Pathways to Long-Term Recovery: A Preliminary Investigation

Abstract

Recovery from addiction is a lifelong process. While there is a large body of empirical data on the short-term effectiveness (1-2 years) of various treatment modalities, very little is known about the processes of recovery over time. This is particularly unfortunate as treatment gains are often short-lived and even multiple treatment episodes do not always succeed in breaking the addiction cycle. Further, treatment represents only one of the paths to recovery.

This paper reports on a study of individuals in long-term recovery from substance abuse (median = 12 years) and examines the factors they cite as important in establishing and maintaining their recovery status. Key factors reported were social and community support, affiliation with 12-step organizations and negative consequences of substance use. Implications for clinical practice and future research directions are discussed.

Recovery from addiction, a chronic, relapse-prone disorder (Leshner, 1997), is a lifelong dynamic process. While we know a great deal about addiction, we know very little about recovery. The majority of studies conducted among substance abusers have follow-up periods ranging in length from 1 to 24 months - a short time relative to the lifelong challenges of recovery. What little is known about the natural history of addiction and recovery indicates that the recovery experience changes substantively over time and makes changing demands on the individual (e.g., Biernacki, 1986; Chapman, 1991; Freyer-Rose, 1991; Margolis et al., 2000; Vaillant, 1983/1995). One important yet under-investigated question is whether factors identified as predictors of short-term abstinence are also implicated in the maintenance of long-term recovery. This paper addresses that question with findings from a small-scale study among individuals in long-term recovery.

Factors associated with short-term abstinence

Findings from studies using follow-up periods of up to 2 years indicate that participation in formal treatment (e.g., Anglin & Hser, 1992; Hubbard et al., 1989; Prendergast et al., 1994) and longer time in treatment (e.g., Fiorentine and Hillhouse, 2000a; Simpson et al., 1999) are consistently associated with better outcomes. Affiliation with 12-step fellowships (e.g. Narcotics Anonymous) during and after treatment is helpful in maintaining short-term abstinence (e.g., Humphreys et al., 1994 and 1999; Laudet et al., 2000; Timko et al., 1995 and 2000), especially for those who attend regularly or become actively engaged with the 12-step program of recovery (e.g., Fiorentine, 1999; Kingree, 1995; Mckay et al., 1994; Montgomery et al., 1995; Watson et al., 1997). Post-treatment 12-step affiliation is also is a critical ingredient in the recovery process, increasing the likelihood that gains made during treatment are reinforced and sustained (Etheridge et al. 1999; Fiorentine 1999; Fiorentine and Hillhouse, 2000a).

In addition to formal treatment and informal recovery resources such as 12-step groups, researchers have examined the role of a variety of psychosocial factors in achieving and maintaining short-term abstinence. Among cognitive variables, several forms of motivation have been associated with good substance use outcomes (e.g., Downey, 2000; Morgenstern et al., 1997). In particular, commitment to total abstinence, as opposed to less stringent recovery goals, has been found to predict short-term abstinence (e.g., Hall et al., 1991). Having “something to lose” (e.g., friends, health, employment, freedom) if substance use continues also motivates change and is associated with positive outcomes (e.g., Costello, 1975 et al; Havassy et al., 1993; Vaillant, 1995). Social support from family and friends has been consistently found to predict positive outcomes (e.g., Havassy et al, 1993; Humphreys and Noke 1997; Laudet et al., 2000; for review, see El-Bassel et al., 1998). Further, there is evidence that while general support may be more important for overall well-being, the supportive network’s attitudes toward substance use and recovery are better predictors of future substance use (e.g., Beattie & Longabaugh, 1997). Friends’ acceptance of substance use is consistently found to be negatively associated with short-term abstinence (e.g., Havassy et al., 1991; Longabaugh et al, 1998; Project MATCH Research Group, 1997). Conversely, friends’ support for abstinence is significantly and positively associated with short-term abstinence (e.g., Humphreys et al., 1997 and 1999).

In what follows, the authors present findings from a small scale study about factors associated with long-term recovery from substance use and discuss these findings in light of what is known about predictors of short-term recovery.

Methods and Procedures

A pilot survey was conducted in collaboration with the Connecticut Community for Addiction Recovery (CCAR) to explore factors associated with the maintenance of long-term abstinence. Funded by the Center for Substance Abuse Treatment (CSAT) and the Connecticut Department of Mental Health and Addiction Services, CCAR seeks to organize the recovery community (made up of recovering persons, family members and friends) and to develop recovery networks at the regional, state and local level. To that end, CCAR conducts advocacy trainings and make presentations to legislators, public health agencies, media and universities. CCAR has been in existence for four years. Its active membership consists of approximately 90 individuals who meet monthly to plan and discuss the organization’s activities. CCAR considers its membership to be representative of the recovery community “from all levels of Connecticut society and population.”

The instrument, developed in collaboration with CCAR organizers, focused on the history of substance use, substance abuse treatment and other recovery efforts. In addition to structured items, participants were asked to describe significant recovery experiences. (Answers were coded so that up to 3 answers could be provided for each item.). The 5-page self-administered questionnaire was mailed to CCAR’s active membership of recovering individuals (N = 90) in the spring of 2000; a total of 51 completed questionnaires were received, representing a 57% return rate.

Results

Sociodemographics and Background

The sample was 54% female, ranging in age from 23 to 74 years (Median = 46). Ethnic distribution was 73% Caucasian, 16% African American, 6% Hispanic and 5% “other.” One-half (51%) were married; 20% single and 30% widowed, separated or divorced. Education levels were high, with 57% holding a college degree and 28% reporting having attended “some college.” The majority of members were employed full (71%) or part-time (18%). One-half (55%) had been arrested and charged with a crime, 41% had spent some time in jail.

Substance Use and Treatment History

As can be seen in Table 1, substance use history was extensive, beginning in adolescence and lasting, on average, 20 years. Although 71% reported alcohol as their primary substance, all but one participant had been polysubstance users.

Table 1.

Substance Use and Treatment History (N = 51)

	Median	Range
Age of first use	14 years	8 - 29
Lifetime length of use (years)	20	1 - 40
Length of abstinence (years)	12.2	0.42 - 36
	Primary substance*	Ever Used
Alcohol	71%	94%
Cocaine	22%	65%
Crack	6%	35%
Heroin	12%	33%
Marijuana	6%	80%
Ever in formal treatment**	65%
Alcohol detox	24%
Alcohol treatment	18%
Drug detox	16%
Drug rehab or outpatient	19%
Methadone maintenance	8%
Residential or TC	13%

	Median	Range
Number of treatment episodes	6	1 - 49
Total in treatment (months)	6.9	1- 81.6

^*Five respondents reported two primary substances;

^**Results add to more than 100% to reflect multiple treatment episodes

Almost two-thirds had attended formal substance use treatment (65%) and most reported multiple treatment episodes. Greater number of treatment episodes and more time spent in treatment were associated with a longer drug and alcohol history (r = .24, p = .1 and r = .46, p = .01, respectively).

Affiliation with 12-step Fellowships

All participants had attended 12-step meetings (Table 2); 90% were attending at the time the survey was taken. Median length of AA and NA membership were 12 years and 6 years, respectively. Current levels of affiliation were high as evidence by frequency of meeting attendance and sponsoring activities.

Table 2.

Affiliation with 12-step Fellowships

	Ever*	Current*	Length of affiliation (yrs)
Any 12-step Fellowship	100%	90%
Alcoholics Anonymous	96%	80%	12
Narcotics Anonymous	49	35	6
Cocaine Anonymous	18	8	2
Al-Anon	16	2	1
ACOA	12	2	>1
Frequency of current meeting attendance
Less than once a week	28%
Once a week	17
More than once a week	55
Has a sponsor	60%
Sponsors someone	52%
12-step program an active part of life	90%

^*Adds to more than 100% to reflect attendance at more than one 12-step fellowship

Among those currently attending 12-step meetings, frequency of meeting attendance was negatively correlated with length of time in recovery (r = -.47, p= .001), indicating that individuals with longer abstinence attended 12-step meetings less often. There was also a significant association between current 12-step attendance and length of time abstinent whereby participants with longer abstinence were less likely to report attending 12-step meetings at the time the survey was taken (mean years of abstinence 18.5 and 11.7, F = 3.42, p = .07); however, the size of the subsample not attending 12-step meetings was very small (N = 5).

Length of substance use and utilization of recovery resources were significantly associated whereby participants who had attended 12-step groups only had a shorter substance use history than those who had attended both 12-step groups and formal treatment (16 vs. 22 years, p = .02).

Recovery

All participants but one reported their sobriety date (the date when they had last used drugs and alcohol). The length of participants’ abstinence ranged from 5 months to 36 years (median = 12 years). Respondents were asked to describe their “most significant experience(s) that helped start and maintain recovery.” The results are presented in Table 3.

Table 3.

Recovery Experiences and Supports

Describe the most significant experience(s) that helped you start and maintain your recovery
46%	Escalating consequences of substance use
30%	Support of peers/family/friends
26%	12-step fellowships (AA/NA)
22%	Substance-related accident/arrest, legal trouble
22%	Treatment/professionals
16%	Surrendered/want to move forward, recover
10%	Birth of child/ want to be responsible parent
10%	Spirituality/my higher power

Note: the sum is greater than 100 because of multiple answers.

Most participants (65%) provided more than one answer to describe significant recovery experiences. The escalating negative consequences of substance use were cited most often as important reasons for either getting or staying sober (46%). Negative consequences spanned all areas of life, from physical and mental health to economic and social. Substance related accidents, arrests and legal trouble were cited by 22% of respondents, bringing the total percentage of negative consequence-related answers to 68%. Help and support of family, friends and peers (including “interventions by someone”) were also cited frequently (30%). Twelve-step fellowships were mentioned by one-quarter of respondents as important to their recovery.

Discussion

Survey participants reported an extensive substance use history. At the time the survey was taken, most respondents had achieved and maintained abstinence over long periods of time and were employed full-time. Two-thirds had used both treatment and self-help groups to recover, particularly those with more severe (longer) substance use histories. Most were still actively affiliated with 12-step fellowships, as evidenced not only by regular attendance but other critical activities as well (e.g., sponsoring). Findings from this study attest to the fact that individuals with extensive substance use histories can and do recover to become productive members of society. In addition, the data elucidate how long-term recovery is maintained and suggest that several factors previously identified as predictors of short-term abstinence - consequences of substance use, social support and affiliation with 12-step groups - may also be beneficial to long-term recovery. The relevance of these findings is briefly discussed.

Among recovering substance users, “hitting bottom” is often cited as the turning point and the beginning of their recovery. Hitting bottom is the realization of how much has been lost to substance abuse (home, health, friends, self-respect) and how much more will be lost - life itself - lest a drastic change is made. Hitting bottom is often what brings people in treatment and to 12-step meetings. The negative consequences of substance use have previously been identified as a significant predictor of short-term abstinence (see earlier discussion). As early recovery progresses, one begins to regain health, social connections and self-respect. With increased stability, the stakes get higher: one of the most important single prognostic variables associated with remission from addiction is having something to lose (e.g., friends, health, job, or freedom) if substance use continues or resumes (e.g., Costello, 1975 et al; Havassy, 1993; Vaillant, 1995). This in turn may strengthen commitment to abstinence (Fiorentine and Hillhouse, 2000b). There has been no investigation of the role of anticipated negative consequences of resuming substance use (something to lose) in maintaining long-term recovery. Many long-term members of 12-step fellowships report that they keep attending meetings to “keep it green, “ and to remember where they came from by listening to newcomers (members in early recovery) who often speak of the negative consequences of substance use and of hitting bottom. A common saying in the 12-step program of recovery is that every day one is abstinent is a “daily reprieve” from addiction. It may be that “keeping it green” is one of the mechanisms through which continued 12-step affiliation contributes to long-term abstinence (also see later discussion).

The support of peers, family and friends was also cited as an important factor in recovery, replicating findings from a handful of studies of long-term recovery (e.g., Margolis, et al., 2000; Rychtarik et al., 1987). As previously discussed, recovery is a dynamic process that makes changing demands over time in terms of coping strategies and can thus be stressful. Social support has several benefits that may contribute to the recovery process over time. For example, social support has been found to buffer stress (e.g., Taylor and Aspinwall, 1996). Moreover, the support of, particularly recovering peers, provides hope, coping strategies and role models, giving strength in trying times.

Providing support is the hallmark of 12-step fellowships, a factor cited by one-third of participants as instrumental in their recovery. In spite of a vast body of literature on 12-step groups (particularly AA), little is known about the prevalence or effectiveness of long-term affiliation with 12-step groups. Present findings, indicating that the majority of individuals in long-term recovery continue to attend meetings and sustain their involvement with the 12-step program of recovery, suggest that the beneficial effects of 12-step groups on short-term abstinence (see earlier discussion) extend to the long-term as well. From a recovery perspective, 12-step groups have the unique advantage of being consistently and widely available in the communities where members live. The chronic, relapse-prone aspect of addictive disorders make it necessary for many substance users to have access to lifelong support that formal treatment cannot provide. Further, 12-step groups often engage members more intensely and for longer periods than do professional treatment programs (Humphreys et al., 1999). Unlike visits to a treatment program, affiliation with 12-step groups, when it develops, “is often measured in hundred of meetings and spread over years” (Vaillant, 1995, p. 257; also see Humphreys et al., 1997). All members of the current sample had attended 12-step groups and most still did. In addition, this sample demonstrated other affiliative activities identified as beneficial to the recovery process, such as having a sponsor and sponsoring others (e.g., Caldwell and Cutter, 1998).

Most participants, even those not currently attending meetings, reported that the 12-step program of recovery was an active part of their daily lives. This finding, paired with a negative correlation between meeting attendance and length of recovery, speaks to previous work suggesting that there is more to 12-step affiliation than meeting attendance (e.g., Montgomery et al., 1995). The 12-step program of recovery as formulated by its founders (AA, 1939/1976), is a 3-pronged approach: unity (fellowship, traditions and principles of the program), service (chairing meetings, qualifying, setting up the meeting space), and recovery (“working” the 12-step program). It is likely that the benefits of working the recovery program are at least partially independent of meeting attendance and available in the absence of attendance, especially among individuals in long-term recovery where a program of recovery has been largely internalized. This does not imply that meeting attendance is not crucial to the recovery process, especially early on. It may be that over time, recovery among individuals who have come to embrace the program and live the principles suggested by the 12-steps is less dependent upon meeting attendance. Recent findings suggest that embracing 12-step ideology (e.g., commitment to abstinence, reliance on a Higher Power, needing to work the 12-step program) predicted subsequent abstinence independently of meeting attendance (Fiorentine and Hillhouse, 2000c). Morgenstern and McCrady (1993) have suggested that 12-step members may use different processes available within the 12-step framework to resolve their addiction. Similarly, it may be that different aspects of the 12-step program are more salient or more beneficial at different stages of the recovery process.

Finally, a brief discussion of the use of formal and informal recovery resources among study participants. There has been virtually no research on this topic using a long-term perspective. In the present study individuals had an average of 12 years of recovery. Interestingly, we note that one-third had recovered without formal treatment; all had a history of 12-step affiliation. To date, there are little data available on the effectiveness of 12-step groups alone; most studies have assessed the effectiveness of 12-step recovery groups as an adjunct to formal treatment. One exception is the work of Timko and colleagues (1995, 1999 and 2000) whose eight-year follow-up data showed that participants who had received some kind of help (formal or 12-step) were more likely to be abstinence than untreated individuals. The present study provides some support for the benefits of long-term 12-step participation, either alone or with formal treatment (also see McKay et al., 2001).

Implications and Future Directions

Findings from this study, examining correlates of long-term recovery, suggest that several factors previously identified as predictors of short-term abstinence appear to be beneficial to long-term recovery as well. Results point to the importance of motivational constructs (especially consequences of drug use) and of social and community resources in maintaining recovery. Clients in treatment are often ambivalent about quitting substance use (e.g., Miller, 1996), especially early on. Identifying important life domains and assessing the deleterious effects of substance use in these areas may hasten or strengthen the decision to become abstinent. Later on in recovery, there is a risk of believing one is recovered and testing that by having “just one” substance use episode. While some individuals in recovery may be able to return to controlled substance use, many are not (e.g., Burman, 1997). Therapists should work with clients on keeping in mind the potential consequences of any future substance use. The significance of social support reported here underlines the importance of social context in addictive disorders and in their resolution. In clinical settings, it is critical to learn about clients’ social networks and about network members’ attitudes toward abstinence and recovery. Finally, clinicians should emphasize the importance of establishing and maintaining affiliation with recovery support groups such as 12-step fellowships. The important role of clinicians in referring clients to 12-step groups has been consistently recognized (e.g., Caldwell, 1999; Humphreys, 1997; Cross et al., 1990; Vaillant, 1983). There is evidence that 12-step affiliation patterns are often set early on when clients are in treatment and remain rather consistent in the early recovery process (e.g., Weiss et al., 2000). Clinicians are in a position to inform and educate clients about 12-step groups, to redress misunderstandings and to work with clients to find goodness of fit between their needs and inclinations on the one hand and the tools and support available within 12-step programs on the other (Caldwell, 1999; Caldwell & Cutter, 1998). Providing available recovery resources after treatment is perhaps the best way to enhance the likelihood that short-term abstinence become long-term recovery.

Future Research Directions

As this paper suggests, many questions about long-term recovery and contributing factors remain unanswered. First, there is a need for research on recovery independently from treatment effectiveness (see White, 2000); not all substance users seek treatment services to recover and among those who do, treatment represents but a short time in the context of the recovery process. Second, there is a need for research about the process of recovery over time. This includes the investigation of psychosocial changes, necessary coping strategies and helpful resources. Researchers have much to learn from long-term recovering individuals whose experiences can provide a holistic view of the processes of addiction and recovery process over time. Finally, there is a need to assess the effectiveness of 12-step affiliation independently of enrollment in formal treatment and using a long-term perspective.

This preliminary study represents an initial step in the critical yet scarcely addressed topic of long-term recovery. The current study has several limitations, most notably the small sample size, self-selected respondents who are members of a recovery community, and the use of a short, self-administered instrument. Furthermore, given the scarcity of data about the recovering community (e.g., White, 2000) it is difficult to determine whether the present sample is representative of individuals in long-term recovery. The current study should be replicated using a larger, more sociodemographically diverse sample and a more detailed, semi-structured instrument; separate items should be used to learn about factors associated with the initiation and maintenance of recovery; moreover, abstinence status should be verified through biological assay or collateral reports. It is the authors’ hope that this study will stimulate further, large-scale investigations into the important topic of long-term recovery.