The Phenomenology of Addiction & Recovery (fancy title, straightforward article)

Why do some people need to hit rock bottom before they find recovery? Why does AA work for some, SMART for others? Why do some need years of on and off treatment, while others simply walk away from addiction, going cold turkey, almost on a whim? Particularly intriguing, why is your therapist MORE important than the program you attend?

There has been a growing understanding that there isn’t a one-size-fits-all approach to effective treatment. We also hear more and more about evidence-based treatment. Yet, despite decades of effort, addiction in the US has become a bigger problem rather than a smaller one, at least looking at data like overdose deaths.?

What determines this large variance in outcomes and why do we seem to have such a hard time moving the needle on addiction overall even though the number of providers has exploded over the past 5-10 years?

There are really two primary determinants in effective treatment that all research supports, and this goes for mental health in general as well as addiction specifically.

1. Length of time in treatment
2. Therapeutic alliance (Therapist-Client rapport)

What’s the connection between those two factors? And we’ll notice that modality, or what’s generally referred to as evidence-based treatment, is not present in either. In fact, the research on therapeutic alliance specifically indicates that this relates to positive treatment outcomes regardless of modality used!

The Missing Link in Effective Treatment

The key to this puzzle is understanding that addiction and recovery are highly subjective experiences (hence the use of the word phenomenology in the title of this article). An individual’s outlook as it regards their connection to a particular substance or behavior, in addition to any external pressures influencing that view, is the primary factor that will drive behavioral change.

Let’s start with an interesting experiment involving vodka and tonic, then take a look at the world of educational research and its often overlooked implications for behavioral health.?

In an experiment by Demming, Reid, and Marlatt that goes way back to 1973, they tested the idea of whether or not the drug itself, in this case alcohol, drove abusive use. What they did is created a vodka and tonic drink that masked the taste of alcohol. They then set up a quadruple blind study to determine effects.

What happened in this experiment is that they found alcoholics who were told they were receiving alcohol, even if they weren’t, started to act drunk and drink more. On the reverse side, those we were told they weren’t receiving alcohol, but did, saw no change in behavior in terms of either drunkenness or desire to imbibe more. This study has been replicated over and over again in subsequent decades with similar results.

What this shows us is that subjective expectation is far more important than the actual substance involved. If you believe you will get drunk and, as we’ll see later on, if you believe you need to drink more, you will, regardless of whether or not the drink contains alcohol. Expectation, subjective belief, is more important than any substance used.?

You may have experienced similar situations. Have you ever taken a drink of alcohol and started to feel buzzed, even though you couldn’t possibly have drunk enough to have a physical effect yet? Or, what about being accused of drinking or using when you weren’t. Suddenly, you start to act funny and it seems harder to put words together right even though you’re completely sober. Somehow, someone simply accusing you of drinking or using can start to trigger a response as if you had been using.

The World of Education Meets Behavioral Health

In the education world, the work of Carol Dweck is incredibly well-known and famous. Most readers will be familiar with the comparison between a fixed mindset and growth mindset, or the term “self-fulfilling prophecy”.

What she found was that, for those children who believed that such traits as intelligence were innate, they tended to do poorly over the long-term vs. those children that believed hard work led to growth. Much of Dweck’s work centered around how children were praised and what kind of internal beliefs this created (this will be very important to us shortly).

When children believe that intelligence is fixed, they define themselves by results and also tend to give up faster when it comes to difficult problems. A good grade, for example, is simply reinforcement that they’re innately smart. A bad grade or a problem they can’t solve tells them the opposite, that they aren’t that smart. Since they believe their intelligence to be innate, bad grades lead to the idea that they’re not intelligent. For difficult problems, they simply give up because they believe that, innately, they aren’t intelligent enough to solve them.

For those with a growth mindset though, this works much differently. Their self-worth or identity as intelligent or not is not defined by grades and outward praise, but by the results they achieve through focused effort. They believe they can become better. So when they fail at a problem, they simply look for other ways to solve it or work at it until they do.

In a much broader sense, if a child believes in innate qualities, such as intelligence, they will believe they are whatever people tell them combined with what they feel themselves to be whether this is stupid, “trouble,” a “problem child,” angry, rude, etc. Those with a growth mindset understand both their behavior and abilities to be malleable, so they will work to change things they don’t like about themselves or to be seen better in the eyes of others.

The conclusion of Dweck’s work was that the growth mindset is not only the accurate one from a neurological standpoint, but the one that will help individuals succeed most in life. From a neurological standpoint, our brains are plastic, they are always building and changing. It’s pretty common sense. We’ve seen others or ourselves learn to be less shy, learn to be less angry, learn to become a better soccer player or a better writer or a better leader. People’s abilities, and the behaviors surrounding them, can change quite often, but only, as Dweck’s research indicates, if they believe they can.?

Most of our ideas about ourselves are self-fulfilling. Where does this fit into behavioral health? It should be pretty obvious here. If you believe, “once an addict, always an addict,” you will act accordingly, as our patients did in the vodka and tonic experiment. In fact, as research indicates, one of the largest predictors of relapse is the belief that addiction is innate and unchangeable. If you believe you can’t have just one drink, you will self-fulfill that prophecy and drink or use heavily to the point of going on extended “benders.” But, for those who don’t believe that this is the case, they will stop themselves before going too far, in the case of those committed to abstinence, or they will learn to moderate their drinking and use down.

When we assign fixed labels to people, and people believe and internalize these labels, such as “alcoholic,” “addict,” “liar,” or “manipulator,” they lock themselves into a fixed mindset. They act according to those beliefs and, like Dweck’s students, give up on trying to change or to work through difficult situations.

The Effect of Others on Our Perceptions of Self

As we saw with the students in Dweck’s studies, other’s opinions and beliefs regarding ourselves tend to have a very large effect on our overall self-perception. Students that have parents and teachers praising them for “being smart,” begin to believe they are smart and that’s an innate quality. Those praised for effort, find value and meaning in the process of learning and growth. This is particularly true if this message comes from people in authority that we respect or think are more knowledgeable than ourselves, those close to us, or from many people vs. a few.

In leadership circles, we like to talk about the fact that you are the five people you spend the most time with. And this largely turns out to be true. Are you more likely to do drugs if your five closest friends all use or if they’re all on the drama team instead? Pretty obvious there.?

This is seen just as clearly in linguistics. We take on the accents of the places we are, especially if we’re young, but adults do it too. In fact, a common problem among English teachers when I lived abroad is that incorrect constructions of English sentences would start to sound normal and teachers would even catch themselves saying things incorrectly themselves! As I’ve written about before, most habitual behaviors and ingrained learned processes, such as language, are learned unconsciously through consistent exposure, so what’s normal linguistically is what we’re used to hearing. Habits, beliefs, and behaviors are often learned unconsciously in the same way.

This was even the goal of many older or more traditional forms of treatment. If they could just convince and browbeat the patient into understanding they were an addict, if they could break through the “denial” and get them to internalize that identity, the belief went that this would then start them on the road to recovery. Sometimes it even worked.

This is the same mechanism being used in AA where each person must repeat that “My name is ____ and I’m an alcoholic” every meeting. The goal is to internalize that identity to ideally foster a change in behavior.

Denial itself is simply the conflict between the subjective view of those around the individual vs. the individual struggling with addiction’s subjective view of him or herself.?

Through this mechanism of the influence of others, one begins to form an identity of “a person in recovery.” By constantly going to AA or other support group meetings, we surround ourselves with others focused on sobriety and other purposeful activities in life that don’t involve drinking or drug use. Again, we are the sum of the five people we spend the most time with. As we start to change our self-perception, we change our actions, and are also likely to change our environment/social networks.

Changing Our Identities Often Takes Time

When was the last time you met someone that converted religion or political party overnight? Doesn’t happen often, if ever, does it? Any time a belief has gotten deep enough to be part of one’s identity, change usually takes a long, long time.

And there are many identities that go into abusive use of drugs or alcohol - “I’m a more social person when I use”, “I can’t stand myself or my thoughts when I’m not using”, “using helps me fit in with my friend group or my family”.?

Because changing beliefs about self isn’t easy and, especially, changing those around us is not easy, this change can take a ton of time. This is why length of connection to treatment correlates strongly with positive outcomes. If I’m only in treatment a short time, I’m unlikely to change my opinions of myself. If I join a support group and leave after a month, this is not enough time for those people’s opinions to rub off on me, for me to internalize a new sense of self and way of behaving.?

This is also why length of treatment is not necessarily connected to type of treatment. I could be in a 12-step program or an alternative to 12-step program. I could be in a program solely composed of reiki, acupuncture, and equine therapy. The most important piece is my buy-in to that program and if I believe it’ll work for me. And, sometimes, regardless of our beliefs going in, if I’m in long enough and surrounded by enough people thinking along the same lines, I’m probably likely to eventually take on the beliefs and ideas of those around me.

The problem here is that that old idea of self still exists, the one as a user or an addict. So, once I go home and am connected to friends, family, or environment where use is common, it’s very easy to re-adopt those old beliefs and behaviors. It’s one reason why extended use of support groups is so important post-treatment (again connecting length of involvement with treatment being the key factor regardless of type of support group).

The Power of Subjective Experience and Group Think:?Is It Real?

One of the most fascinating aspects of belief and behavior is that, in many contexts, reality is what we make it to be. Over one third of the entire US population believes that there was some kind of government conspiracy involved in 9/11. Much like JFK conspiracies, people will take this belief in stride if they hear it from someone they know due to the sheer amount of people that believe it.?

But, if, on the other hand, your neighbor told you there was a government conspiracy to listen to your thoughts using commercial jets flying overhead, you’d think they were crazy.?

In the same sense, a small group of UFO believers would be deemed cultish as it’s outside the mainstream. One’s subjective reality doesn’t make something true, even if one-third of the US population believes it.?

Yet, this is the argument often used by individuals promoting various treatment modalities. “It worked for me and it works for those around me, so it must be the right way”, is how the thinking goes. So our point here is two-fold: one’s subjective reality is very very real to that person, but not necessarily accurate in an objective sense.

I recently was involved in an online discussion where a treatment professional stated that alcoholics have an allergy to alcohol, a theory of alcoholism popularized in the Big Book. Her argument was that everyone she met in the rooms related to an immediate and unusually intense liking for alcohol.?

Of course, this idea was debunked more than 50 years ago as we linked to in our quadruple blind studies above, but it’s the kind of situation that illustrates our point, people buy into their subjective experience, and their own interpretations of it, more than to well-established research. Just as importantly, group reinforcement of an idea makes it more real.

The lesson to be learned here is NOT that people can be fooled, but that understanding the power of an individual’s own beliefs on their behavior, and the power of like-minded individuals to influence behaviors and thoughts of others, is critical to understanding how treatment can be effective in creating behavioral change, irrespective of modality.

So, in our example of the professional believing in an allergy to alcohol, the most effective ongoing treatment approach would be to work with that belief and use it to therapeutic advantage rather than try to convince them otherwise, at least at the onset of treatment.

And this is exactly what we see in treatment. At Above and Beyond, a non-profit providing free behavioral health to the homeless and disadvantaged on Chicago’s west side (and of which I’m on the board), we offer multiple treatment modalities and support groups, including AA and SMART. We find clients that identify better with one or the other and their outcomes are positively influenced by us providing the option that works best for them rather than forcing them into the option we think is “best”.

The bottom line is that, just because a method works for you or you believe in a particular method, doesn’t mean that it will work for the person struggling with addiction sitting across from you.?

What Makes People Likely to Change?

As Daniel Pink and so many others have clearly shown regarding research on motivation, we only change when we want to. Sometimes external pressure by others can motivate us to change if we trust and respect those individuals, but research is clear that this is rarely the case. Much more important is internal, or intrinsic, motivation.

Think about when someone does an intervention. Who do they work to connect with the most? They identify the person in the family that has the closest relationship to the individual struggling with addiction, the person, therefore, most likely to have influence with that individual. Let’s say, for example, a mother to her son.

That relationship is extremely important to the son, let’s say. For that reason, we have an internal motivation to change - the motivation to maintain the close relationship with mom. Mom may be exerting external pressure, but it’s really the internal motivation that drives the decision to get into treatment. This may also line up with an individual’s own nascent motivations to change for other reasons.?

Going further, interventions will often use prescribed formats, such as the mother telling the son how they used to view them, and how they view them now. If the son’s view of himself is still closer to the earlier version, this creates cognitive dissonance. There is a subjective disconnect between who the son feels himself to be and how someone very important in his life is viewing him. This identity conflict also drives internal motivation for change.

We see the same factors at play in the therapeutic alliance, the relationship between the therapist and the client. If rapport is strong and the client grows to trust and respect the therapist, they will start to believe what they say, creating an internal motivation for behavioral change. It’s not dissimilar to the placebo effect where belief drives positive outcomes. However, in the case of the positive effects of therapeutic rapport, we see stronger outcomes than what we’d see from merely a placebo effect.

Similar to our look at the research on a growth mindset, the client will start to believe recovery is possible for them by using the methods the therapist outlines. It doesn’t matter if that method is 12-step, MAT, CBT, DBT, etc. The primary factor is not, in fact, the modality, but the subjective belief that they can change coupled with the motivation to do so.

Hitting Bottom - Why It Makes Sense Now

Within the context of traditional 12-step and AA, there was often this assumption that an individual had to hit bottom. They had to reach the lowest point for them psychologically before being ready to change. Why is that?

Those struggling with addiction very often have specific beliefs such as fierce independence (or at least an unwillingness to rely on others), issues with authority, low self-esteem, etc. Connecting to the idea of denial, or more accurately understood as differences in subjective perception, the person struggling with addiction is not willing to listen to the advice of others. In fact, if coming from the perspective of someone trying to force their own ideas and judgments onto them, they work harder to actively resist that person.

So individuals in these situations will keep living life until it’s gotten so bad that they completely give up, they see no internal resources capable of solving their problem, so they finally turn to others. By this stage, they’re so broken and so unsure of themselves that they’re willing to adopt, wholesale, a completely different set of beliefs and behaviors.

12-step programs have traditionally been very top-down, a do-and-believe-what-I-tell-you approach that can rub people the wrong way. It’s often not until they’ve lost almost everything that they’re willing to adopt a whole new set of beliefs and conception of self imposed by others in short order.

12-steps, Faith, Cold Turkey, and the Crossover of Pre-existing Identities

12-steps are also largely driven by faith. While possible, it’s very rare to meet someone in recovery that uses 12-step programs not to reference the Grace of God in relation to their recovery.?

As we’ll explore shortly, one way to not have to hit bottom, is to find internal identity or motivating factors that are pre-existing, as a new route for belief and behavior. This makes sense neurologically as the pathway in the brain is pre-existing, it’s already been built. Rather than having to go through the extensive effort of building an entirely new pathway and then the additional effort of connecting old pathways to it, you simply have to reroute existing access routes to a new primary pathway.

Faith is one great example of this. Most individuals in the US grow up either in a Christian household or, at least, with a strong familiarity with Christianity. So when they walk into a 12-step program talking about surrendering to God or a Higher Power, that belief system already exists. All they have to do is take the access routes in the brain that were pointing to the use/addiction pathway, and connect them to the pre-existing faith pathway.?

The same exact thing happens for secular individuals within a SMART program. They already have a strong belief in self-efficacy or rational behavioral change, so it doesn’t take much to reroute those pathways to what else is already there.?

We see the same thing happen with those who simply quit cold turkey one day out of the blue. Let’s take the example of a mother who strongly believes in the importance of being a mother to her children, of taking care of them. One day, she wakes up from a drunken night and finds her child barely breathing on the bathroom floor after having swallowed a toy and partially blocking their windpipe.?

That mother may very likely, that day, quit drinking for good. Now, every time she thinks about drinking, her brain will immediately connect to her prebuilt belief and identity in the importance of being a mom and protecting her children rather than use. But that pathway was already there. There was no need to take the 3 to 12 months needed to build up a new neural pathway in the brain. All she had to do was reroute a connection through an intense episodic event, which is a normal brain function (think about what you were doing on 9/11. You’ll never forget that day. That’s episodic memory and connection building. Now try to remember what you did 3 birthdays ago. Probably can’t. Regular memory doesn’t work the same as episodic).

Connecting to One’s Own Motivations

All of the above is why Motivational Interviewing is a tried and true evidence-based technique. Rather than trying to manufacture external rewards or punishments to motivate change, you identify values, beliefs, purpose, and identities that already exist within the individual and help them make a transition from where they are to where they want to go.

This might (and usually does) start off with an external motivator of sorts. Their spouse is threatening divorce, they’re about to get fired, they’re court-ordered and don’t want to go back to jail. But within all of those is an internal motivator. They love their spouse, they want to keep their job, they want to live life outside jail.

From there, the therapist can bridge from immediate goals to uncovering deeper beliefs and identities. If being a good husband/wife is a strong part of that person’s identity, that would provide the internal motivator to turn away from addiction. If that’s the case, the therapist can use the patient’s buy-in to then teach the coping or communication skills that may be missing, preventing them from embracing that path.?

Whatever the situation, the best therapists don’t impose goals on the patient, but work to uncover the patient’s own goals and then provide the supportive steps to getting there that likely don’t involve heavy substance use or other compulsive behaviors that are causing problems.?This is all doubly true if one is working with adolescents.

Our entire discussion comes together here. Internal motivation is much more important for behavioral change than external, it’s much easier to shift behaviors and beliefs to pre-existing neural pathways over making new ones, and the patients’ subjective view of themselves as someone capable of finding recovery are all essential for success.

Practically Applying a Phenomenology of Addiction and Recovery

One of the greatest challenges with research and data is making it applicable in a clinical setting. Luckily, this is not the case here as very clear guidelines for effective treatment arise out of a phenomenological understanding of the patient’s own view on their addiction and recovery.

Here are the factors to keep in mind when building out any program or patient treatment plan.

• The belief that recovery is possible, and that one can effectively change, is one of the single most important factors in determining positive treatment outcomes. This could be the belief that surrendering yourself to God allows one to change, or that one has the internal resources to affect change themselves. Either way, you must believe it’s possible and that belief is more important as a foundation than any specific actions one takes.
• A belief in recovery will largely determine what successful recovery looks like, most prophecies are self-fulfilling. If you believe touching a drink will initiate a complete loss of control and spiral down into a bender of indeterminate length, then it will. If you believe you have internal resources to stop and change your behavior once started, then you will as well. This goes for simple behaviors to as far as achieving long-term recovery. Those that believe “once an addict, always an addict” will fulfill their own prophecy, whereas those that believe total recovery is possible are the ones most likely to return to moderate use or stay abstinent but not spend time worrying about their recovery a day at a time. Both work and one isn’t better than the other. It’s finding the belief that works for the individual that’s important.
• The therapist must understand what motivates the patient and use those internal motivations to help the patient analyze other thoughts and behaviors. The key here, and this is difficult for many therapists, is that they can’t impose their worldview or pre-formed judgments on the patient. They can help the patient examine different angles of thoughts, behaviors, and lived experience, but it’s ultimately determining what the patient wants that is the key to helping them improve their lives.
• An individual must want to change. However, there are many ways a therapist, friend, or family member can help an individual arrive at a desire to change. They definitely don’t have to hit rock bottom first.
• Identify what core identities are most important to the patient. There is often a conflict between themselves as someone abusing or addicted to a substance/behavior and who they think they are or who they want to be. Finding core motivations and core identities allows for the least time and energy-intensive shift in building new neural pathways or networks in the brain, so, is therefore most likely to see the quickest results.
• Changing behavior and identity is often a long-term process that requires the support of others. If that support cannot be found within current family and friend circles, then ongoing attendance and support groups is strongly recommended. However, just as effective is hanging with a group of, for example, sports enthusiasts. The keys are community, meaning, and purpose that doesn’t involve abusive use or the compulsive behavior.

As a final caveat to all of this, I want to emphasize that evidence-based treatment is still incredibly important. Just because two large factors in positive outcomes for recovery evidence efficacy unrelated to modality does NOT mean that incorporating evidence-based practice isn’t additionally beneficial. It certainly is.?

Really effective treatment simply understands the importance of recognizing the prominence of engaging with an individual’s subjective reality to initiate effective treatment. Once that’s established, then evidence-based modalities should be brought into play for best outcomes.

In the end, why are there multiple pathways to recovery and why do different methods work for different people? It’s because the individuals’ subjective view of addiction, recovery, and themselves is one of, if not the, most important factor when identifying the most successful pathway to recovery for a particular person.

Nick Jaworski is the owner of Circle Social Inc, a growth consulting & marketing agency that helps recovery centers and other healthcare organizations connect with patients and their communities to grow their census. He is also an advocate for a more human-centered, individualized and evidence-based approach to addiction treatment due to having gone through his own addiction issues as a youth. When he's not online, he can be found spending time with his favorite person in the whole world, his daughter.