Recovered From Substance Abuse - An IPA Report

Recovered From Substance Abuse -
An IPA Report

We who have 'recovered' from substance abuse: A positive psychology approach utilising an Interpretive Phenomenological Analysis case study

This study aims to explore the phenomenon of substance misuse in individuals who have recovered from active addiction and to gain initial insight into the introductory posit ‘recovered’. A qualitative method by means of a semi-structured interview utilising interpretive phenomenological analysis identified key themes and some cognition’s behind the behaviour and beliefs of a recovered alcoholic and drug addict. The master themes identified were emotional territory, belief extremities and identity biases, and active addictions. Some evidence was found that illustrated aspects of the recovered phrase and these related to concepts prevalent within the scope of positive psychology. Suggestions are made which propose how emergent themes may be incorporated into future investigations and how these findings may broaden the scope of background research within the field of recovery from substance misuse; particularly within the realm of counselling, clinical and positive psychology per se.

Key terms: Interpretive Phenomenological Analysis (IPA); Alcoholics Anonymous; 12 Step; Recovered; Peak Experience; Self-Acceptance.

Introduction

This report consists of research into the field of what shall be termed addiction (an umbrella label for terms such as substance misuse, alcoholism, drug dependency etcetera). A brief overview of some of the historical concepts within the field of addiction and recovery shall be explored, as well as recent work by contemporary psychologists that focus on both addiction and positive themes respectively. The main body of the work consists primarily of an analysis of a single case study and its findings.

The psychology of addiction as a disease is a model that has its historical roots in the 1960’s with the work of E.M Jellinek (1960). However, in recent years it has fallen primarily within the scope of the Biopsychosocial Model (Engel, 1977) and under the remit of clinical practices per se - both in diagnostic and treatment terms respectively. In political terms there have been recent reports of the Labour government reducing the usual £500 million pound spend on drug and alcohol treatment programs and a reiteration of the success (sic) rates of approximately 3-5%. (The actual figure reported for the year 2006/7 from a spend of £350 million, only 70 individuals still remained clean and sober by the end of the same year (The Guardian, 2007)). Evidently something appears chronically wrong. Is disposing completely of the current system appropriate given these usual sad and fatally high failure rates? Clearly, there is evidence to suggest that substance abuse is not only costing the states health services considerable finance, but perhaps too, that the service users themselves are being offered an unremitting disservice. Undoubtedly people are still dying, so what can be done?

Initial research for this study was perhaps illustrative as it reflected what is perhaps a mirroring of contemporary psychology per se - it concentrates a high proportion of its studies on the treatment of ‘diseases’ and ‘illnesses’. Terms such as psychobiology, brain damage, (dys)function, and other key phrases are commonplace and a mostly bleak view is painted; indeed, background research for this paper elicited an expansive body of dystopian works. However, in the last decade psychology has seen the rise of an innovative, more optimistic school of research in the guise of positive psychology. It has been well termed as ‘The empirical study of happiness and well-being’ (Boniwell, 2005) and this suggests a return to the foundational realms of the science of human experience that appeared to fall by the wayside shortly after the Second World War - the phenomenon of post-traumatic stress has its lineage in the concepts of ‘shell-shock’. Notions such as the building of strengths and virtues and the study of well-being had never received any defining research (Seligman, 2005) and addiction research has appeared to follow the very same uninspiring route. In terms of this specific research it is intended to seek to apply a similar positive phenomenological perspective and experiential thread to the notions of post-active substance addiction and subsequent recovery themes.

Perhaps the most relevant articles on the research of addiction and recovery themes within the field of Interpretive Phenomenological Analysis, or IPA (Smith, 1996), are on studies of intravenous drug users and why this specific method of ingestion is preferable (Giddings, 2003) and a second study on individuals’ subjective reports of both addiction and recovery per se (Larkin and Griffiths, 2002). It is this second paper that offers insight into the area of related interest of this project and consequently this study has been utilised on a peripheral basis for this account.

Larkin and Griffiths studied individuals confined within a residential 12 Step treatment centre utilising both therapeutic principles coupled with an adaptation of the specific recovery program of Alcoholics Anonymous. Subjective accounts of individuals using this method of recovery were analysed and themes of an experiential nature were apparent; master themes such as ‘restoration of self-worth’ and ‘new identity’ were gleaned (2003). The key difference here is the attempt to focus on the prevalence of any similar positive attributes and virtues, or any themes of well-being or so-called ‘positive self-regard’ (Rogers, 1962), also, to explore whether these are prevalent as a consequence of a very specific method of recovery. It is further propounded by this study that positive principles and concepts such as well-being and optimism may be best illustrated by studying individuals who have transformed their own lives from two seemingly juxtaposing ends of our societal strata – if you will, from ‘the bottom to top’.

Historically, it was the founding father of humanist principles Abraham Maslow (1958) who referred to notions of ‘self-actualisation’ and subsequent ‘peak experiences’ respectively. These are states of both personality and experience where the individual is experiencing life at an almost optimum level. The endeavour of this work is to ascertain their prevalence as a consequence of an individual using concepts only common within the original 12 Step recovery program of the organisation Alcoholics Anonymous (1939); in which the key term ‘Recovered Alcoholic’ is used as a posit. This is in direct contradiction to the subsequent and adapted 12 Step Minnesota Model of drug and alcohol treatment programs adopted in the medical field and these are characterized by the use of the phrase ‘Recovering Alcoholic/Addict’ as a contradictory posit (Hazelden, 1950). This concept of permanently recovering from an illness is prevalent in no one singular other phenomena within science or medicine (for example; in cancer an individual is deemed to be in ‘remission’, which suggests and is regarded as resolution and is not process orientated). However, in recovery circles the term ‘recovering’ is used as the prototypical definition for an individual who is abstaining from ‘using’ and ‘on a journey of recovery’ from a particular behaviour/substance of choice and also to reaffirm the notion that there is no permanent ‘cure’ available for the addict. One of the primary downsides to this approach is that it may appear to inform the view that relapses into active addiction is endemic and a consistently pertinent factor for the individual. However, perhaps more pertinent still, it attempts to inform in the individual the negative idea that they remain forever ‘sick’ or ‘unwell’. Here, rather ironically, it was similarly deterministic concepts of Freud’s such as labelling theory and illness models that humanistic pioneers Maslow and Rogers sought to eradicate when they propounded the very notions of psychotherapy that now underlay therapeutic recovery themes (Rogers, 1980). However, the original program of Alcoholics Anonymous with its use of the ‘recovered’ phrase reports no such concept of intermittent relapse, nor any continuation of the sickness theme, whilst notions of happiness, joyousness, purposefullness and freedom prevail (Alcoholics Anonymous, 1939). Historically, the success figures of the organisation appear to uphold this notion with considerable aplomb. Why this is and what the contributory factors are is the endeavour of this study.

Key to this foundational 12 Step program is its emphasis on spiritually orientated principles. These are informed via a vital reliance upon a non-denominational ‘God as we understand Him’ (abstractly labelled elsewhere as a belief in a ‘Higher Power’), or if you will, the concept of a personalised notion of faith. Whilst this theme of faith is a factor in alternate Minnesota models, it is much less emphatic as they proffer a more therapeutic view of the 12 step program. An emphasis on the faith-centred aspect of the process is an indication of a more ‘Gestalt’ (holistic or whole) approach to the treatment of the addictive individual. Indeed, in terms of the potential for any individual to become significantly ‘fully human and fully whole’, Rogers (1968) and more recently Seligman (1994) suggested that the human being in pursuit of a fuller reality need necessarily pursue at least some aspect of a meta-physical or a spiritually principled life, certainly if they will at all achieve some sense of wholeness, fulfilment, or self-actualisation in their own lifetime (Maslow, 1958). Again, the foundational 12 Step program of A.A. historically reports figures with significantly higher success rates without the subsequent therapeutic principles in tow (Alcoholics Anonymous, 1939). Also, whilst the basic text of Alcoholics Anonymous does emphatically reaffirm that there is no cure for alcoholism/addiction, it does report a complete removal of the problem of alcohol (or relevant substance/addictive behaviour) and that it can be completely and permanently arrested on the basis of the individual maintaining factors of daily living which are essential to recovery; such as a life centred in faith and spiritual principles, significant acts of altruism and selflessness, maintenance of contact with recovered peers and continual thought for suffering alcoholics. Consequently, it suggests that the individual may no longer believe their life to be anything other than hugely contextual, meaningful and purposeful (1939). Tangible, realistic factors such as these perhaps provide a real insight into what is suggested by the posit term recovered and are central within the realm of positive psychology (Boniwell, 2005).

As a qualitative methodological approach to subjective research, IPA was propounded by Jonathan Smith (1996; 2004). Its primary function is to allow a more succinct analysis of the individual’s world-view in the relevant chosen area of study. Key to its tenets is the theme that the researcher makes careful and concise analysis of the participant’s subjective account of a phenomenon; for example, addiction. Smith terms this two-way process ‘reflexivity’. He states, “the participant is endeavouring to make sense of a phenomena and the researcher endeavours to make sense of the participant making sense of the phenomena” (Smith, 1996; 2004). This two-stage process is thus analysed in the form of a transcription of a recorded interview(s), this is then carefully read and re-read in an attempt to find themes and subordinate themes that illustrate particular trends. These trends can subsequently be validated when observed across a number of interviews. IPA as a theory is clearly multi-faceted - it allows for a view of many aspects of an individuals use of language, cognitive processes and any physical nuances, then merges these through the relevant interpretation of the collected discourse, emotive dialogue, and may also illustrate the inclusiveness of any positive and negative contours in the text. It is perhaps here that any locale of underlying meaning may be found and this ‘meaning’ is considered a foundational aspect in IPA, phenomenology and existentialism. Many of IPA’s previous works have ‘real-life’ applications in the world of clinical practice in psychology and it is suggested here that similar applications may be relevant as a consequence of this current work, i.e. that the data reported may help to inform and expand a wider clinical or real-world understanding of the concepts and term ‘Recovered Alcoholic/Addict’.

One of the benefits of using IPA in regard to inclusive themes of a phenomena is that it allows for a subjective view of an individuals direct experience of the phenomena, and may also allow for any underlying themes to emerge that may appear relevant from a contemporary point of view with hindsight. Here it is hoped that this perhaps permits a finer overview of the individuals experiences in relation to how they have shaped their present existence and any impact on how they have subsequently adapted in their responses to a previously hostile view of their own waking reality; a key feature in addiction. Simply put, “Are notions of such positive terms as fulfilment, purposefulness, optimism, actualisation, well-being and self-acceptance, available to the individuals’ discourse now they have recovered from active addiction and have subsequently (and perhaps significantly) rebuilt their lives and remain completely abstinent? It is suggested that any prevalence of these factors may give an insight into the beliefs, identity and perhaps most importantly any meaning within the recovered phenomenon.

Methodology

• Participant

One individual was selected for case study interview due to a secondary relationship with researcher - hereafter, known as ‘Simon’ (name changed for protection of anonymity). Participant identified as age 42. Individual identified himself as a recovered alcoholic and substance user and considered his current lifestyle to be non-problematic, purposeful and ‘flourishing’ (Keyes and Haidt, 2002)

• Semi-structured interview

The interview began with the question, “Tell me about your history of drug use”, and was then led almost entirely by the respondent. The interviewer had recourse to prompts and relevant probes which were left as basic cues; though some allowance was made for instinctive probes to manifest spontaneously to further explore the expansive nature of recall and explorational thought. With regard to current identity the key area of emotive dialogue; which were considered paramount, an initial question relating to the phrase ‘How did you feel...” was rejected at the design stage as it merely expanded on the previous (first) question. However, the respondent appeared to fully illustrate key emotions with no prompts. Secondly, it was important to ascertain the individual’s view of their current and prospective ‘world-view’ in order to identify any ‘actualised’ notions or so-called views of positive self-regard. This was illustrated by a question relating to regrets and benefits of all life experiences through hindsight.

Consent was obtained using a replica of The University of East London’s standard consent form (See appendix F). The respondent was informed of the anonymous nature of the research and of their right to withdraw their participation at any stage. Respondent was provided with contact details should they wish to withdraw their participation at a later date, however, this has not manifested.

• Materials

Materials used for the interview were a portable tape recorder, a script for the researcher that included the structured questions and the relevant consent form. The interview was carried out in the home of the respondent at a time and date allotted as convenient for both parties.

• Analytical Procedure

Prior to analysis the formulation of the initial questions and the primary transcription of the recorded interview were conducted by secondary researchers involved in the project. The interview was then conducted by the primary author (I). Acknowledgement is given to the contributory researchers for their participation.

(1) I (first author) read and reread the transcript, and produced a series of first order themes in the left-hand margin upon initial reading. These initial themes were aimed at summarizing and describing in basic terms, attitudes, concerns and experiences of the interviewee. This was conducted using terms perhaps apparent in the actual transcript. (See appendix A)

(2) The second margin on the right-hand side of the text was utilised to produce a secondary set of subordinate themes. These themes were set to capture some of the more defined terminology and more scientific and theoretically related notions that were either apparent or inferred from the dialogue; the process here begins to become significantly interpretive from the researchers standpoint. (See appendix B)

(3) The third stage of analysis consists of collating an initial list of themes (superordinate) that appeared to exist in either a repetitive nature or in as much as they related to the overall theme of the research project per se. (See appendix C)

(4) Here a list of master themes are collated as a list of separate ‘categories’, and titled areas of interest were created to endeavour to begin to bring a deeper interpretation of the text. These themes were defined through the processes concomitant within the interpretive mores of IPA. (See appendix D)

(5) A list of clustered themes was then incorporated to form a table. These included line number, illustrative points and a cross-reference to the text (e.g. Line 2.24 = page 2, line 24). These were then given relevant overall ‘headings’ which summarized areas of relevance to the research project. Here some themes were considered and some were omitted as there content was more appropriately illustrated in other already present terminology. (See Appendix E)

Results and Discussion

A general discussion of the two main themes now follows. This will involve a descriptive analysis of the text that uses key terms from the transcript to illustrate a ‘before and after’ view of the individuals’ self-identity, beliefs, emotional states, and terms that give an exploratory indication of the mind-set of the recovered addict.

There are three sub-themes illustrating key features of the individuals’ worldview:

• Emotional Territory
• Belief Extremities and Identity Biases
• Active Addictions (The Drugs Don’t Work)

Emotional territory: Initially at the design stage it was deemed appropriate to reject a question that related to feelings/emotions as it was considered appropriate to let Simon explore this realm himself - It was suggested that this would give a more illustrative view of the notions of self-identity and depth of belief, with a much wider breadth through an emotional engagement with the interview process. Also here, this may perhaps illicit a sense of what Mihalyi Csikszentmihalyi (2002) termed ‘Flow’ within Simon’s personal recall and reflection. Ultimately Simon was emotionally available to his past, his present and in his hopes for the future; so much so that during the final analysis this theme of emotional territory was deemed paramount - both in terms of past/present expression, but also in illustrating how he felt his way through his reality today. Indeed, it is under this heading that he was able to express not only a significant understanding (through hindsight) of his feelings of isolation and emotive dissonance prior to any substance misuse whatsoever – fear, anxiety, shame etc, but perhaps even more pertinent were the notions of him being unable to describe the wonder and awe of his emotional states in recovery – ‘freedom’ was a key repetitive term and one which appeared three times over two sentences within a portion of the text. This perhaps illustrates that Simon had entered a stage of the interview process which elicited feelings that were indescribably profound. It is the emphatic nature of these beliefs and the depth of tone of expression that suggest insight into how Simon viewed his life as a recovered alcoholic and substance user.

Simon. “Erm…? The experiences that I’ve, yeah, the experience of having the disease of alcoholism and addiction has allowed me to… …taken me to my needs. And they’ve allowed me to sum up my life in detail through the work I’ve done and… Freed me, freed me from my life. Freed me from blame”.

Simon was able to express with considerable emphasis a notion and depth of freedom that he had achieved by taking responsibility for some aspects of his recovery from addiction (…the work I’ve done) is indicative of an individual who has used past experiences to gain a fuller sense of self-actualising and fulfilment. Again, Simon perhaps gave an indication of what Maslow (1958) described as ‘peak-experience’, ‘It (addiction) has also given me a life beyond my wildest dreams (laughs)’. It is during these reflective accounts of his current states that I experienced a sense of the presence of excitation, a glimpse of positive self-regard, awe and a childlike pleasure during certain portions of the interview. This is most evident when Simon actually struggles to describes how deeply happy he is. Perhaps this suggests the inclusion of some of the notions prevalent within a positive psychological worldview. For example, courage, optimism, honesty, perseverance, realism, putting troubles into perspective and finding purpose are all themes in positive psychology that when re-read are themes that consistently elude an individual trapped in a cycle of substance abuse, however, they seem apparent in the framework and perspectives of Simons current worldview, Also, these are not overly predominant themes within a-typical ‘recovering’ circles that suggest an approach more dependent upon support-group and therapeutic principles.

Simon. “My life’s never been better and the relationships I’ve got with people have never been better. Ya’ know? And if it was describable how I felt I’d be able to describe it but it’s indescribable ya’ know? It’s about as indescribable as me telling you how I felt when I was high”

Belief extremities and identity biases: The heading words ‘extremities’ and ‘biases’ were deemed relevant on the basis that feelings, thoughts, perspectives and value systems were all reported at acute levels, e.g. fear, anxiety, paranoia versus altruism, positive self-regard, self-acceptance etc. Clearly, upon a return to states of well-being an individual’s value systems are apt to require some type of overhaul or at least surveying for disparate themes. An integral function of the12 Step program is what founding member William Silkworth termed, ‘the necessary psychic change to bring about recovery from alcoholism’ (1939). This suggests that a whole new set of beliefs may need to be taken on board in order to recreate the social, familial and personal standing of an individual. Therefore, it is perhaps not surprising that Simon has radically juxtaposing themes that are the antithesis of each other from both a positive and negative viewpoint; also these appear prevalent during the negative world of active addiction and latterly in a positive light as a consequence of continual practice of the A.A. twelve steps as a design for his new life (specifically utilising the recovered phenomena). To illustrate; from the outset of the first question relating to a chronology of events, he began to express an inability to accept himself as he was; poor emotional processing, extreme mood highs and lows, and the reporting of his lack of both interpersonal and intrapersonal skills (though interestingly not personal skills). These were all reported as factors underlying why he eventually continued to misuse substances, though were not reported as factors in why he believed he began to initially misuse substances – early, mid and late teenage experimentation is considered commonplace with experimentation fading somewhere between ages 22 to 32. The term misuse clearly suggests extremity. However, in his report of his post-addiction self-beliefs and identity, he reported notions of character which happily consisted of acts of altruism, a desire to enable other addicts to become ‘free’, and concepts such as selflessness, joy and love

Simon. “…about the age of eight I can remember being full of fear, stomach problems, being taken to the doctors, being tested. It was just like a hole in my stomach with anxiety and nerves, very very emotional, very easy to cry. I seemed to have lots of highs and lows. I was either very happy and manic or very…er… (pause)…just easily upset because of the high levels of fear…”

Also within belief extremities and identity biases we may also gain insight into some of the factors that individuals who consider themselves to have recovered from the condition of substance misuse have in place; themes such as altruism, an experiential worldview, specific spiritual beliefs/mores, not conforming to populist opinion in social or worldview contexts, all illustrate themes both fundamental in humanistic and positive psychology principles per se. That these themes are not always prevalent in studies of Minnesota models of the 12 Steps is perhaps an indication of some failings within the more therapeutic, ‘illness’ orientated dystopian model’s of recovery. Certainly this is apparent in the study conducted by Larkin and Griffiths which again demonstrated a reliance on the more deterministic elements of the addiction theme; low self-worth, self-loathing, perfectionism, extraversion. The description by Simon of himself as both a ‘realist’ and the notion of a representation of himself as a holistic entity (“Mind, body and spirit…”) are particularly indicative of an individual living within belief parameters that seem to manifest as healthy, fully-actualised and wholly functional behaviours and characteristics, and they exemplify notions of self-acceptance, well-being and positive agenda. These are themes that have long since been suggested within psychology to be the endgame of a human animal’s mental wealth and a healthy existence.

Active addictions (the drugs don’t work). Here we look at the interchangeable values, moral codes and behavioural cut-off points for the active addict – what appear to be common manifestations of previously grossly termed ‘addictive personality traits’ (Carlson, Buskit, Martin, 2004). Simon states a number of times through the text that using substances was, “Just what I did” and that “I had to do it. I had no choice”. These notions were themed under the banner headings of ‘abdication of agency’, ‘abdication of personality’ and abdication of responsibility’, i.e. for substance misuse. Simon identified that his physical body also declined over a period of time and that his abject behaviour and its consequences rose incrementally with the prevalence of episodic experiences (blackouts) also on the increase prior to his subsequent abstinence.

Simon. “Blackout is… For me its defined where in get to the point where the lights are on, the doors are open, but I don’t know what’s going on and I’ll wake up in the house and I won’t remember driving home, how I got home, who I came home with and where I went after a certain point in the night. Where I was just gone on blackout, autopilot or whatever it was…”

These are experiences consistent with most reports within the realm of substance misuse. The use of the term ‘normalisation of role’ and ‘habituation of substance misuse’ illustrate themes that perhaps go some way to informing his latter joy and expressed sense of freedom and acceptance, of not just his self, but of an individual living within the realms of an experiential, reflective worldview. Here perhaps is scant evidence that can be gleaned in regard to the concept of the phenomena of the recovered alcoholic or addict; though perhaps indicative is that when probed on when the point one recovered would become known to an individual the term was reported as something that one, ‘(I) Just knew…’

Conclusion

This research acknowledges that there are clear limitations of using a singular case study to give an overview of an entire phenomenon. Consequent research would perhaps benefit from focusing solely on the themes of positive attributes and concepts, these that clearly elude an individual in the throws of the much documented ‘illness’ models of active addiction and recovery; notions such as positive feelings, transcendence, optimism, virtues (Seligman, 2002). It is suggested that further research into post-addictive positive agendas may broaden the scope of background research within the fields of counselling, clinical and positive psychology per se. However, as IPA uses a reflexive approach to data, the position of the researcher may affect the non-linear nature of the process. However, as IPA uses a reflexive approach to data, the position of the researcher may reflect how the non-linear nature of the process includes and ‘endemic bias’ that must be factored in to IPA. For example; opinion, experience, interpretation, rapport with the participant, are notions which carry with them their own unique dynamics, these that clearly must be acknowledged.

Clearly there is some validity to the suggestion that this foundational 12 step program offers an approach to this method of recovery that when fully applied has a highly valid in terms of efficacy. Limitations aside the respondent illustrated a potential capacity and outlook toward life that may be valid across the primary body of culture per se, and in that regard perhaps there is some suggestion that it may be time for some 12 step cultures to have a rethink.

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