Self-Reported Sobriety Labels: Perspectives from Alumni of Inpatient Addiction Treatment

Abstract

Background

There is a lack of consensus in the addiction field as to how to refer to alumni of residential treatment who no longer use substances or who reduce their use. In the literature, this label and broader identity are typically discussed in technical (amount and frequency of use) or social terms (environment and social network changes).

Objective

The current paper seeks to simplify the discussion by focusing on personal labels without complex technical or social considerations. Alumni of an inpatient addiction treatment facility were asked how they refer to themselves regarding their sobriety status post-discharge.

Methods

Forty-nine patients were contacted 3 months post-discharge from a residential inpatient addiction treatment (men = 67%; Mage = 47.75 years). The patients completed a post-discharge assessment that was conducted by a trained research assistant over a 20-minute video call. The current study focused on a “sobriety label” measure in which patients indicated what they want to be called. Patients also explained why they chose their answer in an open-ended question.

Results

Most patients identified as in recovery (n = 29; 59.18%) followed by a sober person (n = 7; 14.29%) and four other responses. No alum selected the in remission option, which is notably a common way to refer to patients who no longer use substances.

Conclusion

The current study adds a critical patient/alumni perspective to the existing body of literature and serves as a call to action for researchers to add a similar “sobriety label” measure to future assessments, studies, and batteries in effort to bring consistency to the labels, definitions, and identities that are published. This methodology of understanding how this population identifies will create uniformity in future literature and decrease the stigma surrounding addiction.

Plain Language Summary

There is a history of inconsistent use of labels, definitions, and identities in the addiction treatment field. Few past studies have directly asked patients how they self-label, and it is important to ask those who use substances or who have reduced their use what they preferred to be called. This study asked a simple question to alumni of an inpatient treatment facility what they want to be called. We then asked them to explain why they chose that answer. Most alumni identified as “in recovery” or “a sober person”. This simple tool can be utilized by other facilities and also highlights that many research studies are referring to individuals by terms they do not prefer (eg, “in remission”).

Keywords:

• sobriety
• identity
• label
• addiction
• discharge
• recovery
• sober person
• inpatient

There is a lack of consensus in the addiction field as to how to refer to patients who no longer use substances or who reduce their use post-discharge from residential services.^1–8 In the literature, this experience is typically discussed very technically (eg, based on amount or frequency of use) or socially (eg, how identity, environment, and social network change).^3,4,7–9 Technical definitions are more common and define a person positively via no use (remission) and/or improved quality of life (recovery) or negatively via return to use (relapse).^7,9,10 Alternatively, many studies focus on the concept of social identity for those who no longer use or who reduce their use,^11–13 with many emphasizing the ever-changing nature of labels and identities post-use.^3,9 Notably, incorporating both technical and social aspects of this concept is becoming more common.^1,2,5,14

Thus, the current paper seeks to simplify an aspect of this discussion by focusing on personal labels without the technical or social context of extant literature, as this may be more reflective of how the recovery community prefers to be referred. In other words, we wanted to ask alumni of an inpatient addiction treatment facility what they want to be called and what their current label is. The overarching goal was to inform future research and language in the addiction field. This will hopefully bring more consistency to the scientific literature while giving patients the space to continue exploring and evolving their personal identities.

Properly and carefully defining this dynamic process is an important endeavor, as language is paramount to reducing stigma around addiction.¹⁵ Past studies have offered their own definitions of sobriety,² highlighted the pitfalls of overly strict definitions,⁸ and illuminated philosophical paradoxes that professionals in the field and the lay community may ascribe to those who use or used substances.^16,17 It is very common for researchers to define sobriety themselves within their studies, which had led to wildly inconsistent language being used across the scientific literature. While some studies have directly asked those who no longer use substances or who have reduced their use what they want to be called, the answer options presented in these studies are binomial or offer few categorical choices.^{12,14,18–20} Other studies have interviewed former substance users to dive deeper into the concept of personal sobriety identity,^3,16,21 a methodological process that is lengthy for both researchers and participants and often concludes that identity is a complex process. Thus, few studies have directly asked those who no longer use substances or who have reduced their use how they want to be labeled (and why) while presenting an array of options to choose from.

The goal of the current study was to ask alumni of an inpatient addiction treatment facility what they want to be called at 3 months post-discharge and to summarize their responses. It is hoped that this simple approach will inform this important conversation and assist future researchers with their own study designs, language, and reporting so that we may one day have a streamlined approach to sobriety labels from a scientific perspective (while acknowledging the truly complex identity underneath the label).

Methods

Participants

Data were collected between February 2021 and February 2023 and came from N = 49 alumni of an inpatient addiction treatment facility who were contacted 3 months post-discharge. Alumni was defined as anyone who has sought treatment at the facility and discharged after completing treatment. The mean age was 42.75 years old, and alumni self-reported as a majority male (67%), White (88%), not Hispanic (93%), and straight (75%). The most common primary substance was alcohol (61%) followed by opioids (16%), and the most common secondary substance was cocaine (38%) followed by cannabis (29%). See Table 1 for full sociodemographics. These data were deemed “not human subjects research” by Pearl IRB (ID 2023–1058).

Table 1 Sociodemographic Breakdown of Sample

Variable	Total
Sex
Male	33 (67.35%)
Female	16 (32.65%)
Mean Age at Intake (SD)	42.75 (12.95)
Race (1^st listed)
White	43 (87.76%)
American Indian or Alaska Native	2 (4.08%)
Black	2 (4.08%)
Another	2 (4.08%)
Asian	0
Native Hawaiian or Other Pacific Islander	0
Hispanic
No	43 (93.48%)
Yes	3 (6.52%)
Missing	3
Sexual Orientation
Straight	36 (75.00%)
Bisexual	6 (12.50%)
Gay	3 (6.25%)
Lesbian	2 (4.17%)
Another	1 (2.08%)
Asexual	0
Demisexual	0
Pansexual	0
Queer	0
Unsure	0
Prefer not to answer	0
Missing	1
Primary Substance
Alcohol	30 (61.22%)
Opioids	8 (16.33%)
Cocaine	4 (8.16%)
Amphetamines	2 (4.08%)
Cannabis	2 (4.08%)
Sedatives	2 (4.08%)
Inhaled toxins	1 (2.05%)
Hallucinogens	0
Hypnotics	0
Steroids	0
Synthetic cannabinoids	0
Other	0
Secondary Substance (n = 21)
Cocaine	8 (38.10%)
Cannabis	6 (28.57%)
Alcohol	4 (19.05%)
Sedatives	2 (9.52%)
Amphetamines	1 (4.76%)
Hallucinogens	0
Hypnotics	0
Inhaled toxins	0
Opioids	0
Steroids	0
Synthetic cannabinoids	0
Other

Approach

Data were collected as part of the facility’s comprehensive rehabilitation assessment procedures via REDCap^22,23 and analyzed using R²⁴ and Microsoft Excel.²⁵ A comprehensive rehabilitation assessment includes collecting standardized data from patients at multiple timepoints (baseline, midpoint, discharge, 3 month post-discharge). For this study, only relevant assessment data from the 3 month post assessment are discussed.

The 3 month post-assessment procedures began with calling and emailing patients 1 week prior to their 90-day post-discharge date to set up a 20-minute video call with a trained research assistant. The assessment asks patients to answer questions about their prior 90 day use, consequences from their use, wellbeing, service utilization, sobriety label, education, employment, and legal troubles.

Measures

The only measure being analyzed in the current study is the sobriety label measure which was comprised of one categorical question and one open-ended question. Alumni could only select one answer for the categorical question. This measure was created for this assessment, but similar questions can be found in Fan et al, 2019 and Tucker et al, 2020.^26,27 The goal of the question was to offer insight into patients’ use and how they self-label outside the context of other technical or social contexts that often accompany such questions. The first question was “How do you identify?” with the following answer options: 1) In recovery; 2) In remission; 3) A sober person; 4) A person who abstains from substances; 5) None of the above - I do not have a label to identify my current relationship with substances; 6) None of the above - I have another label that identifies my current relationship with substances (specify); 7) A person who uses substances. The second question asked, “What made you choose your answer above?”

Analyses

The categorical question was analyzed using simple descriptive statistics with percentage breakdown of how many alumni endorsed each question. The open-ended question was analyzed using modified content analysis.^28,29 Due to the heterogeneity of the sample, chi-square analyses were conducted to examine differences between the sobriety labels and sex (male vs female), race (recoded White vs non-White), ethnicity (not Hispanic vs Hispanic), sexual orientation (recoded straight vs not straight), and primary substance (recoded alcohol vs all other non-alcohol substances).

Results

A majority of alumni identified as in recovery (n = 29; 59.18%) followed by a sober person (n = 7; 14.29%), none of the above - I do not have a label to identify my current relationship with substances (n = 4; 8.16%), none of the above - I have another label that identifies my current relationship with substances (n = 4; 8.16%), a person who uses substances (n = 3; 6.12%), and a person who abstains from substances (n = 2; 4.08%). No alumni selected the in remission option. Themes from the open-ended responses for each label where there was at least one endorsement are below.

In Recovery

Those who selected this option commented on recovery as an “ongoing process” largely because addiction is a disease. As one alum noted, “I’m [in] recovery day-to-day. Still figuring things out”. Many acknowledged that recovery is a term used in Alcoholics Anonymous (AA) and also that it is the term that they liked best based on the options presented to them. Some also noted that they did not put much thought into using this term to describe their relationship with substances post-discharge because “everyone understands what it means”, and “it seemed the most common”.

A Sober Person

The same themes for in recovery were also present for a sober person, with some alumni further elaborating that this term is used in their AA meetings and other services that they utilize. One alum noted, “I am sober. No mood/mind altering drug in [my] system in over 166 days. But not just that, [I’m] making more clear decisions and feel [I’m] not just abstaining from alcohol but growing emotionally, suggesting that sobriety is more than simply not using substances but also entails practicing mindfulness.”

A Person Who Abstains from Substances

Similarly, the two alumni who selected this label did so because this is an ongoing process, with one noting that they are “not active in recovery…just not drinking.” Thus, it appears that there may be a qualitative difference between recovery and abstaining.

None of the Above - I Do Not Have a Label to Identify My Current Relationship with Substances

There was variation in the reasons for selecting this response and no clear theme. While some acknowledged the process of this concept, another stated that they are “an alcoholic in treatment” and another stated that “there is no one answer. Whatever I feel like saying [about my sobriety label], I say.”

None of the Above I Have Another Label That Identifies My Current Relationship with Substances (Specify)

Most people who selected this response did not provide another label but shared that they had used at some point in the past 90 days, which made it difficult to find their identity. One stated that he was “a man that gets a new start.”

A Person Who Uses Substances

Those who endorsed this label shared that they still use and were comfortable identifying as a person who still uses. One alum further described their identity by stating “I’m a drug addict, I’m always going to be. Admittedly need it for other reasons, no different than [a prescription]”.

Association Between Sobriety Label and Demographics

A series of chi-square analyses were run between those who identified as “in recovery” vs all other sobriety labels and key demographic indicators. No significant differences in sobriety label were noted by sex (χ²= 0.36; df = 1; p = 0.55), race (test resulted in an error due to too few data points in the cell; χ²= <.001; df = 1; p = 1.00), ethnicity (test resulted in an error due to too few data points in the cell;χ²= 0.80; df = 1; p = 0.37), sexual orientation (χ²= 0; df = 1; p = 1.00), or primary substance (χ²= 0.20; df = 1; p = 0.66).

Discussion

The purpose of this paper was to present how alumni from an inpatient addiction treatment facility identify 3 months post-discharge regarding their relationship with substances. We found that most, but not an overwhelming majority, self-labeled as being in recovery. This is a commonly used term in the extant literature among those who used to use substances.^{14,18–20,30} The primary theme across all responses to our “sobriety label” question highlighted the dynamic experience of not using or reducing use of substances post-discharge. This adds a critical patient/alumni perspective to a body of literature that is largely made up of researcher-driven technical and social labels.

There are several key takeaways from this study. First, the term in remission is commonly used among researchers with many even acknowledging its technical inevitability due to how datasets are constructed.⁷ However, it was the only response that received no endorsements in the current study. It is clear that studies can and should use other more widely accepted terms that patients prefer, even when researchers have limited datasets that only allow them to track the presence or absence of substance use disorder symptoms.

Second and relatedly, recovery is widely defined in the literature as an ongoing, dynamic process that encompasses quality of life^1,2,7,8 - a definition that has filtered down to patients and alumni. It is also a label found to be consistently used by former substance users who discussed that their true personal sobriety identity was still evolving.³¹ Thus, it seems that recovery can be a default label used in this field unless a study specifically asks its participants how they identify, which leads to our final take-away. Third, there were no significant differences in the sobriety label based on demographics, although this was a small sample. Finally, we echo Neale and colleagues⁶ and call for future researchers to add our simple “sobriety labels” measure, or a similar one, to their own assessments, studies, and batteries. This will help bring more mindfulness to the language used in the field as well as either consistency or more veracity to the labels, definitions, and identities that are published in dissemination efforts. There is a feedback loop at play where language used by addiction specialists (eg, researchers, clinicians, peers) is used in the wider community and therefore shapes how those who no longer use or use less substances perceive themselves.

Limitations

There are some limitations to note. First, these data are of a self-reported nature and subject to the biases with that type of response. Additionally, there were too few data points to do the secondary chi-square demographic tests, and potential demographic differences should be further explored in larger samples to better understand any nuanced experiences. Next, the extant literature robustly shows that identity is linked to positive outcomes.^{11,12,17,30,32} It should be noted that the current study was stripped of the social context but nevertheless complements such findings by clarifying preferred labels. Our measure of a “sobriety label” likely taps into a deeper “personal sobriety identity” that subsumes technical and social contexts, as evidenced by the open-ended responses, but that was outside the scope of the paper.

Also, the current study participant pool is biased by those who were willing to engage in our 3 month post-discharge assessment and represents a small proportion of our total alumni. Thus, the stabilit of these lables remains to be seen as alumni’s underlying identities shift in the subsequent months and years. Additionally, findings may not generalize to countries outside of the USA due to cultural context (even other countries where English is primarily spoken). Finally, we used the word “label” throughout this paper even though we asked patients how they “identify.” It is clear that the answer options were labels, not reflective of fuller identities, as explained in much extant literature. We felt this language choice on our end was appropriate given the complexity of personal sobriety identity^{3,4,7–9,11–13,30} as well as the goal of this paper to streamline the language used in the scientific community.

Conclusions

This study highlights the importance of asking those who used to use substances or who have reduced their use what their new sobriety label is. It is hoped that this study will continue to drive the conversation around the need to be mindful of language in this field¹⁵ and that labels, definitions, and identities used in past literature are largely inconsistent.^1,2,4,5,7,8 Additionally, this primarily serves as a call to action for researchers to be clear on what part of this concept they are studying and to acknowledge that they may be imposing their own definition and terms due to data restrictions (eg, using datasets where it’s difficult to ask patients how they want to identify).

Statement on Informed Consent

Analyses of these data were deemed “not human subjects research” by Pearl IRB due to their level of de-identification and utilization in quality-control initiatives (ID 2023-1058).

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

Dr Nehal Vadhan and Dr. Jon Morgenstern report personal fees from Wellbridge Addiction Treatment, during the conduct of the study. Dr. Nehal Vadhal reports personal fees from Cutback Coach, Inc. outside the submitted work. The authors report no other conflicts of interest.

Acknowledgments

We would like to acknowledge all who worked tirelessly to make Wellbridge a reality and who continue to realize its purpose on a daily basis. This includes our clinical, nursing, admissions, administrative, food service, housekeeping, and maintenance staff.

Additional information

Funding

This project did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.