deep changes in life (in 12 excerpts by eight respondents). Commitment to therapy also appeared in six episodes by five interviewees. In the 30 excerpts by the 10 respondents before therapy, we could identify four occurrences of reflections on the participant’s own behavior by three respondents. In the follow-up interviews, we coded 18 occurrences by nine speakers. Initially, reflections on the respondent’s own emotions were presented in five excerpts by four respondents. After one year, this was the second most frequent content with 15 occurrences in nine of the cases. These reflections included a more elaborate view of past relational losses, grief, drug use, and suicide attempts. Reflecting on others’ situations, and parallel efforts to reconstruct one’s relationships were entirely missing from the first interviews but appeared in the second narratives, with five occurrences/four persons of the first one (reflecting on others) and eight occurrences/six persons of the second one (reconstructing relationships). Figure 1 is a summary of the results. The arrow indicates the direction of the changes during the one year.

Figure 1. Changes in the themes and narrative mode   

Discussion

This study used NOI (Hiles & Čermák, 2013) to explore changes in NPS-user polydrug dependent persons’ narratives during early recovery as they were working through the recovery program and progressed from their preparations to actions and reflections.

In light of previous results on the etiological role of psychological trauma in SUD (Van den Brink, 2015), also supported by our research, NPS use corresponds to revictimization. Respondents’ experiences could meet the rigorous definition of psychological trauma by DSM-5 (Pai et al., 2017). This population suffered severe traumas, such as the loss of a parent at an early age, neglect and abuse, criminalization, sex work, rape, homelessness, social isolation, aggression, and severe mental and physical conditions associated with drug use. These traumatic experiences existed either as inner narratives in the domain of the not-yet-said when the respondents entered treatment, or their first stories were chaotic, self-centered, and polarized. Balanced reflections were missing. These features indicate the high emotional significance and low levels of integration of the traumatic experience, which explains speakers’ inability to structure and narrate their life stories adequately. Previous studies found that the appearance of growth meanings was related to enhanced well-being and more adaptive emotion regulation strategies (Cox & McAdams, 2014; Pasupathi et al., 2015). In this study, respondents were able to restructure the disorganized and dissociated narratives that had existed only as inner narratives. Some speakers mentioned exact dates in their texts, conforming themselves to 12-step storytelling traditions. This is how they designated the boundary between the addict self as “damaged self” or “spoiled identity” as in Kassai et al. (2017, p. 1048), or a “beast” as a respondent’s self-identification in the current study, and the sober, recovering, new-born self, more ready to cope with life’s challenges.

The recovery journey is unique and cannot be described as a simple linear movement between the different stages. As relapse is frequent in persons with SUD, respondents’ nuclear episodes may reflect varied levels of commitment to treatment. At the beginning of the treatment, substance use was strongly attached to high point experiences in life, even if ambivalence was present. However, the turning point stories, predominantly negative events in the first excerpts, were exchanged for positive experiences and commitment to treatment.

Speakers mentioned few relationships in the first episodes, and the social connections they reported were either fellow users or close family members. Most low point stories were about substance use-related personal losses or betrayal. A year later, a healing social network was formed, and sober fellows, friends, and colleagues populated the recovering persons’ lifeworld. This is a finding that Costello et al. (2020) could also identify in their study on early recovery.

In their second nuclear episode, the respondents related substance use to their other difficulties in life. Changes in the narrative mode included more emotional and self-reflective content. Several studies have concluded that thematic and stylistic changes in one’s narratives are parallel to transformations in mental states and identity (Cox & McAdams, 2014; Pasupathi et al., 2015; Pennebaker et al., 2003; Stelzer et al., 2019; Stephenson et al., 1997). In a study on a non-clinical sample by Pennebaker and Smyth (2016), expressing and reflecting on trauma-related contents and on the accompanying emotions have resulted in marked and sustained positive changes in respondents’ physical and mental health—even if expressing was initially painful for the participants. Further, naturally switching between the perspectives when relating a traumatic experience has led to marked improvements in physical and mental health (Pennebaker & Smyth, 2016; Seih et al., 2011).

Reflections on others’ emotions and behaviors and efforts to reconstruct interpersonal relationships were key contents in the second nuclear episode. Respondents were willing to consider other people’s perspectives, conforming themselves to shared social realities. These changes can best be described as developments in mentalization, an ability to assess, interpret, and adequately respond to others’ and our own mental states and connect these to our experiences (Fonagy et al., 2002). As a result, guilt and shame were exchanged for responsibility, and respondents could accept their imperfections.

Kassai et al. (2017) identified salient differences between NPS users’ meaning-making processes and experiences and those of the users of classical substances at the beginning of their treatment. The results of our longitudinal study suggest that NPS users with polydrug dependence can learn to utilize the traditional narrative resources of sober communities, most importantly, the AA-story (Hänninen & Koski-Jännes, 1999). Though the AA-story seemed dominant in this study, elements of the personal growth story, love story, co-dependence story, or mastery story also appeared. In the active phase of their addiction, these patients used a variety of substances; now as persons in recovery, they combined the narrative elements of the different recovery stories.

With NPS users, the drugs, the patterns of use, and the initial experiences differ, but the underlying problems of dependence, as well as subsequent constructive meaning-making processes, are similar to those of the users of classical substances. Their recovery processes can be interpreted as post-traumatic growth involving the reevaluation of major life events and people, the appreciation of everyday pleasures in life, and understanding oneself more (Ogilvie & Carson, 2022).

Limitations

The strengths of this study are its novelty, a highly specific sample of persons who are difficult to reach, the respondents’ confirmed NPS use and abstinence to eliminate self-report bias (McKernan et al., 2015), the interview scheme facilitating in-depth explorations, and a longitudinal approach. Patterns of use—NPS use embedded in polydrug use—is consistent with a recent finding by Higgins et al. (2021). This may be a limitation, but perhaps a fact of life that researchers must cope with. Respondents in this sample used different types of NPSs, classical substances, prescription drugs, and alcohol in a chaotic manner, as patients with severe forms of SUD often do. Further, it was difficult to judge respondents’ exact stage of recovery, as it is a cyclic process, and NPS use, with its volatility and unpredictable consequences, probably added to the confusion. The age range was relatively broad, with one female participant in the sample. With all these constraints, the results of this research may add to our understanding of recovery from NPS-related polydrug dependence.

Implications

Our results suggest that the long-term treatment needs of patients with NPS dependence—a form of polydrug dependence—are similar to those of the users of classical substances. Recovering persons in this study could utilize the narrative resources that enabled them to learn and adopt a mentalizing stance, a combination of empathy and mindfulness (Fonagy et al., 2002).

Future directions

Further research, preferably involving larger and international samples enabling cross-country comparisons is necessary to investigate the recovery processes of this specific population. Controlled trials could be convincing, but in such cases, researchers would face many practical difficulties due to the chaotic nature of NPS use and the confused patterns of recovery with frequent episodes of relapse. Further, those not in recovery are usually not motivated to participate in a research project. Case studies to evaluate long-term advances in recovery from NPS use could also be utilized as a complementary in-depth research method.

Acknowledgments

The authors would like to thank the participants for sharing their stories with us and the anonymous reviewers for their insightful comments and suggestions.

Disclosure statement

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

Data availability statement

The ethical approval excludes publishing the interviews (in Hungarian) as these could identify the respondents. The codebook and the frequency tables are generated by ATLAS.ti 8.3 are available at https://pea.lib.pte.hu/handle/pea/44417.

Additional information

Funding

No funds, grants, or other support was received.

Notes on contributors

Ferenc Császár

Ferenc Csaszar, MSc in Clinical Psychology, MD, Psychiatrist at the Department of Psychiatric Rehabilitation, University of Pécs, Clinical Center, Szigetvár Hospital Branch. He is a PhD candidate at the Doctoral School of Neurosciences, University of Pécs. His main area of interest is novel psychoactive substance use and psychotherapeutic methods to increase the efficacy of treatment for substance use disorder, affective disorders, and bipolar disorder.

Marta B. Erdos

Marta B. Erdos, Ph.D. is an Associate Professor in Mental Health and Clinical Social Work at the Department of Community and Social Studies, Faculty of Humanities and Social Sciences, University of Pécs, Hungary. Before starting her academic career as a lecturer and qualitative researcher in 2000, she used to work as a counselor at an outpatient crisis intervention center. Her main area of research interest is identity transformations.

Rebeka Javor

Rebeka Javor, Ph.D. is a counselor at the Medical School, University of Pécs, Hungary and a member of the Social Innovation Evaluation Research Center at the Department of Community and Social Studies, Faculty of Humanities and Social Sciences, University of Pécs. Her main area of research interest is clinical psychology, student counseling, and identity development.

Gabor Kelemen

Gabor Kelemen, PhD, MD, is a Professor Emeritus at the Department of Community and Social Studies, University of Pecs, Hungary, and a consultant psychiatrist at CGL Bromley Drug & Alcohol Service, UK. His areas of research interest are recovery from addictions and the phenomenology of shame.