Episode #127

What is recovery? People talk about recovery with a capital “R”. But what does it mean? Is it something that happens over time? Is it possible to finish recovery? Recovery really is, at its core, the process of change. It is a living and active process through which people make long lasting changes in their lives. There isn’t an end date or a destination. There are stages to it though and everyone goes through it differently from another person. In today’s episode, we’ll talk about all of this and more.

Transcript 

You’re listening to the All Things Substance podcast, the place for therapists to hear about substance use from a mental health perspective.  I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor.  It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice.   So join me each week as we talk about All Things Substance.

 Welcome back to the All Things Substance podcast. This is episode 127. Last week we talked about the phases of addiction. I discussed a six stage model rather than the five stage model that usually gets used because I wanted to have a category for normal use, and a lot of the models that are out there don’t really account for that.

Today we’re gonna talk about the recovery side of things.  A lot of times people think about sober versus not sober. There’s actually a lot more to the idea of being sober or alcohol free or being in recovery. Those things can mean the same thing to one person, but mean very different things to others. 

When we think about recovery in a healthcare setting,  they’re usually in a recovery room right after surgery. When someone is recovering from an illness, they are getting better. They might still have some symptoms, but they’re on the mend. 

 

The American Society of Addiction Medicine sees addiction as a medical illness. It is a brain disease that has medical underpinnings. Therefore, recovery from this illness is the right choice of words. If we look at a straight definition, recovery is the act process or an instance of recovering such as an economic upturn after a depression, or the process of combating a disorder such as alcoholism, or a real or perceived problem.

When we talk about recovery ,from a substance use perspective, one of the go-to sources in the United States is called SAMHSA.  It’s a government department, and SAMHSA stands for Substance abuse and Mental Health Services administration. SAMHSA is the place for all things substance use related and mental health related. They have a ton of resources, but I find it incredibly overwhelming to use their website cuz there’s just so much. 

They put out a pamphlet called The 10 Guiding Principles of Recovery. In it, they talk about the various parts of recovery and what constitutes recovery.  They have a working definition of recovery from mental disorders and or substance use disorders.  This is what they have as their working definition. A process of change through which individuals improve their health and wellness, live self-directed and strive to reach their full potential. 

They believe that recovery has four major dimensions. One is health. This has to do with  managing the illness or diseases, symptoms, making informed and healthy choices that support physical and emotional wellbeing. Home is the second, a stable and safe place to live.

Purpose is the third meaningful daily activities like a job, volunteering, taking care of family, going to school, creative things, and the independent income and resources needed to participate in society. And finally, the fourth one would be community. Relationships and social networks that provide support, friendship, love, and hope. 

So they are describing recovery as  a process of change through which people are improving their lives in these four dimensions, health, home, purpose, and community. If we look at this in the light of Maslow’s Hierarchy of Needs, it does cover those. 

Although we’d be starting with things like health and home, getting to things like community and purpose when we get to higher levels of the hierarchy. According to SAMHSA, they have identified 10 guiding principles of recovery.

I’m not gonna go through all of them here. I am going to link this pamphlet in the show notes so that you can take a look at it. But I will just tell you briefly what the 10 guiding principles are. They are related to hope being person driven,  that there are many pathways to recovery. That recovery is holistic, that it involves peer support, that it is relational, that is sensitive to culture, that addresses trauma, that promotes strengths and responsibility and promotes respect. 

So that’s all the official definitions. Let’s talk about recovery as an average person would talk about it. I have shared recovery stories with all of you at the rate of about once a month for the last year, or. In those recovery stories, each person has shared with you their struggle from whatever their addiction was and their process of coming into recovery. 

Recovery is really different from just being sober, and it is highly individualized. The idea of sobriety really comes from the abstinence based plan of Alcoholics Anonymous. I have talked at length in different podcasts about abstinence versus harm reduction. The short version of my opinion is that it’s not abstinence versus harm reduction, that it is abstinence and harm reduction.

It’s an extremely important designation because not everybody is ready for straight abstinence, and if we’re not talking about addict or alcoholic levels of use, the person may not need abstinence. They might be able to choose moderation if they haven’t quite gotten to the addiction level.

I can’t determine that and I can’t decide that for people. What I do believe is that people who are truly addicts and alcoholics, will not be able to moderate any substance at all. That if someone is an alcoholic, that smoking weed all the time Is going to cause a problem that they won’t be able to moderate that.

The same thing goes for someone who’s been using meth and they think that they can drink because alcohol wasn’t their problem. I am an  abstinence-based person in my own recovery, as are all the stories that I’ve shared with you on the podcast.

Everybody gets to decide for themselves where they’re going to land in terms of abstinence from all mood altering substances  or if they’re choosing a harm reduction method. I do support all pathways to recovery because recovery is a process, not a destination. And like I said, it is highly individualized and it is not my responsibility to police everybody’s recovery. If they are able to moderate,  then that is what they can choose. If they can’t, it will become apparent to them and they don’t need me harping on it. 

Generally, when people talk about being in recovery, they use that word because they are in an abstinence based program. Otherwise, people have a tendency to say things like, I’m alcohol free or I’m cannabis free, or whatever the substance is. That is something that folks will use to describe what they’re doing rather than talking about being in recovery.

That’s not a hard and fast rule because I have lots of people that I know that use the term alcohol free and they’re not using other substances either. It’s just that they don’t identify with the term recovery.  For some people, the word recovery indicates that they were an alcoholic or an addict, and they’re uncomfortable with that, and it also might not be accurate.

They’ve chosen to go alcohol free or cannabis free, or whatever it is, but they aren’t necessarily talking about actively recovering from the brain disease of addiction. Being in recovery is an active thing. It is not something that you achieve and then are done. Recovery is a living, breathing thing that takes continual work. Sometimes it might seem like it’s a fuck ton of work, and sometimes it will seem easy. It completely depends upon where someone is. 

A good friend of mine is approaching his 10th year anniversary of being in recovery. These days, it’s not as much of a struggle to stay away from drugs and alcohol. He has built an incredibly strong recovery and has been able to restore pretty much all aspects of his life from when he was using. Up where I live hunting is a big deal and he was able to get his gun rights restored even though he is a felon and couldn’t own any kind of firearm. He was able to petition the courts based on the last 10 years of his recovery  and now has restored his ability to go hunting. This is something that he wanted because he wanted to restore the things that addiction stole.

Having a solid plan of recovery means a couple things. If I say that so-and-so has a solid plan of recovery,  or has solid recovery, what I mean is that they have managed the symptoms of addiction,  they’re no longer using. They have a support network of friends or family who may or may not be involved in recovery activities, but they’re involved in pro-social activities. The person is taking care of their physical health, their mental health, and their spiritual health, whatever that might be. Recovery encompasses all of those things. 

There’s a term that was created in AA, Alcoholics Anonymous, to describe a person who had quit drinking but hasn’t really dealt with the issues that caused them to drink in the first place.  We haven’t really come up with a good phrase that’s updated in terms of language, but the principles still apply. It’s called being a Dry Drunk. 

Dry in the sense that they aren’t using alcohol anymore. The difference here though is that the only thing that changed is that they’re not drinking. They aren’t necessarily living in a real positive way. And a lot of times people who are in a dry drunk place , are still struggling with mood and they can be angry and they might try substituting one substance for another. They could be turning to other destructive coping habits. 

Someone in recovery is  looking inward at themselves. They are trying to do things in a different way, trying to have humility and do things honestly, manage their emotions and their mental health. For someone  who’s in a dry drunk phase, , they aren’t enjoying themselves. They’re not focused on what’s happening inside. They’re not managing their emotions, they’re ignoring it. This is not sustainable. 

White knuckling it is something that we call it when someone isn’t working a plan of recovery, but instead is just maintaining sobriety. It is extremely hard. The idea is that you are hanging on so tightly to sobriety that your knuckles are turning white. Recovery is not supposed to be like that 24/7, not even in the beginning. It should have periods where it’s feeling easier. Cravings should be less intense over time and happening less often, rather than it being a fight all day every day.

The process of recovery and especially early recovery can be really difficult. And I wanna talk about the phases of recovery. Again, just like phases of addiction, there isn’t an official “this is the pathway to recovery”. There are generalizations about  what recovery, early recovery, later recovery and maintenance really look like. 

The very first stage in recovery is with. The withdrawal stage can last anywhere  from a week to upwards of four to six weeks. On the high end, that’s gonna be for folks who are experiencing protracted withdrawal syndrome. That is a very difficult phase as the person is at a place where they’ve already physically suffered through a lot of the withdrawal, but they’re still not out of the woods. Those first couple weeks  are key to someone’s recovery.

Some people aren’t able to get to the place where they get past those times because the withdrawal gets to them and they end up going back to the substance to manage it. Each substance has a different withdrawal experience  and how bad the withdrawal is gonna depend on the type of. 

For instance, alcohol withdrawal is going to be probably three to five days, and there is an incredible risk  for seizures, cardiac arrest, and death. They may struggle with feeling feverish, having headaches, trouble sleeping. 

For marijuana, it’s very similar to quitting nicotine. There are it’s agitation and irritability, vivid dreams, and potentially headaches that can last for about a week, where it takes about a month for the brain to totally clear.

When it comes to things like stimulants. The drop off is usually really hard and leaves the person exhausted  and feeling on edge and agitated.  A lot of times the person experiences nausea or vomiting, headaches, flu-like symptoms. Once this resolves, the person is able to start moving back into their normal life.

When it comes down to meth withdrawal, that’s about four to five days, and there’s an incredible sleepiness that happens  where people will sleep for incredible lengths of time and are not able to be woke. That can feel like a scary time if someone’s not really used to what it looks like when someone is recovering. When someone is in withdrawal from methamphetamines.

With opiates and heroin, that is a longer process.  The withdrawal is more like seven to 10 days. Opiate withdrawal is physically the worst in terms of how it feels, and that is often what trips people up. A lot of us can do four days of feeling shitty if we know that on the other end we’re gonna start feeling better. 

However,  with opiates and heroin, the withdrawal is painful as well. Since your pain tolerance also goes way down, after using all those pain meds, it can be incredibly unbearable. We have ways of managing that medically and a lot of folks end up needing to do a medical detox because it is so awful. 

Benzodiazepine withdrawal can be longer and it is the other withdrawal  that can be fat. Alcohol withdrawal and benzodiazepine withdrawal should never be attempted without medical oversight. Once somebody gets through the withdrawal, early abstinence is the next four weeks.

A lot of times  this can feel like a honeymoon period. Not for everyone, but for a lot of folks they’re feeling so much better and they’re past the withdrawal and their brain’s feeling somewhat clear and they may not wanna go to treatment anymore or work on anything cuz they just feel like now that they’ve kind of gotten better, they feel like they got this now. 

When it comes to substances like alcohol, that next period of time can be somewhat foggy. Their thinking might be unclear, concentration might not be great. They might be feeling nervous and anxious, and trouble sleeping is often a problem because a lot of folks have been  using alcohol to help them sleep.

The next stage is protracted abstinence. This is about three and a half. So from six weeks to five months, there’s a variety of things that come up. And sometimes this can be annoying and troublesome symptoms. So as the brain is trying to heal, there are going to be things that pop up.  

Sometimes there’s gonna be some really good times where they feel good and other times there’s going to be this period we like to call the wall. As in, somebody hit the wall. This can be really shocking. 

Somebody has just gotten through the withdrawal period. They got through their first month after that, and they’re sober, and they’re working this plan  and moving away from their substance, and then all of a sudden they hit this.

The most common things that people experience are depression, irritability, difficulty concentrating, having low energy and generally not enjoying things. A lot of times they have a lot of strong cravings for their substance during this time. The relapse risk here is really. They start to wonder why they’re doing this, and it feels like this is all life is ever going to be.

It’s sort of like when you’ve been sick for a while and it feels like you don’t remember what it’s like to be well. In your brain. You can think about the fact that of course, you haven’t been sick your whole life. You have had periods where you were healthy and feeling okay. The trouble is In this place where someone’s hit the wall, they aren’t able to access that better feeling self. 

This is where the support network is really important. Taking it a day at a time, focusing on the moment rather than this long stretch is super important because they have to wait for it to pass. It does pass if people are able to stick with their recovery during that time. 

A lot of times this is where relapse does happen and we have to go back and start the process over, which isn’t terrible as long as the person has kept themselves safe while they’re using and going through withdrawal again. But it is often the shock of hitting this wall and how hard it got that makes people falter in their recovery.

After about the five month range, we’ve got a period of readjustment, and this is about two months long. So the brain has recovered a lot during this time. When it comes to meth, that person’s brain could take up to two years to recover totally, but for the most part with other substances at this five to seven month mark, people really are doing a lot better. 

And now what they’re focusing on is building the rest of their life, fulfilling their lives with things that they enjoy, activities, relationships, a different job, going to school, all of those things that are past just survival. 

So when we’re thinking about the dimensions that we talked about earlier, we’re talking more about things like purpose and community rather than home, safety, stability, and health. That’s the goal of the beginning of recovery. The first five months or so after that, we start turning people’s attention to more higher level concepts.

This is really similar when we have someone come in who is struggling with deep depression. The very first things we do are stabilization. We’re looking for a way to help them rise out of this pit of depression that they’re in and helping them feel better. We’re looking for some stability and some consistency before we go moving other things around and encouraging them to do new and different things.

Once we get to a year, what I have noticed is that the second year can feel really different. The first year is all about the firsts. The first holiday, the first birthday, the first New Year’s Eve, the first tragedy, the first death, whatever it is that people experience. When they get to the second year, sometimes that can feel harder because they’ve already celebrated these things, and so there really isn’t much to say.

This, I would term middle recovery.  I feel like years two and three and somewhat year four is middle recovery. There are other things that the person is learning to manage. A lot of times these are deeper things. This isn’t about finding activities or finding friends. This is about the other layers, the emotional stuff, the reasons why they started using to begin with. 

The American Society of Addiction Medicine have stated in the past that trauma really shouldn’t be dealt with until someone has about two years of solid recovery. I’m not sure that I would necessarily wait two years,  but I am definitely aware that in the first year of recovery, doing in-depth trauma work  really isn’t wise in most cases.

I might do some trauma work if there were symptoms that wouldn’t go away. But I wouldn’t be going and digging through all sorts of things just yet. I find that there needs to be a certain amount of emotional and mental space that people have in order to do trauma work. They may want to, because after all, the addict and alcoholic has this balls to the wall or not at all attitude.

And once they experience the way that recovery can be freeing, they wanna be free of all the things. What is better is slow and steady here. Building sobriety, building recovery,  and solid foundation so that the work can be done in a way that is going to last.

This stage of middle to late recovery  can last for years and then they move into the maintenance phase. Maintenance for some people is something they’re not really aware of. What I have found is that  in the maintenance phase, or what we would call long-term recovery they’re no longer really fighting with themselves about the substance. 

They accept that they can’t use it. They have found other ways of coping. They have built new relationships. They are managing life without substances. Recovery then isn’t the most primary thing on their mind every day. For myself, I’ve been sober a really long time, and recovery isn’t really something I think about all the time anymore. 

I am part of a recovery community after not being a part of one for a very long time. The reasons that I joined the recovery community are varied. It wasn’t that I was worried about relapse or feeling like my recovery was shaky. It was that there was a group of women that I felt were like-minded that were also talking about recovery, and it was done online. It was a really neat opportunity to join with other healthcare professionals and women  with a commonality.

Part of recovery and being in recovery is about growth. We’re always moving and trying to change and trying to do.  Not that who we are is somehow flawed. But we want to be the best versions of ourselves to benefit us and our friends and our family. 

There are some folks who are involved in a recovery community for their whole lives. Who have been sober 30 years and have gone to meetings ever since. There are others like me who didn’t have a recovery community in the beginning because I didn’t know that I needed one.  Have had periods of time where I was in a recovery community and then long stretches without it. 

Everybody who’s got long-term recovery does things a little differently, but what I have found is that we can all tell you what our recovery consists of. What it is that we do in our recovery. It’s a very intentional thing, and it’s not something you just sort of stumble into. Recovery is a living and breathing thing, whether it’s the primary focus depends on where the person is in the process.

I have found that there are some folks who are uncomfortable with the word recovery. I had this experience with someone I was talking to recently when I mentioned something about their recovery, and they hesitated and backed up a bit. They were fine with the idea of choosing to be alcohol free, but the implication of being in recovery was that they had a problem. This person wasn’t at the place of feeling like they could say that they had a problem from which they needed to recover. 

I think there’s a finality to that, that people struggle with because one of the hardest things moving into recovery is the idea of abstinence, permanent abstinence. It seems harsh. It seems cruel at times. 

For folks who have never struggled with any kind of addiction or any kind of compulsion, it seems weird that somebody could be afraid  of not being able to engage in an activity again. It is a very real feeling though. Perhaps you don’t have anything that makes you feel fearful if it never existed.

There’s a question that people will ask sometimes about if you go to a deserted island and you can only have this, what would you choose? We’re supposed to think about that one thing and not the logistics of being on a desert island. That if I’m on a desert island and all I can have is a book, we have problems. I need lots of other things. 

But the idea is to make you think about what you don’t wanna be without. When it comes to substances for the person who is addicted, the idea of living without their substance is scary. The idea of having to live without their substance while everybody else is able to use. That is terrifying. 

It can make it feel like life will never be happy or full of joy or have color in it. I remember feeling that way and as I look back over 20 years later, it seems weird because I haven’t used drugs since 90. I don’t miss it. I don’t want it. I don’t think about it. Yet. I remember very deeply how terrifying it was to feel like I wasn’t gonna be able to use a substance.

It didn’t last very long,  and by the time I ended up not drinking anymore, that was okay with me because I wasn’t using alcohol to numb myself. I was quitting drinking because my relationship with alcohol wasn’t normal. It’s not normal to drink six times a year, and all of those six times do stupid shit that’s not something I want to have in my life. So when I gave up alcohol, that didn’t feel like it did when I had to give up using. I had learned how to live without it. 

When you have a client that is considering making a change in their relationship with substances, I wanna encourage you that to be in recovery it is a very active way of moving towards a different lifestyle. Not everybody is ready to jump into recovery. A lot of times they will move in and out of the stages of change from contemplation to preparation, to pre-contemplation and all over the place because the reality of having to give up a substance is really.

One of the things that I have talked about and will continue to talk about is that we have to stay in step with our clients. Even if we are concerned about their health and their wellbeing, we can’t get ahead of them and try to pull them with us. 

It’s like when we try to help someone stop cutting or self-harming, we’re concerned about it. We want them to stop doing it. It’s very clear to us that they need to stop doing it, and it can be tempting to push them to make a choice to give it up before they’re ready. The difficulty there is that people don’t give up things successfully until they’re ready, until they’re convinced that they need to do this differently.

It’s important for us to stay right in step with our clients or even a step behind where we’re just noticing what they’re talking about, what they wanna do about that, letting them completely lead. I encourage you to check in about the kind of language they wanna use. If they wanna try giving up alcohol or another substance for a little while, what should you guys call?

Is that, that they’re trying to get into recovery or is it that they’re going to be substance free or alcohol free  or free from self-harm, whatever it is. Finding the right language can also be really important when working with people on these habits.

We wanna make sure we understand the parameters of what they’re committing to also. Does this mean that they are going to be abstinent? Does this mean that they’re going to try moderating their drinking or using what it is that they are after? Wanting to make sure that we aren’t subtly leading them in a direction that they aren’t ready to go, but clarifying that, you just wanna understand exactly what they mean. 

We have the skills for this. We do this all the time. When we say, tell me more about that, or can you explain that a little more  I’m not sure I totally understand. Helping them develop the boundaries for themselves about what they’re going to include in this plan they’re putting in place and what’s not included. This way when they feel like they’re struggling or they feel like they have failed in some we can help reflect back what their original intention was. 

For instance, I had a client who was seeing me because they were struggling with alcohol use, and their partner was getting upset. When I would talk with that person and they would tell me that they drank, there was always this shame attached to it that I could hear in their voice.

What I would remind them is that they didn’t tell me they wanted to quit drinking. They told me that they knew they had been drinking too much, not that they were going to give it up. So we talked about what it was that they did, that they were trying to change. It helped us have a much better conversation than when they’re feeling like they’re a bad person because  their intention was not to stop. I didn’t make that assumption. 

They felt like they had two choices. Drink or don’t drink. That person seems to have been able to moderate their alcohol use thus far. I wasn’t sure if they were going to be able to or not because it seemed like they were heading towards an alcoholic direction, but thus far they’ve been able to do it. And we’ve reflected on times when they have drank in a way that wasn’t what they.

We talked about what triggered that, what they could have done differently, and how to manage it in the future. There is a lot of work that we can do as we  stand with someone just looking at their behavior and helping them process what they want to do differently or what they’d like to add, subtract, et cetera.

Recovery is a process and we do recover. It can seem sometimes like addicts and alcoholics don’t. A lot of people, and a lot of you even listening, have known people in your lives who either haven’t gotten better or never did get better and ended up passing away. I want to encourage everyone that people can and do recover.

Why do some people recover and others don’t? I don’t know. I can tell you that it’s not for lack of trying. That it’s not about them not caring about people or loving their substance more than someone else. There are complex, powerful forces at work here that if you haven’t experienced, can be really hard to understand.

In the last few weeks we’ve been talking about the process of addiction and how it progresses and the process of recovery. This brief overview is an example of the information that I cover in much more depth in my group program. Charting the Course. This is a six week live taught course with 12 continuing education credits and follow up consultation calls after the program’s over.

I encourage you to head over to the website and check out betsy byler.com/course. The registration doors are gonna be opening and you can be one of the first to know by signing up for the wait list. Again, the website’s, betsy byler.com/course. 

I am so thankful that you chose to spend your time with me today, and I hope to see you on the next podcast. Until then, have a great week.

This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, clinical or any other professional information.

Helpful Links

betsybyler.com/course

What Is Recovery? – PMC

SAMHSA’s Definition of Recovery – Measuring Recovery from Substance Use or Mental Disorders – NCBI Bookshelf

10 Fundamental Components of Recovery – NAMI Thurston-Mason

Recovery Definitions

What are the 6 Stages of Recovery? – Tara Treatment Center

The 4 Stages of Alcohol and Drug Rehab Recovery