By Tom Horvath, Ph.D.
How often have you heard the following statements?
“Using buprenorphine (Suboxone, Bunavail, Zubsolv, etc.) or methadone is not real recovery.”
“Harm reduction is not real recovery.”
“Using psychiatric medications is not real recovery.”
“Moderation is not real recovery.”
“Real recovery” is widely viewed as abstinence from all intoxicating substances. You can still be in real recovery if you use (or over-use) caffeine, nicotine, and food, or engage or over-engage in potentially addictive activities (also termed processes or behaviors, including gambling, video games, pornography, sex, etc.). The real recovery perspective is that any use of intoxicating substances is very likely to, or will inevitably lead to returning to the previous level of (severe) problems, but other addictive behaviors are acceptable.
There are several ironies to the real recovery perspective. Cigarette smoking and overeating are associated with more deaths than all the other substances combined. Medication assisted treatment (MAT, including using buprenorphine or methadone), which might also be termed “substance substitution,” is associated with substantial improvements in functioning. Addictive activities (like gambling) can lead to very serious life problems (even if they don’t kill you). What is considered real recovery may not meet a commonsense definition of recovery (because you still have other addictive problems). What appears to meet that commonsense definition, at least the part about having an improved life (with MAT), does not count.
Related to the concept of real recovery are the labels “addict” and “alcoholic.” Real recovery is for addicts and alcoholics (used as all-or-none terms), and irrelevant to anyone else. What results from this language is debate about whether someone is an addict or alcoholic, and whether an individual is in real recovery. The irony here is that the energy which could be used for solving problems is instead diverted into the effort to label them.
Rather than arguing about whether someone needs real recovery or is in it, we could consider the alternative perspective of “ideal recovery.” Ideal recovery is not a place but a direction of movement. At any place along the path to ideal recovery one would still have improvements to make, but could also recognize and even celebrate the success that has occurred. With real recovery you only get to celebrate reaching one threshold, rather than the many thresholds you actually reached as you made progress. From a behavioral perspective it is much more effective to reinforce small changes than to withhold reinforcement until a major change has occurred.
Most changes in life happen in small steps. By comparison, changes that happen suddenly may happen dramatically or even catastrophically. We would prefer that most people change in small steps, before a dramatic change is needed. Unfortunately, a real recovery perspective may inhibit someone from taking small steps to change, because only someone who is an “addict” or “alcoholic” needs real recovery. Someone might easily say, “I may have problems, but I’m no alcoholic, so I don’t need to do anything.”
A typical example of small-steps change would be someone deciding that it’s time to cut back on drinking (because of recent problems). Many individuals accomplish this cutting back, and do not seek outside help to do so. They do not come to the attention of the recovery industry.
If the individual is among the 3 of 4 problematic drinkers who do not appear to progress, a real recovery perspective suggests that nothing needs to be done: “I’m not an alcoholic (yet).” Nevertheless, even small alcohol problems are problems, and presumably worthy of attention. Moderation training is a sensible step for these individuals.
If the individual is one of the approximately 1 in 4 who does appear to progress from smaller to larger drinking problems, once that progression has occurred, a dramatic change would then be needed. If the individual is progressing, would it not be better to make small changes sooner, rather than waiting for the need for large changes later? Perhaps small changes sooner could avert a need for larger changes later.
From the perspective of ideal recovery we can all continually be making improvements on the apparently universal tendency to be distracted by short-term satisfactions at the expense of long-term satisfactions. Recovery consists of adequately weighting long-term satisfactions as we make decisions about how to behave. For almost all of us that weighting process is a major part of life, whether we consider ourselves addicted or not.
We could celebrate every small step toward ideal recovery, rather than using the all-or-none thinking perspective of “in real recovery or not.” We can also recognize that as we engage in the process of recovery we will mature, and our conception of an ideal recovery will similarly mature. Perhaps we will still be moving in the same general direction, but perhaps with greater maturity whole new vistas of life will open before us, and our behavior will change in important ways. If we are clinging to a sense of having arrived at real recovery and having nothing further to do, we may miss chances for personal growth that could make life even more satisfying.
Professionals need to remember that the language of recovery is highly personal. If someone says “I’m an addict, I’ve struggled for years, but now I have achieved real recovery” my first response is going to be “congratulations!” This real recovery language can be asked about later. Perhaps it has been used at the suggestion of others, and might be given up in favor of the language of ideal recovery. However, at most I would only suggest such a change, rather than demand it. If real recovery language appears to be helping someone it makes little sense to disrupt it.
As professionals we need to distinguish the language we use when speaking to the public, and the language we accept from the human beings sitting in front of us. Our clients are doing their best to make sense of what is going on in their lives. They do not need further challenges from us.
The public might be helped to understand that recovery is a process of small steps, and that we all are challenged to place sufficient emphasis on long-term satisfactions (which means frustrating short-term ones). With such a change in perspective we might reduce the stigma associated with problematic addictive behavior and get more people moving sooner into whatever recovery process would be beneficial for them.