Three months ago, I accepted a new position as Director of the Center for Rehabilitation and Recovery at the Coalition of Behavioral Health Agencies. During the interview process, I was asked about my understanding of mental health recovery as it related to addiction recovery (an appropriate question, since I was then working for a large drug treatment organization). I was very interested in the job, and wanted to show my interviewers that I had a strong recovery orientation, and that my knowledge of substance abuse would be applicable to the mental health world. So, I talked about the many similarities between these two kinds of recoveries.
I must have demonstrated an appropriate understanding because I landed the job. And since I’ve started, I’ve been asked this same question many more times. How is mental health recovery different from addiction recovery? Are they the same thing? Now my answer is a little different. Now I say, “it’s complicated.”
A good place to start looking at this issue is to focus on the problems themselves. Both addiction and mental illness are brain diseases that affect behavior, attitudes, moods, and cognition alike. Both are profoundly stigmatized and those who struggle with these issues too often deal simultaneously with social isolation, poverty, family estrangement, unemployment, and a loss of social status both at home and in the community. Many end up treated more like children than adults – people unable to make their own decisions or have control of their fate. Recovery represents a stark contrast to this reality.
Recovery is a multi-purpose word. There is economic recovery, post-disaster recovery, and of course, recovery from illness. When we talk about recovery in a health context, we are referring to an acute condition – a bout of pneumonia or a broken leg. In these cases, we are talking about a return to a state of good health following illness or injury. When we want to apply this same idea to a chronic condition, we opt for words like “remission” or just “has it under control.”
To recover can also be a verb, and it is in this sense that it may be more applicable to behavioral health situations. To recover can mean to get something back that was lost – such as when we recover stolen property. So from the perspective of mental illness or addiction, recovery can refer to getting your life back, living a post-diagnosis life beyond the narrow confines of the illness.
There are many overlapping features in mental health and addiction recovery – SAMHSA actually lays out 10. Leading the charge is hope – the idea that tomorrow may bring something better. And there is empowerment – feeling like you have the agency to make your own decisions, to be in control of where you are headed, and to take a stand when you don’t like where things are going.
Recovery recognizes that people are multi-faceted. The symptoms of the illness are only one part of the picture. There are strengths, interests, and priorities. So the person with schizophrenia may also be a first-rate writer or a music lover, have a close relationship with family, or be a valued employee. And the person who has struggled with alcohol in the past may now be a drug treatment counselor, church member, or community advocate. The symptoms and the illness are a part of the person, but not the entirety.
Treatment can be a starting point for recovery, but it is not the end. The behavioral health system has developed a sophisticated continuum of care that includes intense episodic residential services at one end, and ongoing community-based recovery services at the other. In the addiction world, there are 12-step programs, faith-based groups, recovery coaches, and recovery centers. In mental health, there are clubhouses, advocacy programs, supported employment and housing options.
This carries its own problems. Some professionals think that true recovery means that you fully integrate with the general population, and leave that community behind. But we know that recovery communities are vital resources – most people in recovery find it comforting to be with others at least periodically who share similar experiences and concerns.
Recovery is clearly an evolving process, often lifelong. It is not a straight line, but like life, has its ups and downs. And it is individualized – no one person shares the same recovery story as another.
So are mental health and addiction recovery the same thing? No – there are still some very clear differences.
Probably the most obvious distinction between the two is that in the addiction world, “recovery” is used as a synonym for abstinence, almost like saying “I’m on the wagon.” Some people even start using this word as soon as their immediate withdrawal symptoms begin to wane – “early recovery,” they state, alluding to the fact they are trying to stay clean but their head may still be a little cloudy, their decision making poor, and their relapse vulnerability high.
The connection between recovery and abstinence has become more complicated as the drug treatment world has increasingly acknowledged the vital role of medications to support treatment. So people might say they are “in recovery” when they are taking methadone or suboxone as treatment options. Or they may use psychotropic medications to manage co-occurring disorders.
While the general public might substitute “recovery” for sobriety, drug treatment professionals are more expansive in their definition. They recognize that sobriety is far from permanent, and it doesn’t embody the true spirit of recovery. For most addiction professionals, the goal is a recovery that incorporates personal values, attitudes, and behaviors that leave no room for drug or alcohol use. A person who embraces honesty and healthy problem solving, for example, is not likely to turn to substances when the going gets tough.
While addiction recovery is not synonymous with abstinence, it is inclusive of it. Traditionally, people cannot be considered “in recovery” if they continue to drink or use drugs.
So unlike those in mental health recovery, people transitioning to addiction recovery have to make a conscious decision to stop using in order to regain control over their own lives (even those who are court-mandated to treatment). The very first step of recovery is itself an act of recovery.
Finally, it is important to note that we expect a person in addiction recovery to no longer show any signs of that illness, although internally they may remain vigilant against possible relapse. Our recovery role models tend to be those who have re-integrated into society fully, and are indistinguishable from the rest of the population. In fact, if we were told that the person used to have a drug problem, we would be surprised. After all, they would show no outward signs of those past behaviors or ways of thinking.
When we talk about mental health recovery, we are looking at a whole other kettle of fish. In mental health recovery, we are not looking so much at a remission of symptoms, as an equation that reads “past life” + “diagnosis” = “new, improved, fulfilling life.” (That said, it is important to acknowledge that there has been extensive longitudinal research documenting that for somewhere between one-quarter to two-thirds of people, there is a total remission or substantial improvement of symptoms.)
In mental health recovery, it is about a person moving forward with his or her life despite the diagnosis and the illness. People who are in mental health recovery have found ways to regain control of their lives. They work and have hobbies. They participate in their communities. They have family and friends. They have their own priorities.
Some of the underlying thinking about mental health recovery is borrowed from the disability movement. We know that someone who has become a paraplegic as
a result of an auto accident is not expected to recover the use of his legs before he is able to move forward with his life. Instead, we expect that person to integrate the new disability reality into his approach to life, and go on. People in wheelchairs work, get married, travel, volunteer, exercise, and in all other ways contribute to society. Their disabilities are woven into the fiber of their beings. But we do not expect, nor wait, for a remission of symptoms. Similarly, those in mental health recovery do not need to wait for their symptoms to magically disappear. There is no reason they cannot move forward in life.
Another difference between mental health and addiction recovery is advocacy. Unlike addiction recovery, the mental health recovery community has included a well-developed advocacy movement, formed by both individuals in recovery and their loved ones. They routinely demand their place at the table, speak out for their rights, and insist that their experiences be recognized. And in so doing, they are ensuring that their needs and concerns are respected. (The addiction system is starting now to develop its own advocacy moment). So the next time I am asked that question about mental health and addiction recovery, I’m going to answer as before. “It’s complicated.”