Abstract
Substance use disorders (SUD), as defined in the DSM-5 (APA, 2013), represent a major threat to physical health and may impinge on psychological well-being, daily life functioning, as well as social relations and occupation opportunities (Davidson et al., 2008). Sobriety may then counter such threats. However, former SUD patients may live a good life while continuing to use substances (Hystad and Vangensteen, 2022), and previous findings (Laudet, 2007) indicate that although sobriety may be a dichotomous foundation, it need not be inconsistent with recovery regarded as more continuous in nature. Indeed, recovery from SUD (or other disorders) may be understood to be a process, but also a vision, a philosophy or attitude, and a set of outcomes (Silverstein and Bellack, 2008). Conceptually, systematic reviews of the recovery literature (De Ruysscher et al., 2017; Leamy et al., 2011) have identified recovery as encompassing “connectedness”, “hope and optimism about the future”, as well as “empowerment”. To some extent, recovery is a personal process, where the self-determination theory (SDT) (Deci and Ryan, 2012; Ryan and Deci, 2017) may provide a framework to depict a five-stage transformation from not recognising a problem (“amotivation”), to regulating, for instance, sobriety through external sources to the introjecting, identification and integration of new behaviours, attitudes and values to build a new identity. The importance of creating a self-identity as a non-addict has been pointed out in previous studies (Chen, 2022; Dingle et al., 2015; McIntosh and Mc Keganey, 2000; Reith and Dobbie, 2012) and reviews (Subhani et al., 2022), notably in terms of searching for a better and more meaningful life (Laudet, 2007; Lynch et al., 2022; Wangensteen and Hystad, 2022) as a pathway out of (self)-stigmatisation (Burges et al., 2021; Fraser et al., 2017; Pienaas and Dilkes-Frayne, 2017) and searching for non-drug-using relationships to strengthen a new identity (Fomiatti et al., 2017). Moreover, the SDT model of motivation and change has a parallel in stage models of identity development in adolescence (Marcia, 1980), a development that has been shown (Schoenberger et al., 2021) to be a relevant issue in the understanding of recovery from SUD. While recognising recovery as a personal process (Jacobson and Curtis, 2000; Jacobson and Greenley, 2001; Jaeger and Hoff, 2012), previous studies (Stall and Biernacki, 1986; Stimson and Oppenheimer, 1982; Waldorf and Biernacki, 1981) have also shown the importance of positive or negative life events acting as “turning points” aiding a decision to refrain from substance abuse on a journey towards a new identity, and thereby changing the delay discounting rate, i.e., the ubiquitous tendency to devalue distal outcomes and not devaluate the proximal ones (Franck et al., 2023). Resting on the seminal work of McIntosh and McKeganey (2000), other studies (Järvinen and Ravn, 2015; Selseng, 2017) within the realm of symbolic interactionism (Erickson, 1995) have shown that the construction and reconstruction of identities in recovery processes are interactional achievements related to the social context in which they were produced.
A consensus on the meaning of recovery from SUD has not been reached (Ashford et al., 2019; Inanlou et al., 2020). Yet, the concept of “recovery capital” (Cloud and Granfield, 2008; Granfield and Cloud, 1999; Laudet and White, 2008) as a variant of the term social capital (Bourdieu and Wacquant, 1992) has driven the field of SUD recovery forward (Keane et al., 2014) by drawing attention also to the social and sociological aspects of recovery, for instance, in terms of social (Bahl et al., 2022; O'Sullivan et al., 2019) and family support (Veseth et al., 2019) that promote intrinsic motivation to recover, which has been shown to increase quality of life (O'Sullivan et al., 2019) Moreover, concept analyses (Brophy et al., 2023), systematic reviews (Hennesy, 2017) and meta-syntheses (Klevan et al., 2021) have pointed out that the recovery capital encompasses both individual, cultural and social resources that ease the journey of recovery. In this respect, recovery capital illustrates the well-known concept of “resilience” and how it may be operationalised (Friborg et al., 2003). Building on the above-mentioned elements and resting on dissonance theory (Festinger, 1957; Festinger and Carlsmith, 1959), a final step in a possible route to recovery may be the resolution of a cognitive and emotional dissonance between the attributes of an “addictive identity” and a “recovered identity”.
Despite numerous previous studies, it has also been pointed out (Best et al., 2016; Mellor et al., 2016) that we need to expand our knowledge about the interplay between life events, turning points and social contexts in shaping the change process towards a new identity as a non-addict. Considering recovery as a long-term process (Keith et al., 2021) poorly captured by controlled studies (Bjørnestad et al., 2020), qualitative studies are most likely to bring forward more processual knowledge. Hence, the present paper adds to this field of knowledge by exploring how former patients in recovery from SUD experience the benefits and challenges of a reoriented identity and way of living.
Methods
Data sources
Eligible to the study were informants aged >18 years with a minimum of three years of lived experience with SUD (mainly illegal drugs), who had a history as patients in some kind of treatment for SUD and who, at the time of this investigation did not receive treatment and considered themselves either recovered or in an ongoing rehabilitation process. Using purposeful sampling through a patient organisation for people with a former SUD, 10 eligible individuals were approached. Their mean age was 42 years (age range 33–48 years). Eight participants had partners, six held jobs and six had children. All lived in the north of Norway. They were established in their recovery process and, within an SDT-frame (Deci and Ryan, 2012; Ryan and Deci, 2017), had passed well beyond a state of ambivalence considering the positive and negative aspects of change. Hence, 10 informants were considered satisfactory for capturing detailed and rich insight into recovery processes.
Due to the explorative nature of the study, qualitative and inductive methods were used. Specifically, qualitative methods are suitable to provide a route to understanding the experiences, meanings and perceptions of individuals in a complex social environment (Sparkes and Smith, 2014).
The informants participated in an individual qualitative interview of 1–2 h, carried out by the first three authors. They were interviewed at The Arctic University of Norway or the University Hospital of North Norway, except for a few who wanted to interview at their home. The interview guide contained the main theme; how they conceived the meaning of being recovered or rehabilitated from their addiction. The main theme had open-ended questions to ease the conversation between the researcher and informant. All interviews were recorded and transcribed verbatim.
Data analysis
The transcribed interview texts were analysed using content analysis (Downe-Wamboldt, 2003; Graneheim and Lundman, 2004) and the consolidated criteria for reporting qualitative research (COREQ
Results
Category 1: avoiding illegal drugs
This category concerns what the participants described as an important prerequisite for the new life. Some participants had struggled for years to recover, and a few of them used Subutex®, strictly regulated by the health services. For all participants, with one exception, their new life required them to stay away from illegal drugs. The participants reported the importance of not using illegal drugs, such as cannabis, amphetamines, heroin and other illegal drugs, and that sobriety gave them a feeling of liberation and mastery. For some, sobriety also included alcohol. However, many were able to drink moderately because they did not associate drinking alcohol with having a substance use problem. As one participant said it: “For me, recovery from substance use is not about being 100% ‘clean’. I drink alcohol, but I still define myself as free from drug addiction.” “I will always be addicted to drugs, so I need to stay clean, even from alcohol, because alcohol, for me, is a trigger.”
Even if many participants had been sober for years, they would still think about drugs and the feelings they could recall from the past. For some of them staying clean included a struggle to keep such thoughts at a distance and remind themselves about the negative consequences of substance abuse and their earlier life. One participant described it like this:
“Naturally, you think and even daydream about the good feeling of intoxication, but you manage to stay sober. I know better. I am very aware of the consequences of relapsing.”
This citation illustrates both some active decision to stay sober but also a recurrent struggle not to yield to temptations, buffered by the fact that they realised that a relapse could quickly destroy everything they had been working for.
However, one of the participants experienced himself as recovered, yet still felt it necessary to sporadically use cannabis to induce sleep and to avoid nightmares about his past life. He was now in employment, had two children and maintained a tight connection with public health services. He stated that: “I view myself as recovered from substance abuse that has followed me since I began with hashish at age 12 and heroin at 15. Now I use cannabis in the evenings sometimes instead of sleeping pills, which helps me cope with memories from the past that keep me up at night.”
Category 2: avoiding contact with substance use relations and milieu
To manage quitting illegal drugs and staying clean, the participants stressed the importance of avoiding the substance use milieu they had been a part of for years.
The participants described that staying clean and avoiding temptations required avoiding contact with old friends and people they had known in the substance use milieu. This was described as demanding, mainly because they lived in small towns where physical contact with old acquaintances and places where they had sold drugs for years was almost unavoidable.
Moreover, detaching oneself from previous friends and the addictive milieu was also a matter of changing culture, language and ways of talking. As one said: “You cannot stay in the addictive subculture when you want to live in the ordinary society as sober. It is a matter of attitude, language and ways of doing things.” “I still live in a city where I was a drug addict, making me fragile. The city is small, rumours travel fast, and there are several people from the old days that I don’t want to meet. For me, that can be both challenging and demanding at times.”
However, challenges were faced, and many had foreseen how to act and respond. Many reported that they had to be hard on themselves and others if they met people they knew from the substance use milieu, like one participant said:
“One must face oneself, and the life one has lived. I have not reached out or been in contact with friends from the milieu. If our paths cross, even to this day, the first thing they ask me is if I can sell them cannabis. I then firmly decline, informing them I have no drugs to sell and that I had quit many years ago.”
All participants had a criminal record related to buying, using and selling illegal drugs as well as smuggling and robbery, and most of them had served time in prison. Thus, to “start living”, to “feel free” and on the “right side of the law”, many reported it as necessary to stay away from the addictive milieu and the “old friends”. One participant said it like this:
“It is so nice to walk in the city, see the police and know that they are not searching for me – I can just relax and not be afraid.”
The citation shows another part of staying clean, i.e., the freedom from drug-related crime and violence. The freedom from crime, criminals and the fear of being caught by the police pawed the way to detachment and distance from their former ways of living. Freedom also served to strengthen a way of living that did not cross their values. Thus, being an addict forced them to do things they were not proud of today. As one of the female participants said:
“Being an addict made me do things that conflicted with my personal values. Yet, I did them to get drugs. I was unable to look at myself in the mirror without having a bad conscience.”
Altogether, with one exception, a non-tolerance attitude against illegal drugs was reported, and avoiding friends and other relations from the “old life” as a substance user was highlighted as a condition for moving on to the “new life”.
Category 3 renewing non-addiction relationships and social network
Re-establishing good relationships and communication with their own family and being able to take care of their children were stressed by the participants as essential aspects of the new life. Renewed and positive relational experiences were also a motivation to recover, stay clean and work hard to establish a new life. Many participants reported that avoiding illegal drugs had the positive consequence that close relations, for example, family members, could improve. As one said: “My contact with my dad has changed. We had a very cold relationship earlier, but now we have a good one. I guess my dad thinks that I finally grew up. I can see my dad is flourishing, and that is so good. We have never had any reconciliation talk, but we both know that it is the present and the future that matters.”
Some of the participants had become parents during their addictive period in life. Some had lost custody rights, which they regained after recovery. Others could re-establish contact with their children. These participants reported better child–parent communication as a crucial part of the new life as sober.
Similar reporting involved how they slowly managed to build a healthy social network. Some had established new relationships through participating in organised physical activities, following up on their children and their activities or re-establishing contact with family members or friends from their childhood. As one said: “It takes time to build and establish a whole new network when you have been a part of a drug milieu for 30 years. But having a healthy network is perhaps the most essential thing to stay clean.”
Category 4 establishing an occupation
An important aspect of a new sober life was a daily structure and meaning, as was accomplished by having a job or studying to get a job. As one participant said it: “My dream has always been to get a life, not only exist. Without any papers or job references, you must start from scratch. To be sober is just the first step.”
Participants also voiced job benefits like self-acceptance and self-worth. All participants except the one on a disability pension also expressed that a job was important to be able to support themselves economically, as put like this:
“Without work, I felt like an inferior human being. Not being able to buy food and fill petrol on the tank made me feel so worthless.”
Some found meaning by having educated themselves in a health profession and thereby being able to offer professional help to current addicts. Others found purpose and dignity solely by doing “honest work”. Studying or working was also a way of taking on a new social role, as more than an ex-addict. As one said:
“I am not just an ex-addict working to get money to buy drugs. I am an educated, professional healthcare worker. That is my new platform in life. Now I look forward to working, having a good salary, and I feel blessed.”
Category 5 discovering the value of the great, little things in everyday life
Overall, the participants emphasised the importance of enjoying the great, little things in everyday life, such as interpersonal relations, forming social networks having an occupation and participating in meaningful activities in the local community. “It is all about the small things, such as good conversations and supporting others, or spending time with my girlfriend, physical exercise or cooking. Even receiving my monthly salary can be great. These are the daily life things I have been dreaming of. It is weird to think about the old days when I would spend all my money on drugs. Now I’m saving up money in the bank, paying rent and even afford to buy things I want, such as a fleece jacket. Even though I have wasted half of my life on drugs, I am now able to enjoy having an occupation, a good family life and a network of sober friends.”
Some participants reported experiencing rough patches where they felt vulnerable due to their past as drug addicts, and many had trouble comprehensively expressing their needs and feelings. Moreover, several highlighted that they had to relearn the informal norms of social interaction. Some also reported anxiety and psychological problems related to dental injuries resulting from drug use, which presented a clear link between their past life as drug addicts and their new, sober life. As addicts, participants described a failure to take responsibility, most participants described their new life as more predictable in terms of economy, living conditions and family life, where a part of the predictability was due to having new responsibilities.
Moreover, despite some flashbacks, most of the participants were able to make use of their addictive history positively.
Category 6 establishing new coping strategies
For the participants, recovery from drug addiction was a matter of leaving their old identity as an addict and turning over a new leaf. The participants stated that accomplishing this leave of identity required a “reset” in thinking, attitudes and even the way of speaking to communicate and get feedback from other people according to the new identity as a non-addict. All participants reported that this was a long process.
An important way to stay sober was to manage substance cravings by adopting more healthy strategies. As one participant said it: “I have learned a lot about myself, who I am, my needs, where my borders are and how I can express them properly.”
The participants experienced having changed through treatment and during their recovery process. An important aspect of a new life as a non-addict was having learned to cope with daily strains, stress and challenges. As an example, one participant reported on a situation where his manager told him that he did not have much work for him at the time: “If this situation had occurred years earlier, I would have yelled, hit and run out of the office. Now, I was able to handle such a situation more appropriately by sitting down and thinking things through.”
For some participants, an ordinary way to react to frustrating situations was using violence or simply interacting or communicating with others in a wrong way. As one participant said:
“Before, I used to think that closed doors meant lost opportunities. Now, if I meet a closed door or a barrier, I manage to find possibilities and solutions.”
Category 7 developing a new identity
Most participants had been using illegal drugs for years and reported that their substance use had been an important part of their identity. The participants described how they had worked hard for years to acquire new social roles related to study or work, or being responsible parents and partners, thereby developing and establishing a new identity. Hence, a new identity without substance use was a long process, including many areas and domains in life. At the same time, they had to accept their addictive history. As one said: “I have been frank and open about my past. All my colleagues know about it. One day a journalist came to a café I used to visit, managed by former drug addicts. I noticed the journalist and thought that I did not want to be recognised and identified as a former drug addict, as that part of me belonged to the past. Now, I am developing a steady and solid life and have many years left.”
Part of the identity aspects of a new life also comprised encountering old values set aside in their life as addicts. As one said:
“I don’t have to cheat others or feel like a horrible person not in control of myself anymore. Now, I can live according to my genuine values and feel balanced and in harmony with my surroundings. It is my new identity, yet it is still fragile even though I have been sober for eight years.”
Nevertheless, the participants experienced challenges in constituting and confirming their new identities. Some experienced reminiscences of their addictive life, which they had to cope with, such as feeling bad when meeting contacts from their former addictive life or having to cope with shame looking at themselves in the mirror and all the dental problems caused by many years of drug use. Many experienced a challenge dealing with grief, having wasted so many years of their lives on being addicts.
Discussion
The aim of the present study was to explore how former patients with a SUD experience the benefits and challenges of a reoriented way of living. The seven categories extracted from the interviews were the importance of (1) avoiding illegal drugs, (2) avoiding contact with the substance use relations and milieu, (3) renewing relations and social network, (4) daily occupation, (5) discovering the value of the great, little things in everyday life, (6) new coping strategies, and (7) developing a new identity.
In the following, these findings will be discussed related to knowledge about the interplay between life events, turning points and social contexts in shaping the change process towards a new identity as a non-addict.
Abstaining from using illegal drugs was reported as being a challenge but also as a door-opener to a new life and new possibilities. The fact that personal recovery requires sobriety aligns with previous findings, indicating that sobriety is helpful in initiating mental health recovery processes (Green et al., 2014). Consistent with previous findings (Silverstein and Bellack, 2008), the present results point to more dynamic and processual aspects of sobriety rather than just regarding sobriety as being dichotomous in nature. Hence, staying away from illegal drugs was a decision that had to be confirmed or “renewed”, for instance, by coping with cravings, memories about the positive aspects of intoxication, or by just staying away from social triggers, and thereby gradually changing the delay discounting rate (Franck et al., 2023; Keith et al., 2021) in the process of recovery. Notably, the participants reported hard work in distancing themselves from drug dealers and other criminals, criminal actions and fear of the police. Apart from the occasional craving for illegal drugs and alcohol in controlled forms, the participants experienced their new life as non-addicts as a kind of freedom, for instance, from the fear of the police and criminal prosecutions.
Hence, sobriety represents a gateway to a range of positive and self-reinforcing circles such as social networks, an occupation, and thus a new life and identity. Such self-reinforcing circles may well illustrate the importance of a gradual increase of recovery capital (Cloud and Granfield, 2008; Granfield and Cloud, 1999; Laudet and White, 2008) and previous studies (Bahl et al., 2022; O'Sullivan et al., 2019) reporting on the importance of the social and interactional aspects of recovery, for instance, through family support (Veseth et al., 2019), that promote intrinsic motivation to recover and increase the quality of life (O'Sullivan et al., 2019). However, our findings indicate that the social and interactional aspects may go beyond the “support” aspect of staying sober. Consistent with theories of symbolic interactionism (Erickson, 1995), the quality of social interactions may contribute to a transition of self-image and identity towards a non-addict. However, our findings also indicate that a new identity and a new life do not imply a dichotomy between the life and identity as an addict. Thus, rather than repressing the past, participants found it useful to keep their history in mind as an impetus to continue on the road to recovery.
Our findings are supported by a review of qualitative studies on recovery (De Ruysscher et al., 2017) also showing that better communication with one's family and having an occupation because of sobriety are important facilitators and favourable self-reinforcing circles towards recovery. Hence, when our participants underscored the importance of having an occupation, it may be understood as building meaning, empowerment, self-worth and resilience through offering a daily structure. Our finding that these five overarching phenomena need to be materialised, e.g., by valuing “the great little things” in everyday life echoes previous studies (Pettersen et al., 2013; Rosenvinge and Pettersen, 2012) that have focused on recovery as a long-term process of achieving a good life based on a sense of hope, connectedness, belonging, empowerment, and the experience of becoming a trustful and responsible individual.
Like other studies deciphering time-related aspects of life (Mananita et al., 2011; Sanvicente-Vieira et al., 2017), categories of meaning do not stand out as mutually exclusive in their logical structure. The present study is no exemption as the seven categories appear intertwined and interrelated. However, in attempting to build a latent and theoretical model, the categories may be grouped at different conceptual levels.
Thus, sobriety and avoiding triggers (categories 1 and 2) appear as a prerequisite and a gateway to the second level (categories 3–5), recovery is a matter of reconstruction of identity through an interplay between the inner sense of “self” and the individual's “theory of mind” (Sanvicente-Vieira et al., 2017) social interactions (Erickson, 1995) and social structures that pave the way for strengthening a new life and functional ways of coping with stress (categories 6, and 7). One latent category encompassing all seven categories is the transition from “existence” to “living” in a new life through “connectedness”, “hope and optimism about the future”, as well as “empowerment” (De Ruysscher et al., 2017; Leamy et al., 2011), with an orientation towards the present. This aligns with other studies and models of recovery from addiction (Mananita et al., 2011), as well as related disorders (Pettersen et al., 2013; Rosenvinge and Pettersen, 2012). A present- and future-focused journey of personal recovery also require a distance from the past, not retroactively, but proactively by protecting oneself from triggering situations, contexts and individuals. Interestingly, the social and interpersonal dimensions in holding on to the presence differ somewhat from previous accounts of recovery as a psychological process of distance from a former life by realising and acknowledging the illness (Mananita et al., 2011); Pettersen et al., 2013).
The present findings support a favourable position concerning the possibility of leading a new life despite a history of heavy drug addiction. A clinical implication of such findings is that sobriety is an essential goal for personal recovery. To reach such a goal, patients must be assisted in learning to cope with personal, interpersonal and social triggers. In addition, treatment should focus on identity and reorientation, social relations and preparation for the future, considering the realisation that new challenges will appear. Thus, rather than using retrospective and introspective psychotherapy to promote psychological insight or control regimens to secure total sobriety and abstinence, treatment should include and (re)vitalise the patient's social network to initiate self-reinforcing good circles of change and the psychological and social management of daily life situations.
Conclusions
Rehabilitation from former heavy drug use is possible. The present interview study has shown that sobriety is a prerequisite, but that rehabilitation should take a broader focus by keeping attention to psychosocial aspects of recovery.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical considerations and data security
The study was approved by the Regional Ethical Committee of Medical and Healthcare Research in Northern Norway. The approval rested on participants’ informed consent, the option to withdraw from the study unconditionally, secure data storage, and the use of deidentified data in the reporting of results.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article
