Longitudinal outcomes
In reviewing the progression of the 9 individuals who had addiction at the 2-year mark, two were judged to be “in recovery” (e.g. only minor lapses (<week) in past year), three were judged to be “improved” (e.g. taken control/improved self-esteem within the past 6 months), three were “unchanged” (e.g. major lapses (>week) in past year/no change in control). Finally, one person had “relapsed.” The core recovery construct (final model) was self-verification of positive identity (pride in socially acknowledged role). Five recovery related process themes were identified in total: (1) positive identity-building activity, (2) support perceived as ineffective (enmeshment), (3) support perceived as effective (mindful management of power imbalance), (4) taking control, and (5) self-verification of positive identity.
1.
Positive identity-building activity: Successful recovery (the cases of “Recovered1” and “Recovered2”) was linked with having support relationships that focused on a personally defined growth project (as opposed to the conversation). This was furthermore linked with a change in social status, increase in self-esteem, and internalization of responsibility for substance use. The successful support in these instances was instrumental as well as emotional and the common project was recognized by an emphasis on learning or skill building. Being recovered, in both cases, meant being recognized as improved by themselves, their sponsors, as well as the other addicted participants. For neither person it meant total abstinence, but rather improved self-esteem and confidence in their ability to refrain from using. Reflecting back, “Recovered1” attributed much of his success to being able to focus on a shared interest with his sponsor, namely computers:
When I heard there was a sponsor program, I had some things I knew I immediately needed help with. Specifically, it was computers… and I was looking for a person who knew a specific computer programming. It turned out, that need was so specific, it was too specific for him (the sponsor) to do. However, he had some knowledge of similar programs, and was able to help me with a lot of the organizing that I needed for school. I had managed to get by with my schooling up until that point without any real computer skills… so I got the help I needed from him to get started on a lot of these things. So in our first meetings, we talked and did a lot of things related to that. But we turned into good friends. And I was invited to his cottage, and even though I didn’t go, it all went really well.
Recovered1, follow-up, p.3
For “Recovered2”, the process of building positive identity was also evident. However, in contrast with “Recovered1”, who only “dabbled” in the recovery community and otherwise was largely focused on his education, “Recovered2” relies on multiple connections in the community and uses the program with great frequency. In fact, he did not only stop using drugs, but effectively adapted his social life to revolve around recovery-related activities. Encouraged by his sponsor and building confidence, he also started sponsoring someone else. To him, recovery first and foremost meant honesty and pride in his work. Recovery was thus a self-recovery more than it was quitting drinking. During the follow-up interview he reflected back on his process:
“Recovered2”: Yes and I was able to maintain a sense of competence all the way, even if I wasn’t too sure all the time, I got positive feedback from Jack… and things never seemed to move faster than I could handle. I’ve had a number of setbacks, but they didn’t last more than a few days, and I usually had them during the weekend. So on Mondays I returned. I’d decided this was where I was going to be (indicating recovery community)
I: So what words do you use to describe yourself now?
“Recovered2”: “I”m an addict. Current. And I’ll always stay that way, but it doesn’t mean I have to drink. And I’m not an ex-addict. I’m just dried up. The second you distance yourself from the addiction you’ve lost. Once an addict, always an addict.
“Recovered2”, follow-up, p. 8
2.
Support perceived to be ineffective: enmeshment: One important pattern that emerged from the data was the tendency for the support person to worry excessively about the person affected by addiction and the amount of drugs they consumed. As the enmeshment emerged, it was found as a likely consequence of the dyad not having successfully defined a personal project that provided a means for mutual activity., and while one pair sat still while conversing, the other conversed while walking. This pattern only concerned the support relationships of those people with addictions whose dyad activities were centered on the pair itself (e.g. meeting in café, talking while walking), rather than on some other activity (e.g. meeting to take computer to repair shop or to research new art ideas). The pattern was exemplified in people who seemed otherwise quite different; ranging from quite assertive to reluctant to set boundaries, but it was particularly prevalent with two women who both abused prescription drugs. A problem faced by all the sponsors was the frustration of “never knowing how much they have taken.” The value tied to their evaluation of their own support was tied directly to the idea of how much the participant affected by addiction had used on the day of meeting, or days prior to. These thoughts were then connected with verbal confrontation, as in the dyad evolving quickly with “Improved2” and her sponsor, and more gradually with “Unchanged1” and her sponsor. In both instances, however, the lack of trust in the person affected by addiction reduced the sponsors’ appraisal of the value they placed on themselves in spending time with the other.
Both these relationships went on long-term, and seemed to make little impact on the addicted person. To “Improved1” the issue caused resentment, as if her worth was reduced to her ability to reduce drug consumption. The addicted participants developed paradoxical bonds where they and their sponsors were preoccupied with their own worth and the others’ behavior. The focus on the drug abuse became a mutual obsession that neither could depart from, despite the fact that the drug abuse rarely affected the sponsors directly. “Improved2” and her sponsor have multiple ruptures due to this tension, and only partially succeed in repairing the tares. The relationship is repaired to a point, but the sponsor confronts “Improved2” (again) about her level of intoxication during their meetings. To “Improved2,” who was a sensitive and private person, her sponsors’ demands were hurtful and her apologies were made too swiftly for “Improved2”s hurt to be healed:
At the time, I was happy she apologized, but in hindsight, she has told me that she felt very… I mean, she says to me that she “hadn’t expected such a resourceful person”. She had expected somebody in need of greater help. So then I asked her if she couldn’t get another person she could supporter in addition to me? And she quickly shifted the conversation over to something else. Like, “chop chop” (motions in air). So, it is kind of hard to receive an apology like that.
“Improved2” p. 11
An enmeshment that was slower to evolve in terms of confrontations was found between
“Unchanged1” and her sponsor.
“Unchanged1” was afraid of being rejected and reluctant to assert herself and her sponsor continued to reassure her for a long time. Over time, however, she became frustrated and like
“Improved2”’s sponsor, started making demands to know more about the drug-use, and plans to get clean.
3.
Support perceived to be effective - mindful management of power imbalance: in addition to supporting the addicted individuals in a practical way, the sponsors of all those who made improvement asked the addicted person for help, particularly in personal matters. “Sponsor1” involved with both “Recovered1” and “Improved1” perceived “Recovered1” to be more vulnerable in the relationship, and out of respect, maintained a distance. At a distance, however, it was difficult to be supportive. To help even out this power imbalance, he started asking “Recovered1” for favors:
4.
Taking control: At the 2-year follow-up, only 2 addicted persons were in a process of “active recovery.” That is, they had maintained their reduced consumption and had no more than a minor slip in the past year. Additionally, they and others affirmed this status. Psychologically, the persons were different; “Recovered1” had an internal locus of control, believing himself capable of exerting a high level of influence on events affecting him. In the last year, however, he seemed to have lost control in defining his own identity due to financial problems. He had struggled with an additional stigma of mental illness most of his life, which was medicated. As such, he saw his emotional fluctuations as a normal part of himself and he was used to the idea that he chooses to self-medicate or regulate these fluctuations by the use of drugs.
“Sponsor1”: …he is a friend… and for me it is very natural that he sees me as one as well. I’d be very happy to be his friend… a friend means, you can talk about stuff, and you can ask for favors, small stuff. Actually, I have started doing that… I asked him for a favor… just to.. I mean, I didn’t have to ask about it… but I knew he could do it… so I asked, on purpose. To help build him up, let him give to me.
I: So, you give him your confidence, like that?
“Sponsor1”: Yeah, because often you feel like, no, you shouldn’t… hassle the other. But I mean that sometimes, it is actually the opposite. That by asking the other, you honor the other… if they want to give, then they can. That builds them up, they build their esteem and their confidence.
“Sponsor1” p. 36
“Recovered2,” in contrast, had an external locus of control, low problem and stigma awareness, and went from having a long-term pattern of heavy drinking, which he “denied to his children for years” (“Recovered2”, follow-up interview, p. 4), to acknowledge his problem and change behavior and identity, virtually overnight. The abrupt change was caused by a doubly concerning event: being caught for drunk driving when too intoxicated to recall driving, and having his adult children find out about it. To both “Recovered1” and “Recovered2” the responsibility for consumption seemed already internalized prior to the onset of our study.
For those who had recently improved, increased change-talk was observed after they had rejected their sponsors. In both cases, the individuals had struggled long-term with the feeling of not having their needs met in the relationship, and the process of rejecting the sponsors had a positive effect on the internalization of responsibility for using drugs. For “Improved1” the experience brought on the insight that he did not need a sponsor or “friend” because of his drinking problem. In fact, meeting his sponsor reminds him that he already has friends who are important to him.
I: Have you had any contact with your sponsor since the program?
“Improved1”: No, and we had talked about that, about having contact… and I said something like “that would be fine”… but that never happened. He has never initiated anything, and neither have I. And I don’t see a reason for it (laughs).
I: You are laughing (inquires)…
“Improved1”: … I’m laughing, as it seems kind of comical to me… like, “never mind” maybe… lackadaisical in relation to…I mean, if I were to contact this person, whom I have gotten to know… I mean, this and that. Yeah, well, I laughed, because that is not the way people typically know me… people know me as pretty pleasing, you know? Almost to the point of self-destruction for the sake of caring for the other… and be kind and pleasant and good and right, in every way… but then this is a bit. I laughed, because it felt liberating to say that “no, there is no point to that”, kind of… (laughs)
“Improved1” p. 17
Both “Improved1” and his sponsor attribute the difficulty in finding something organic to do together to be the main reason why the relationship dissolved. They usually met in a café, but once “Improved1” decided he did not have to please his sponsor, the relationship lost its thrust in the recovery process. At the two-year follow up, and with increased self-esteem and continued progress, “Improved1” was on his way to building a new identity. As well as having a problem with alcohol, he now defined himself as traumatized in childhood, and he was exploring other interests by taking up new studies. At the 2-year follow up, his identity was shifting from someone afflicted by a condition that was like cancer “which is something you can sometimes manage, but not cure,” to the idea that he had been traumatized by abuse in his childhood, but chooses to drink when he gets scared. The relationships that were focused on the conversation itself did not impact the addicted individuals until they themself rejected the connection. Such rejections were made both by “Improved1” and “Improved2” late in the research study, who seemed enhanced in self-esteem by the events. For “Improved3” the internalizing of responsibility was not related to rejecting the sponsor, but to events where the sponsor asked for help.
“It is such a wonderful feeling. You have the best conscience in the world; like you just got in the door after logging in the woods in the midst of winter, and you can finally relax.”
Improved3,
p.
23
5.
Self-verification of positive identity: Some participants (3) identified their addictions as disorders, a couple (2) did not identify with being disordered at all, defining themselves as living a “different” lifestyle. The remaining participants described themselves with a mix of stories including both disorder and lifestyle attributions. While we detected no difference in level of emotional distress between these groups at the onset of the study, the individuals labeled as “lifestyle users” did not seem to feel equally “out of control”, appearing more confident in their own control, and less worried about consequences related to their drug-use. They furthermore spoke of their using experiences with “plain speak”, comparing it to “normal”, and even socially condoned practices. One of the participants described being high on heroin like this:
As no participants were substance-free at the onset of the study, some (4) had encounters with their sponsors where they were forced to defend their decision or need to continue using drugs (or to use them with moderation), whilst continuing to benefit from the support program. These confrontations resulted in drop-out (1; mixed self-definition), failure to improve (2; “disordered self”), and firing of the sponsor (1; mixed self-definition). None of the “lifestyle users” reported of such experiences. While sponsors and others responded to the “lifestyle users” with suspicion at first, by the end of the study, two of them were nonetheless in the “improved” group. In fact, this group included two “disorder users”, two “lifestyle users”, and one user with a mixed definition. Members in this group all appeared to have more social opportunities, however, enabling them to present themselves as holding roles other than as “patient, or “user”. to present themselves to their sponsors as someone other than a “patient” or “user”, and other than someone in relationship with someone else. All had access to alternate social roles that they used to verify their self-worth throughout the recovery process. None of the participants appeared to be negatively affected by sponsors’ accepting a moderation approach to managing drug-use, and how negatively people were affected by sponsors’ confrontations depended on the availability of having alternate, positive identities to help obtain the sponsors’ respect.