“And Then the Rest Happened”— a Qualitative Exploration of the Role that Meaningful Activities Play in Recovery Processes for People with a Diagnosis of Substance use Disorder

Abstract

Background: In this qualitative exploration, we report on a thematic analysis of the key role that engaging in meaningful activities may play in recovery processes for people with a diagnosis of substance use disorder (SUD). Methods: We conducted semi-structured, individual interviews with 30 participants and analyzed the parts of this material that were related to meaningful activities. Results: The findings are summarized through the development of three broad themes: (a) the central role of work—“The wages suck, but the job is gold”; (b) mastery and commitment—“I had to get up early, find my spot, I had to be present and fully functioning all day”; and (c) repairing the bridge to community life—“It's my job and working out that has made this possible, really, I see that now.” Conclusion: We discuss these findings in relation to a recovery perspective and relevant empirical studies, highlight some important implications for research and practice, and consider the strengths and limitations of the present study.

Introduction

The notion of recovery is increasingly being viewed as fundamental for people with mental illnesses and substance use disorders (SUDs). 1 ^, 2 Although recovery means different things to different people 3 and there are divergences between the fields of mental health and addiction, 4 a prevailing understanding of the concept may be summarized in the following description provided by Davidson et al. 5 They define recovery as “a process of restoring a meaningful sense of belonging to one's community and positive sense of identity apart from one's condition while rebuilding a life despite or within the limitations imposed by that condition” (p. 25). This insight is in line with the World Health Organization's 6 depiction of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (p. 100), a definition that has not been amended since it entered into force.

One implication of this understanding is a shift away from focusing solely on illnesses and disease. Another is the greater emphasis placed on peoples’ lived experiences. Writing from a recovery perspective, Borg and Davidson argue that the sphere of everyday life has traditionally been invisible and taken for granted when we have tried to understand people's recovery processes. 7 Focusing on experiences within health care services, researchers and clinicians have overlooked a natural and key context for a person's recovery processes: his or her everyday life. A similar pattern can be found in the psychotherapy research literature. Here, phenomena that are more likely to be controlled in a randomized controlled trial setting, for example, the specific interventions, have garnered a great deal of research interest, while factors that are common across therapies, for example, the therapeutic relationship, have received less. 8 Interestingly, however, the element that is responsible for most of the outcome is neither the specific techniques nor factors in the relationship with the clinician. When summarizing studies on the outcome of psychotherapy, the factors that have been found to explain most of the variance are often located outside a therapist's office—namely, extra-therapeutic factors. These include diverse things such as finding stable housing, forming an intimate relationship, or caring for a pet, and they are typically estimated to be responsible for approximately 40% of the outcome in psychotherapy. 9 Although such numbers must be considered with caution, they clearly highlight the need to explore people's everyday life in relation to recovery processes and to find ways of integrating this knowledge into research, treatment, and care.

In this article, we aim to contribute to developing new knowledge on recovery and everyday life by examining the descriptions of 30 participants regarding the role of meaningful activities in recovery processes following a diagnosis of SUD. We do so because the things we do and the practices we engage in are a key part of everyday life. We have previously described the participants’ experiences of long-term recovery as a developmental process from dependency and reactivity to personal autonomy and self-agency. 10 We have also explored their experiences of how close relationships may have impacted recovery, 11 their perceived benefits of drug use, 12 and how ongoing monitoring and feedback on the data results in a longitudinal follow-up study on SUD recovery were described. 13 Now, we examine the parts of this material that focus on the role of meaningful activities. In doing so, we have approached these activities in a broad sense and included both work and leisure, as both are found to be associated with important health benefits for people with an SUD. 14 ^, 15

McKay argues that helping people engage in valued activities needs to be a built-in part of SUD treatment and suggests it as a way to make recovery more satisfying. 16 While fear of negative consequences may help someone stop using alcohol or drugs, he asserts, being able to enjoy the advantages that this transformation brings is probably necessary to sustain the changes made. This may be particularly important not only because a longstanding use of substances may lead to problems with a person's reward system but also because it brings a sense of meaning, purpose, and excitement to the person's life. 16 Laudet similarly emphasizes the need to better integrate quality of life into addiction research and practice. 14 Here, engagement in valued activities plays a significant part. Moreover, in developing what they term a social identity model of recovery, Best et al. view recovery for people with an SUD as a process of changing one's identity. 17 The transition occurs in their conceptual framework through processes of making changes in one's social networks and engaging in meaningful activities. A small qualitative study conducted by Nordaunet and Saelør also substantiates the importance of meaningful activities to recovery processes. 18 Based on interviews with five male participants with dual diagnoses, they describe three overarching themes: (1) achieving a positive identity through actions and by feeling worthwhile; (2) being physically outside but inside the norms of society; and (3) idleness, isolation, and obstacles on the road to recovery. In the present study, we aim to contribute knowledge to this growing body of evidence on the role of meaningful activities in recovery processes following an SUD diagnosis.

Methods

Participants

Thirty participants were recruited from the STAYER study (n = 202). This is a prospective, naturalistic follow-along study of change trajectories for people with an SUD in Rogaland, Norway. The inclusion criteria for participation were (a) starting a new treatment sequence at the time of inclusion; (b) fulfilling the criteria for SUD; (c) being 16 years of age or older. 19 ^, 20 For the present interview study, we recruited participants consecutively at their 4- or 5-year follow-up in the STAYER study. 10 – 13

Data collection

Semi-structured interviews 21 with the participants were conducted at Stavanger University Hospital (n = 25), at the participants’ homes (n = 1), or by telephone (n = 4). As detailed elsewhere, 11 all data were collected by interviewers with lived experiences of recovery in SUD to stay close to the first-person perspective. 22 ^, 23 The interviews were conducted between October 2017 and April 2018 and ranged between 27 and 96 min (mean: 57 min). All were audio-recorded and transcribed verbatim. The following focus areas related to recovery processes guided the interviews: (1) person-specific factors; (2) environmental factors; and (3) treatment-related factors. Each of these areas was introduced with an open-ended question, for example, “How would you describe the treatment you received?” Follow-up questions were used and all participants were invited at the end of each interview to provide any relevant information that had not yet been elicited.

Data analysis

We used a team-based approach 24 to reflexive thematic analysis. 25 ^, 26 More specifically, we proceeded through the following steps: (1) MV, CM, TSS, and JB read all of the interviews to familiarize themselves with the data, and we arranged a 1-day analytic seminar to discuss first impressions and to develop an overall sense of the participants’ experiences. (2) MV reread the entire dataset to identify the parts of the material that were related to meaningful activities. (3) These parts of the data were discussed in another 1-day analytic seminar with CM and JB. (4) MV closely examined the data and identified units of meaning. (5) MV suggested tentative themes to sort the different units of meaning. (6) These themes were reviewed and discussed in collaboration with all coauthors. In this process, TSS served as a critical auditor. (7) Final agreement was reached based on this consensual discussion in which we defined and named the themes.

Ethics

The study was approved by the Regional Committee for Medical Research Ethics in Norway (201/1877). All participants gave written informed consent to take part in this study. As meaningful activities are often closely related to people's identity, ethical considerations in the presentation of the data have been important to protect the participants’ confidentiality but, at the same time, to stay close to their descriptions. In this process, we have replaced some personal and contextual identifiers regarding the specific jobs and activities that the participants engaged in.

Findings

Participant characteristics

Seventeen of the participants were male, and thirteen were female. Their mean age was 25.9 (SD = 5.5), and they reported a mean of 12.9 years of drug use (SD = 6.0), with a mean age of initial use of 13.1 (SD = 1.8). We used the following criteria for stable substance abstinence and social recovery: (1) DUDIT-C scores <1 and AUDIT-C scores ≤2 as a measure of abstinence; and (2) four variables related to social functioning status: housing, income, friends without addiction, and participation in work or school. For the present study, recovery was defined as meeting both criteria for stable substance abstinence and adequate social functioning in the past 2 years.

Thematic results

The participants’ descriptions of the role of meaningful activities in recovery processes after an SUD diagnosis clustered around three broad themes: (a) the central role of work; (b) mastery and commitment; and (c) repairing the bridge to community life.

The central role of work—“the wages suck, but the job is gold”

An overall finding in this study was the central role of work in the participants’ recovery narratives. In the interviews, the participants discussed a wide range of meaningful activities that were important to them, including sports and outdoor activities, arts and crafts, movies and video games, music, animals, gardening, and food-related hobbies. Nevertheless, work stood out as paramount in the participants’ accounts, playing a key role in their recovery. This was even the case even though the topic of work was not an explicit focus of our interview guide. The following quote exemplifies how work spontaneously came to be discussed:

Interviewer (I): What were the most important turning points for you, for good and for bad?

Participant (P): I got a job, which made me achieve something. I was finally able to be okay with something. That was a turning point. And then, there were my colleagues, and from them, I got friends and stuff. So, it was feeling I could achieve something. I'd never done that before. And it became a pattern, it built up, I got more and more responsibility.

Although some participants described the importance of paying down their debts for their recovery processes, the economic side of work was generally not emphasized. One participant, who had a job as an exterminator, described this basic value of work in the following words: “I like this. I like to go in, tear down the walls, find the entrances for these rats and close them up. I'm [originally] a builder, so this is kind of in my DNA.” This participant had been given the opportunity to be promoted but did not accept the offer from his employer:

I: And why did you refuse that position?

P: Because I want to do what I do now, I don't want to sit in an office and do paperwork or go on inspections.

I: That's what the job is about?

P: Yes, and it would have provided me with [600 EURO] more each month, but…

I: You want to be on the floor.

P: For me… This is what I like. The wages suck, but the job is gold.

This central role of work was also implicitly communicated in some of the participants’ stories about hitting rock bottom. In their narratives, not being able to work because of alcohol- or drug-related problems was seen as a particularly negative life event that in some cases prompted their decision to seek help. The following quote exemplifies this theme:

The first time I remember really wanting to sober up was in 2012. I had fallen extremely hard and lost my job, put myself in a crappy situation, getting hooked on different drugs. At that point… That was the first time I entered treatment for myself.

Similarly, another participant used the following words to describe how fear of becoming out of work pushed him into going to therapy:

I realized it because I saw that my employer picked up on the gravity of my problems, right? And I got scared of losing my job because then I wouldn't be able to keep up appearances. I realized that if I don't have a job, then I would be an addict for real.

In the interviews, work was portrayed as a relatively straightforward arena. Compared to the participants’ experiences with the health care system, their working life was more hands-on, direct, and honest—qualities that were of great importance for many of them. The participant quoted above, for example, said this when discussing his employer's reactions to his ongoing problems: “I put all the cards on the table, I instantly knew that there was no point in tricking and luring here, I needed to tell it like it was.” Work was also described as a diverse phenomenon. This means that there was, in a sense, a job for everyone. The participants in our interviews described a variety of jobs reflecting their diverse resources and interests, including working in merchandise or politics, as a scientist or carpenter, as a social worker or nurse, in kindergarten or meat production, as a peer supporter or cobbler. They also outlined many different pathways into paid work, where some of them were in need of assistance but others were not. Importantly, however, the job needed to reflect the participants’ real competencies and capabilities. As one of them said when discussing the difference between having a paid job and being in periods of prevocational training: “When I was tattooing, my job meant a lot to me. But afterwards, when I did these courses and had training here and there, it was mainly in order to not feel like I was a complete junkie, right?”

Mastery and commitment—“I had to get up early, find my spot, I had to be present and fully functioning all day”

Meaningful activities stood in contrast to the participants’ previous experiences of living from hand to mouth. Many had few arenas where they had been able to put their strengths to use, describing an everyday life in which they had often felt bored, worthless, and alone. As such, finding ways of tapping into their abilities was important for the participants. Both work and other meaningful activities represented a context in which they could be capable and grow as a person. The following dialogue from one of the interviews in which the participant emphasized the importance of seeing the results of his work illustrates this point:

I: Being able to demonstrate that, it must give you some kind of status?

P: Yes, you learn a craft, right? And that's useful at a later point as well, right?

I: And then you're talking about mastery?

P: Yes, really. So, working has been important to me.

Another participant described how sports provided him with this valuable sense of mastery. As an integral part of his rehabilitation program, he had trained for and competed in a large athletic tournament. This served as an important reminder of his personal resources and strengths:

And I got the chance to play in the Homeless World Cup [abroad]. To play on the national team, what the hell?! That was huge. That was amazing. Just to have those things to work for. It doesn't need to be [that] big either, just being able to notice all the things I can do. I have all these options ahead of me.

Yet another example can be drawn from the account of a participant who emphasized training and bike riding as essential in his recovery process. In the interview, this was discussed in the following way:

I: What was most helpful in your recovery process?

P: I don't know. Cycling?

I: Are you talking about that race from Tromsø to…

P: Trondheim—Oslo.

I: Yes?

P: Yes. So that's been fun. And it comes back to this with results. If you ride your bike from one point to another, you get mastery, and you really can do it. Before, you used to cycle to get drugs; now, you ride for fun.

Working and performing meaningful activities required the participants to make important changes to their everyday lives. As such, engaging in these activities provided them with important help in organizing their lives. As described by one of the participants, “Because now I had to get up early, find my spot, I had to be present and fully functioning all day.” As such, by bringing meaningful activities into the repertoire of their everyday life, the participants started making small but crucial changes. Again, these changes would impact their quality of life. A female participant reflected on this in the following way:

And my life is ten times better now compared to my best days getting high. Because… I'm not really bored; I have things to do with my days. And if I'm home, it is… It's because I deserve it, and then it's nice to relax, sort of.

The participants’ stories of mastery and responsible living often involved experiences of being treated as a trustworthy person. As such, in discussing the role of meaningful activities, they described being let in by the community, as opposed to needing to fit in. In these processes, the people they met along their pathways played important roles. In the following quote, one of the participants talked about a job interview at a supermarket. He had decided to be open about his problems with illegal substances and his criminal activities:

He seemed cool, the manager. And we talked for a while, he asked questions, and I answered the best I could. And at the end of the interview, I got the question I feared the most: “You did burglaries, was it mainly houses and stuff?” And I thought, “Shit, should I answer that or should I…” And then I said, “No, not houses, mainly shops and warehouses”. And then I thought that this was pointless. But he only looked at me and said, “If I told you I've got [7 million EURO] in my safe, what would you say then?” “Okay, that's cool”, I answered, and I thought I might as well walk out of there. But before I was about to leave, he asked if I could start the very next day.

This participant similarly emphasized the importance of trust. He had served his community sentence contributing to, among other things, a competitive shooting sports club. In this process, he gradually became interested in this activity, and he also wanted to obtain a hunting license:

P: And I took the test and signed up for the local shooting sports club. But then I needed a permit. And I was unlucky because the local police chief had retired, and there was this new guy… But my boss phoned him, and I handed in an application. And then I waited for a helluva long time. And I got no feedback, so I called him. But he didn't want to sign it because of my accomplishments.

I: Your accomplishments!?

P: Yes. And then I thought, “Shit”. He had to send it to the police headquarters. And I thought, “There's no way this is gonna work. If they so much as see my name on that paper, they'll throw me back into jail”. But I did a smart thing, I called the old local police chief, he had followed up on me and on my community sentence, and he had seen the changes I had made. And it turned out that he was best buddies with the head of the gun control.

This participant received his weapons permit and emphasized this as key in his recovery journey and shifting away from unhealthy substance use. He commented, “For me, I might as well stay on this path because I see all the great things that are happening here.”

Repairing the bridge to community life—“it's my job and working out that has made this possible, really, I see that now”

Descriptions of meaningful activities were frequently characterized in terms of trajectories, in the sense that they were important pathways to life in the community. Moreover, when the participants were asked what they were hoping for in their future, meaningful activities were typically emphasized:

P: Our next goal is to buy a house, a smallholding, with room for the dogs.

I: Yes, that's what you will be doing?

P: I don't think we're ever gonna stop.

I: Is there any money in it?

P: No, it's more… That is, you can make money, but things can also go to hell. Our first puppies… Their mother fell ill. And then we had [4000 EURO] in veterinary bills. […] So, I wouldn't say there is any money in it.

I: You're doing it more because of your interests?

P: Yes.

I: A smallholding, where they can run around, having fun.

P: That's our goal, yes.

Similarly, another participant described how his future goals were intimately related to his current practice as a tattoo artist. Now, however, he also hoped to advance his artistry in regard to painting:

My next mission is to get an arrangement where I tattoo for two weeks and then I do two weeks of painting. To develop my skills on paintings and such. […] So that's my hope for the future, that's my goal. Just doing what I love and being able to make a living out of it.

A third example can be found in the following excerpt, which underscores the role of meaningful activities in participants’ processes of building an ordinary life. For this participant, his own efforts in reclaiming a life were of immense importance for his recovery:

It's this thing that I wanted to get on my feet again and lead a normal life together with all the others, both my family and everybody else, right? And I initially felt that I did it for everybody else, the first few rounds, but this last time it was mostly for me. So, I got into [treatment institution] and started working out and looked healthier and fresher and all that, right? I started to work again, and… It's my job and working out that has made this possible, really, I see that now. And then the rest happened.

Many participants had felt socially isolated in their drug-using lifestyle, struggling with boredom and loneliness. In this context, meaningful activities provided them with an important arena for connection and belonging. Several of them discussed the value of work colleagues or training partners in their recovery processes. The tattoo artist above, for example, emphasized in the interview not only the basic value of his work but also the social aspects in meeting his clients:

Yes, it's really magical. Magic. I feel like a wizard. It's pretty cool what's going on down there [at the tattoo shop]. Great conversations with people all the time. Getting to know people along the way. It's really positive.

Another participant similarly described how starting studying had provided her with a new and important social network that enabled her to lead a meaningful life:

And it's about being in a good environment. It's about having good friends. It wasn't until I started at the university that I felt I connected with people at a more fundamental level, having people who care, if that makes sense.

As a variant finding, some participants also described needing to keep remnants of their action-filled lifestyle present in their ongoing life. In these narratives, this was not only about community inclusion and building an ordinary life but also about letting some of the best parts of their former ways of living be present. One participant, for example, emphasized his passion for illegal and exotic animals as central. Rather than moving toward the mainstream, this hobby was more about keeping a thrill in his life through smuggling or researching about them:

P: I've had… I don't know how many reptiles I've had, but it's supercool. Building the walls, making real stuff, right? Doing some breeding of them, with different genes and seeing different types develop, and…

I: You're experimenting on them?

P: Yeah

I: Dr. Frankenstein?

P: Yeah, it's great fun.

Discussion

In this article, we address the role of meaningful activities in recovery processes for people with an SUD and present three broad themes: (a) the central role of work; (b) mastery and commitment; and (c) repairing the bridge to community life. Taken together, the themes from our analysis shed light on the indirect nature of recovery processes. Engaging in meaningful activities is often seen as somewhat unrelated to the real matter at hand—that is, the goal of abstaining from or moderating substance use. However, engagement and activities are not without importance, nor are they any less real. In fact, our findings indicate that participating in meaningful activities can be understood as providing a necessary foundation for approaching such goals.

“And then the rest happened”—recovery as indirect processes

Davidson has suggested that recovery in schizophrenia may be seen as a by-product of being recognized as a real human being through prolonged and cumulative micro-affirmations. 27 These are small and ordinary gestures of compassion that confer dignity and shared humanity. They often involve other people paying attention to the individual and how this person exists beyond his or her diagnosis. A participant in a study on mental health inpatient experiences conducted by Eldal et al., 28 for example, describes being met not like a “piece of paper with letters on, but as a real person with a name” (p. 92), and Amy Johnson 29 summarizes her lived experiences of this phenomenon in the following words: “I can come to recognize that ‘I am a human being’, […] because I found someone who can identify me as one” (p. 260). As such, micro-affirmations involve seemingly little things such as looking for common ground or acknowledging how “they” are in fact just like “us.” 30

Such affirmations are also of relevance to people with an SUD, in which an increased sense of personal agency is correspondingly important for recovery processes. 10 ^, 31 At the same time, engaging in meaningful activities is probably not as closely related to restoring personhood, that is, a person's sense of self, as these micro-affirmations may be. Nevertheless, our findings emphasize how engagement is intimately connected to processes of restoring and reclaiming one's life. As such, we may argue that engaging in valued activities plays an important role in providing social affirmation, which is of immense importance for people's recovery processes. The reason is that it is precisely this social engagement that lays the groundwork for finding ways of being abstinent or moderate with substances. As the participant giving voice to the title of this article emphasized after stating that his job and working out were key to his recovery processes, “And then the rest happened.”

Implications and limitations

The quote giving title to this article also sums up the heart of the idea behind models of supported employment for persons with mental illnesses. In these practices, people are not excluded from work on the basis of factors such as readiness, diagnosis, or involvement in the legal system, and a rapid job search is integrated into treatment and care. 32 This means that people reexamine and return to their working lives while still having symptoms and problems instead of the other way around, that is, waiting for mental health symptoms to abate or for unhealthy use of alcohol or drugs to cease before returning to work. 27 This model has documented effects not only through increased income and increased quality of life but also on symptom alleviation and a reduction in substance use for people with mental illnesses. 32 ^, 33 An important implication of the present study may be the need for policymakers and clinicians to initiate processes of developing and integrating models for supported employment into the addiction field as well. For such practices, it will be necessary to keep in mind that recovery processes are complex and nonlinear phenomena, and such practices will need to take into consideration that they will often involve setbacks and relapses.

For some readers, it may come as no surprise that work had a central position in our participants’ accounts given that social functioning, including having a job or attending school, was a criterion for participation in the present study. Nevertheless, we argue the importance of our findings, as they pay attention to processes that underlie practices aimed at supporting individuals in reclaiming a job. Being employed is a typical role for most adults in our society, and a person's job is one of the most essential social arenas in his or her everyday life. 34 As such, our study findings clearly highlight the need to integrate a focus on work into treatment and care for people with an SUD. At the same time, we also need to consider the possibility that conventional notions of employment and productivity may have risked guiding both the researchers and the participants in our study. The Norwegian context is characterized by low unemployment, high job security, and an extensive welfare system, 35 which may have led to normative ideals about lifestyles and standards in the present study. We will therefore need to remind ourselves that our study findings also emphasize the importance of activities in addition to work, underscoring the need to expand what we view as normal, viable, and valuable today. We argue that an implication of this is the need to build communities that acknowledge the full extent of the various ways in which people can lead good and meaningful lives and to recognize that this can also be a life that does not consist of engaging in paid work. As such, our study findings have important implications for community inclusion because, as Svanberg 36 writes, “This isn't just about the people at the bottom rungs of the ladder; it's about the kind of society we all want to live in” (p. 95).

Excessive and unhealthy substances restrict the lives of people with an SUD. Meaningful activities, on the other hand, expand and open up their lives. As demonstrated in our findings, engaging in everyday activities was important, as it connected the participants with a different environment, a community at odds with their old social lives. This is important because what we do is closely related to who we are. As such, our identities are interwoven with the activities that we engage in. Kellogg 37 claims, “People will not maintain their long-term recovery—whether based on abstinence or nonaddictive use—unless they are able to develop viable, meaningful, and reinforcing identities that can compete with and replace those based on substance use” (p. 90).

We set out to study not meaningful activities but recovery processes in general. If we had asked focused questions on this topic, we may have had more in-depth discussions with our participants. On the other hand, this broad focus allowed an open exploration of what the participants saw as important for recovery, which suggests that placing meaningful activities in a central role in people's recovery processes is data-driven. Another limitation in the present study is that our sample consists of a heterogeneous group of people with SUD. In order to acquire different narratives of recovery processes in SUD, we sampled widely from the naturalistic follow along STAYER study 19 ^, 20 in the present qualitative investigation. Future studies are therefore needed to examine if there are differences in the role work and meaningful activities may play in relation to recovery processes in more specific populations (for example people with alcohol use disorder or opioid use disorder), as well as to people who do not currently experience being in recovery. Furthermore, our study focused on the experiences of people in a Norwegian population. As argued, this is a context characterized by high access to jobs and a relatively beneficent working life. We, therefore, need to be careful when transferring the study findings to different cultural contexts.

Conclusion

In conclusion, this qualitative study strongly suggests the need to integrate work and other meaningful activities into treatment and care for people with an SUD. Neglecting the role of involvement in meaningful activities may render other therapeutic efforts ineffective, as they fail to establish anchors in everyday life. The study also highlights the importance of building communities that recognize the full extent of the various ways in which people can lead good and meaningful lives. We advocate for research teams to further explore the everyday lives of people with an SUD and to develop interventions that aim at full community inclusion.