Support in Recovery study
An interpretive study into what helps people stabilise their emotions in the transitional stage of abstinence based recovery.
The recovery from drug addiction debate continues; how can we help individuals maintain good quality long term abstinence based recovery? It is mostly agreed on by experts in the addictions field that many addicts relapse because of an inability to cope with their emotions. To answer my question it became clear to me that I needed to break this down as what might support someone of fifteen years clean may well be different from what supports someone in the first few years (Laudet & White, 2010). I decided to concentrate on individuals in the transitional stage of recovery which for the purpose of this study I set at between one and three years. It emerged from the literature review that there were four main themes in connection with emotional support in recovery from substance misuse. These were 12 step affiliation (Laudet & White, 2008); spiritual practices (Cook, 2004); helping others / belonging to a group (Zemore, Kaskutas, & Ammon, 2004) and the use of mediums such as music and humour (Baker, Gleadhill, & Dingle, 2007) (Sumners, 1985). My interest in this particular subject came about because I wanted to improve my own practice and find new ways of facilitating these courageous individuals in trying to change their lives, toobtain theadequate stability in thererecovery in order to stay abstinent. In my literature review I found an abundance of papers on twelve step involvement and spirituality in regard to addictions recovery support(Cook, 2004) (Chen 2011) (Timko et al. 2006). I am interested to see if my findings correlate with supports that were cited in the literature review.
Method and design
I wanted to explore the experience of recovering addicts and get an understanding of what types of support had helped them. I hoped to be able to look beneath the surface and find some meaning and possible themes within the data I had collected (Ritchie& Lewis2003). This would involve studying shared human meaning and perspectives (ibid). For this reason I decided to use qualitative research as this method is often used in social science when one is looking at meaning, qualities, stories and opinions (ibid). Qualitative research consists of a series of practical skills that illuminate the area that’s being studied such as interviews, conversations, focus groups, recordings and memos to self (ibid). Originally I was going to recruit participants from my agency, however because of losing my placement I had to think of an alternative and fortunately this wasn’t a difficult process as I had people within Narcotics Anonymous who fitted the criteria I needed for my research project. After exploring different methods of obtaining data for qualitative research I decided to use semi- structured interviews; classic ethnographers stress the importance of talking to people to grasp their point of view (Burgess, 1982) and personal experience is seen as having great importance in research because of the power of language to highlight meaning (ibid). I used purposive sampling because I wanted participants with particular characteristics, which would enable detailed exploration and understanding of the central themes and difficulties which I wanted to study (Richie &Lewis 2003). The criteria I was looking for was continued abstinence of over a year. To make sure my own bias was not going to cloud my data analysis, I realised that it was important how my questions were phrased and that the phrasing of questions also played an important part in how rich the data would be. I wanted to use questions that would explore the detail which lies within each element of the process in the interview, to access the meaning it holds for each participant and to obtain a deep understanding from the participant’s frame of reference (ibid). I realised after reading literature on interviewing techniques, that asking short clear open questions was the best way to proceed with the interview whilst being mindful of not using leading questions (Richie &Lewis 2003). I aimed to interview four participants and ended up with three. The interviews lasted twenty minutes and I had three main questions; these questions were designed to enable me in answering my research question and are included in my appendix. I wanted to stay as detached as possible to avoid bias (Firestone, 2013). Although I was aware that I held my own ideas about this subject, I attempted at be rigorous in keeping my opinions to myself. In qualitative research there is some emphasis on the value of the researcher’s personal interpretations (Ritchie &Lewis 2003).
In order to achieve the level of depth that I required, I also used other techniques. Verbal and nonverbal probes are highly effective techniques (Ritchie &Lewis 2003); probes are not used in isolation and the reply to the probe will require another and so on; this process will end up revealing a vast amount of information which will be rich in data (ibid).
Firstly I set about filling in the ethics document for BERA and returned this to my tutor. My participants were recovering addicts in the community who had been in the maintenance stage of recovery for some time (Gorski 1990) and so there was very little risk attached to gathering the data. However I made it clear that if they felt uncomfortable at any time they had an absolute right to withdraw from the study and they were all given my contact details and I explained I would be available if they had any concerns. I formulated information sheets and consent forms for the participants. A basic principle of qualitative research is that participants are given sufficient information about what’s involved in the research so they can make a fully informed choice (Sullivan et al 2012). I made it clear in the consent form that confidentiality would be paramount and no names would be used in my report (Richie &Lewis, 2003). I recorded my interviews on my Hewlett Packard laptop and backed the interviews up using my I Phone. I began to use coding to analyse my data; I was looking for similarities and themes within the interviews. By labelling different categories of words I managed to find themes and examples which didn’t appear in an orderly way in the data. This method helped me get an idea of comparisons and connections within the data analysis (Ritchie& Lewis).
Substance misuse recovery can mean different things to different people; in this study when I refer to recovery, it is Twelve Step abstinence based recovery.
I immersed myself in the data by listening, transcribing and coding. I used colour coding which was recommended by my tutor and by using this method I was able to group words into different categories. It quickly started to emerge that other people were critical of the participant’s recovery; by looking closely at the utterances, the word ‘talking’ occurred regularly. Throughout all the interviews there was also a sense, whilst actually doing the interviews that this was a (connection) between people and more than just talking and for this reason my first theme is connecting to people. One of the other significant findings within the data analysis was some sort of change of outlook on the world. I chose to use this as my second theme Changes in Perspective. The subthemes that have emerged from these two main themes are Acceptance and Spirituality. It appears within the data that indeed spiritual meaning is held by two of the participants in regard to their recovery. Spirituality is hard to define as shown in Cook’s (2004) paper “Addiction and spirituality”. This along with the fact that this is an interpretation of what I see within the data, made it a difficult area within the project, however I felt it was important and should be included. I set the second sub theme acceptance after rereading the transcriptions and noticing this word appeared regularly throughout the text. I also noticed within the literature review that acceptance seemed to be a key element to recovery (Laudet & Morgen 2008p62) (Miller 1998 p991). The themes I set, do appear to link to some of the themes that were found within the literature review. I will analyse the themes throughout this study whilst linking this to theory. I will also use quotes from my interviews as examples.
Connecting to People appeared to be the strongest theme in relation to my findings within the data. In all my interviews participants discussed their main source of support was other people. This came in various forms such as Twelve Step fellowship, family and friends. It appeared that feeling accepted in a totally non-judgemental way enabled people to connect to something which profoundly changed their lives; another benefit was it appeared to have the effect of stabilising their emotions (White 2000 p14). When one is accepted not in spite of one’s imperfections but because of the very fact one is imperfect a great belonging can occur (ibid). By finding one’s self in other people stories and then having a shared story , identification may occur which in turnencourages self-acceptance and forgiveness of self (ibid). A sense of discovering and connecting to a community where you can truly belong can all contribute to emotional stability (ibid). This is shown in the example below.
“ it’s just been great because it’s the only place in the world where I have felt like no onehas ever judged me for something that I have said or I have never felt weirder than everyone else in the room because I just know from hearing feedback from other people that I am in the right place”.
The sub theme of acceptance is also shown within the above quote and in the quote below it is clear that as White (2000) says, by finding one’s self in other people’s stories identification occurs. This is shown in the following quote.
“Just seeing a woman and seeing so much of myself in someone else and that kind of yeah you feel you know someone’s story so well cause it’s so close to yours... ”.
One of my participant had experienced many relapses in his past and this time he reported feeling different and he attributed this to connecting to other recovering people. This is illustrated in the following quote.
“For me it takes a long time before I totally get connected towards a person, and I think this time around I’m willing to be connected with other people. Before it was no, that ain’t happening”.
Open listening without judgement in mutual support groups can result in the healing of isolation and alienation. Through support of others, it would appear that people experience less anxiety and more stability (Kissman & Maurer 2002 p37).There was a real sense that being in a group and being able to have healthy friendships is a very important part of recovering from the terrible isolation and degradation of active addiction. Acceptance was a key element which appeared to be thread that ran through both of the themes within the data.
The importance of a social network of people who can provide encouragement and acceptance is a need that most recovering people appear to have (Laudet & Morgen 2008 p62). By allowing themselves to accept emotions as part of life, they appeared to suffer less anxiety. Two of my participants explained very clearly about how this had enabled them to better cope with the way they managed their emotions. This also runs into the theme of Changes in perspective. This quote from my transcription is one example of many, of how the participant’s views have changed regarding how they react towards their emotional world.
“The value as it were. I mean it’s not fair to say emotions have value and that one is more important than the other. However in the 12 step recovery programme I am learning to accept that they do have value and they all matter”.
This new realisation, that even negative emotions are important and valuable also came through strongly in another participant’s interview. In fact this theme of acceptance emerged strongly in two of the participant’s data and to a lesser extent in the third. This is illustrated in the following extract.
“…..I think that’s probably the word acceptance and also gratitude for not being in an anesthetised state anymore you know, I feel and that’s alright you know and it is an acceptance. Yeah it is an acceptance no matter how bad I feel I actually feel. And it’s not all bad anyway because I experience great joys and it’s not …… that sense of being anesthetised that has gone and now I can experience it and accept it all ……”
Several studies show that drugaddicts underwent significant changes through spirituality based recovery programmes(Chen 2006 p1). It may be possible that that the attribution of positive meaning to suffering may initiate a process of self-change (Frankl 1965). This acceptance and fundamental change of perceptive along with taking responsibility for one’s self seemed to have enabled an internal shift within the participants in this study. Talking to other people in recovery was another type of support that participants used to process their issues; it appeared there was a therapeutic value in these conversations. An example of which is provided in the following quote.
“I usually try and talk to people that are close to me …… I speak to my best friend who I have met in recover. I talk to her, I talk to my boyfriend as well ….. I call my friends because I care about them. I get in contact with them because I want to see how they are.”
The theme connection with others ran strongly through one particular interview and this participant used connection as her main support, not just to others but in other ways to. It was interesting to see how many different strategies she used to connect and this is evident in the example below. Whilst interviewing her, she lit up when talking about these new connections and it was clear they were very valuable to her; it was inspiration to witness this level of commitment to her new way of life.
“One really big pledge that I’ve made is I like to send things in the post cause I love receiving a letter and sending letters …… lot of correspondence to America I send things to my boyfriend’s family . ……really big and important thing for me is to connect with nature. That’s really helps me, especially if I can go for a walk or go running ….I am so much stronger to, closer to women….. I always call women …I just text someone to make them smile”
Whilst reviewing literature it became apparent that the act of ‘surrender’, a concept that is used within in twelve step programmes, might possibly be the point when the shift of perspective starts. According to Tiebout (1954) the act of surrender is the moment when the addict’s subconscious forces of defiance and grandiosity stop working effectively. This is often a relief and there is no more fight left in the addict. This is shown in the following example.
“Admitting surrender! I am such a control freak that’s so good that I can surrender……I have given my power over to, in my case, mother nature, my higher power…… I have to have faith that she has the best intentions for me. Even when times are really shit… I know that every cloud has a silver lining. And I know that’s spirituality. Spirituality is so important to me.”
This surrender possibly may be part of what the participants view as a spiritual experience, although that was not actually said. However, I endeavoured to look behind the words for deeper meaning; this was also conveyed in body language and tone of voice whilst interviewing. However I am mindful that this is an interpretation and so should viewed with that in mind. As cook (2004) states there is considerable ambiguity as to what exactly spirituality means (Cook 2004). I conclude it is very individual and explicit to each person. There is an extensive amount of literature on the connection between spirituality and addiction. In Caters (1998) study, there was indication that there was a relationship between spiritual practices and long term recovery. Twelve step recoveries have maintained over the years that spirituality is the foundation of successful recovery (Carter 1998). Prayer and meditation were both mentioned within the data that was collected, although not as much as I had anticipated. This is illustrated in the following extract.
“I do a lot of prayer in the evenings. I mean a lot of prayer ………. When I can feel myself resentful and angry I’ll go into a sort of meditation. I’ll sound over the serenity prayer quite a few times.”
This does tie in with the spiritual aspect of recovery in twelve step programmes. I have thought deeply about how this connection with a “higher power” helped the participants within the study. People are encouraged not to be solely dependent on other people (Alcoholics Anonymous Big book p60) however the study shows that connecting to other people is indeed the main source of support. Could this external / internal connection to a “higher power” be another type of relationship which helps to support and stabilise these individuals? There was no data to substantiate this idea; however this could be an area for further research. There were other types of support that emerged from the data such as music, exercise, counselling and humour. Music and humour were themes that showed up in my literature review (Baker et al. 2007) (Sumners 1985) however I am not going to explore these but it seemed important to acknowledge that participants had a myriad of strategies that were very individual as well as sharing some wider themes between them. It appears there are similarities between participants in the way they support themselves and as well as differences. My analysis from this study was that the recovery journey is one which involves connecting to other people and this of course was the strongest theme within the data analysis.
Implications for my professional Practice
It seems that within this study that connecting to others is the main support for people as far as stabilizing their emotions. It was refreshing to see as this is the very thing we do from day one in my placement agency. Encouraging a client to connect with their peers is a primary objective within the treatment community. We assign a buddy to every new client and this facilitates a direct connection to a specific person and can increase the likely hood to connecting to the group. It is important to get a connection going between the client and the recovery group they are entering into as soon as possible (W. White & Kurtz n.d. p11). In placement within the structured day programme, we encouraged clients to put in place a support network outside of the agency as well as inside in order to sustain themselves in their recovery. It is clear from my study that support is needed for many years into recovery. As Laudet & White (2008) say “There is a need for a paradigmatic shift in services and in research, from an acute illness/crisis mode (assess, admit, treat, discharge) to a model of recovery management that parallels approaches used in the treatment of other disorders characterised with chronicity”.
Recovery is an ongoing process of change that appears to be never ending; adapting to a total change in life style, after which for many is years and sometimes decades of dysfunctional living, is a momentous task. It is important for services to realise that different types of support are needed to promote particular stages in recovery (Laudet & White 2008). There appears to be a significant difference in service provision geographically within the UK (Addicted Britain 2006). The participants I used were from Cambridge in East Anglia and this area is drastically short of abstinence based recovery agencies.
The implications of this study for me as an addictions counsellor are to remember the importance of interpersonal relationships for recovering addicts/alcoholics. My endeavour is to build therapeutic relationships wherever possible between clients and staff and nurture these relationships as they are crucial to positive outcomes in treatment. Staying aware that recovery supports are also individual and creating activities that are fun for clients is also important.