Polyphonic narratives: The mixing of Alcoholics Anonymous and relapse prevention in stories about recovery and relapse

Abstract

Aim: This exploratory study analyses the interplay between the treatment philosophies of Alcoholics Anonymous (AA) and Relapse Prevention (RP) in personal stories of addiction. While the basic ideas of AA and RP are compatible in many ways, they also carry some fundamental differences. Methods: The data consisted of interviews with 12 individuals recovering from substance use problems, who had experience of both AA and RP. The analysis drew on a dialogical narrative perspective, and the concept polyphony was used to shed light on the interplay between different treatment philosophies in personal stories of relapse. Findings: Although sometimes resulting in incoherence, the treatment philosophies were combined idiosyncratically, in ways that appeared productive for the participants’ self-images and recovery journeys. Conclusion: The combination of AA and RP philosophies in narratives of relapse and recovery may reflect a new treatment discourse where individualisation and responsibilisation stand in a complicated relationship with collectivism and surrendering to so-called addicting processes.

Introduction

Treatment philosophies shape how people make sense of their past, present and future in relation to substance use and recovery (Andersen, 2015). The central role of storytelling in Alcoholics Anonymous (AA) has been explored in several studies on how personal substance use and addiction narratives are shaped by established discursive patterns within these contexts (Cain, 1991; Hänninen & Koski-Jännes, 1999; Humphreys, 2000; Weegmann & Piwowoz-Hjort, 2009). Storytelling has been identified as fundamental for the transmission of basic AA values and ideas, and according to Thune (1977, p. 87), the life story provides “the metalanguage, through which members discuss and redefine the structure of reality”. Old members’ stories become models for how new members reinterpret their selves and past experiences (Cain, 1991; Strobbe & Kurtz, 2012; Thune, 1977). However, less attention has been paid to complexities and contradictions in the ways the basic ideas of AA are taken up by individuals. As pointed out by Glassman et al. (2021), more research is needed on how the AA narrative is adapted to individuals’ pre-existing and developing beliefs and self-images.

People in recovery from substance use problems, who are from an AA perspective defined as chronically ill (Cain, 1991; Thune, 1977), can be understood as part of a “remission society”. The term was coined by Frank (1995) to highlight the situation of those who have experienced illness and getting well, without being completely cured. The remission society includes, for example, people with cancer in remission, people living with diabetes or allergies demanding self-monitoring, but also those recovering from substance use problems. Its members are trapped between health and illness, although many times passing as healthy in the eyes of others. Frank (1995) argues that these experiences impact on storytelling, as they urge narrators to reinvent themselves within the limitations set up by current conditions. As narratives are important arenas for negotiating and presenting identities, they also shape the narrators' self-images. Identity can be understood as a context-dependent and interactional construction, constantly under revision (De Fina, 2015), highlighting the importance of social and relational aspects in storytelling (Smith & Sparkes, 2008).

The discursive resources accessible through the classical AA narrative are not drawn upon in a fixed or simple way – there is always room for negotiations and creativity (Glassman et al., 2021; Weegmann & Piwowoz-Hjort, 2009). For example, previous therapeutic experiences can be of importance in this process (Ratliff, 2003; Weegmann & Piwowoz-Hjort, 2009). The most influential research on AA storytelling (e.g., Cain, 1991; Steffen, 1997; Thune, 1977) was carried out before the launch of Cognitive Behavioural Therapy (CBT) approaches in treatment of behavioural problems, and is therefore exclusively focused on the AA discourse. Since the profound spread of CBT-based talk therapies, such as Relapse Prevention (RP), in the field of substance use treatment, the narrative resources available to people who try to make sense of their recovery experiences are probably different today compared to a couple of decades ago, and more focused on behaviour control in order to avoid relapse. Previous research on how treatment philosophies influence personal recovery stories has tended to focus on AA exclusively (Arminen, 1998; Cain, 1991; Humphreys, 2000; Steffen, 1997) or categorised the AA narrative as one of several mutually exclusive ways to structure personal experiences of substance use and recovery (Hänninen & Koski-Jännes, 1999). There is a lack of research exploring how different treatment philosophies are combined and negotiated in personal recovery stories. We have not been able to find studies on the uptake of different treatment philosophies that contain potentially conflicting perspectives on how recovery identities and relapse experiences are made up.

The aim of this study was to explore how people with experience of both AA and RP integrate elements of these two treatment philosophies into their personal narratives about recovery and relapse. The analysis targets how these philosophies can both match up and clash when people in “remission society” talk about their experiences and self-images. Both AA and RP focus explicitly on helping the individual avoid relapsing into substance use and they are very common in the Swedish treatment system for substance use problems (Socialstyrelsen, 2018). Personal narratives about relapses and ways to avoid them can therefore be considered especially useful to analyse in order to grasp how different treatment philosophies are negotiated and adjusted to fit the everyday lives of those in recovery.

The basic treatment philosophies of AA and RP

Below, the basic treatment philosophies of AA and RP are outlined. As stands clear, while these two approaches are overlapping and compatible in several ways, there are some small but important differences in their overall understanding of substance use and recovery.

AA

In the 1970s, Thune (1977) explored AA's ideas on alcoholism and recovery and found that a redefinition of the self was viewed as essential to successful recovery. Several studies have shown how individuals active in the community internalise central AA ideas through formulating their own life story in line with an archetypical AA story, built up around certain narrative elements (Cain, 1991; Hänninen & Koski-Jännes, 1999; Lederman & Menegatos, 2011; Steffen, 1997; Thune, 1977). Briefly, it contains the retelling of how denial of escalating substance use problems finally leads to hitting rock bottom – an experience detrimental enough to break through denial (Cain, 1991).

Substance use problems are defined as an emotional disease in AA (Denzin, 1993), and the importance of admitting wrongdoings and moral defects are stated in the 12 steps, where changes considered necessary for recovery are done step-by-step. An important key to recovery, formulated in the first of the 12 steps, is to admit to being powerless in relation to alcohol/substances and to recognise how they have made life unmanageable. By doing this, the necessity of healing becomes obvious (Swora, 2004), and some studies have shown how AA members paradoxically define the recognition of powerlessness as empowering (Bond & Csordas, 2014; Myllmaki, 2011). The next 11 steps include, among other things, to come to believe in a power greater than oneself, to make a moral inventory of oneself and to make amends to people one has harmed. For further reading see Alcoholics Anonymous (1952).

To quit using substances is consequently, according to AA, a mere first step in the process of altering other, more fundamental, character flaws. According to this reasoning, the non-drinking AA member is also viewed as an alcoholic (Humphreys, 2000; Thune, 1977). The challenge of handling the potentially stigmatised identity of being a “sober alcoholic” has been explored by Hill and Leeming (2014). They found that one way of resisting stigma for the individual was to emphasise acceptance of the alcoholic identity as a sign of self-understanding and awareness, in this way claiming an identity of a new, more authentic self. Aspects of internalising AA ideas have also been studied by Glassman et al. (2021), who explored to what extent AA members experienced struggles with belonging to the movement. They found that while some individuals aligned fully with AA ideas after only a short time as active members, others were ambivalent even after several years. Glassman et al. (2021) also showed that while it was possible to negotiate and adapt some AA ideas to personal views, the collective belief that “alcoholics” are incapable of controlling their alcohol use was non-negotiable. Another important aspect of AA is its collectivistic character. The recovery of the individual AA member is in many ways dependent on interactions with other group members. New members are encouraged by established members to continue their AA engagement and find a sponsor who can guide them through their work with the 12 steps (Best et al., 2016).

Finally, spirituality is central to AA, and the second step states that believing in a higher power is the only chance for the individual to restore sanity (Swora, 2004). However, as there is no formal definition of spirituality within the AA movement, the concept of “a higher power” is open to individual interpretation and can refer not only to a metaphysical God but also to connections with other human beings and with nature (Bristow-Braitman, 1995; Myllmaki, 2011).

RP

RP was developed during the 1980s but had its international breakthrough at the turn of the millennium, with the Project Match study in 1997 identifying CBT-based RP as an effective treatment for substance use problems (Ortiz & Wirbing, 2017; Project MATCH Research Group, 1998). RP has developed over the years, and some versions have also come to integrate mindfulness-based elements (Witkiewitz et al., 2013). Nonetheless, the core of the model remains intact, centred on strategies and skills that should be mastered to prevent relapse (Ortiz & Wirbing, 2017). A basic idea is that abstinence can be maintained through thinking and acting in new ways. An important treatment goal is therefore improving the ability to identify triggers and high-risk situations, and to handle them (Dimeff & Marlatt, 1998; Marlatt & Gordon, 1985). The intervention is given as a course with several sessions led by professionals, and attendees are encouraged and helped through professional guidance to solve their own problems (Ortiz & Wirbing, 2017).

Compared with AA, abstention is not the only possible treatment goal in RP. Although total abstinence in the RP literature is considered the best alternative for most people with substance use problems (Saxon & Wirbing, 2004), depending on personal preferences and preconditions, controlled drinking is also presented as a viable alternative (Marlatt & Gordon, 1985; Saxon & Wirbing, 2004). RP advocates have also challenged the disease model of addiction, including the notion that the individual cannot control substance use (Dimeff & Marlatt, 1998; Saxon & Wirbing, 2004). These understandings are believed to increase the risk for the individual to interpret occasional shortcomings in ways that reinforce feelings of hopelessness. For example, RP founders Marlatt and Gordon (1985, p.8) state that: “If an alcoholic has accepted the belief that it is impossible to control his or her drinking (as embodied in the AA slogan that one is always ‘one drink away from a drunk’), then even a single slip may precipitate a total uncontrolled relapse”.

Even though manuals describe in detail how the intervention should be carried out, service providers tend to make local adaptions when applying RP in practice. They use the intervention as a general approach rather than a fixed technique (Ekendahl & Karlsson, 2021a), and professionals tend to lack a shared understanding of RP (Agboola et al., 2009). RP approaches have also been criticised for individualising responsibility for recovery (Theodoropoulou, 2020). As the RP narrative's focus on progress and individual responsibility echoes neoliberal valorisations (Ekendahl & Karlsson, 2022), it should not be seen as isolated from broader cultural discourses within Western society.

Methods

The study is part of a research project on how craving and relapse are understood and handled in the Swedish treatment system for substance use problems, from the perspectives of both treatment staff (Ekendahl & Karlsson, 2021a, 2021b, 2022) and service user (Ekendahl et al., 2022; Månsson et al., 2022). The analysis of this study is based on interviews with 12 service users, carried out in 2019. Because of the limited number of participants, the study should be considered exploratory. All participants had attended RP-based counselling and had experience of AA or Narcotics Anonymous, through formal treatment and/or self-help groups. Ethical approval for the research project was given by the Regional Ethical Review Board in Stockholm, Sweden (2018/1064-31/5). Eight participants were male and four were female. Six participants described having had problems with alcohol exclusively, and six participants described polydrug problems.

The interviews were carefully read in order to identify those parts where participants reflected on relapse. The focus on relapse was motivated by how relapse throughout the interviews was narrated as a constantly present threat that must be handled in ways that impacted the participants’ senses of who they are. The selected parts were then closely analysed in order to identify “small stories” (Bamberg & Georgakopoulou, 2008). According to Bamberg and Georgakopoulou (2008, p. 381), small stories are “underrepresented narrative activities”, such as telling of ongoing events, future or hypothetical events. At AA meetings, personal recovery stories are often told in fragments or shorter episodes illustrating specific points, as members interactively share experiences on different topics (Cain, 1991). The small story approach thus resembles the actual preconditions for storytelling within AA contexts. In this way, the approach allows for analysing those narrative activities that are typically dismissed, since they do not qualify as coherent narratives with temporally ordered events, and it is useful for analysing interview material (Bamberg & Georgakopoulou, 2008). Altogether, 38 small stories that referred to relapse were identified.

In order to highlight the relational and dialogical aspects of storytelling in the analysis, we also paid attention to how the narrators positioned themselves in relation to the audience, through justifying and/or valuing the events narrated. The audience can be both actual (the interviewer) and imagined, with the latter being potentially just as influential as the former in shaping the narrative (Litt, 2012; Riessman, 2015). The interviews were obviously carried out within the context of research, and most participants had recently been, or were currently in, treatment. Both these factors may have influenced the narratives, and potential imagined audiences could for example be academics and service providers expected to take interest in future research results.

In the analysis of the stories, the basic ideas of AA and RP, as outlined in the sections above, constituted theoretical frameworks for interpretation. Certain narrative elements of the stories were thus understood as deducible from either AA or RP ideas, such as ascribing oneself a high degree of agency or emphasising the importance of identifying high-risk situations and developing personal skills in handling cravings (RP), or emphasising the importance of admitting powerlessness, or describing a reliance on higher powers or a dependence on a collective (AA). As a narrative analysis carried out from a constructionist perspective cannot draw conclusions on people's inner states or mental processes leading up to certain statements, there is of course a possibility that the statements interpreted as derived from RP or AA ideas could be the result of other influences in the study participants’ lives. The categorisation of these narrative elements as either RP or AA was thus made by us to elucidate how statements compatible with RP and AA ideas, although sometimes seeming logically at odds, can co-exist in personal narratives of substance use and recovery.

The concept of polyphony was used to elucidate how the interplay between the treatment philosophies of AA and RP were reflected in the participants’ stories of relapse in ways that made “multiple voices find expression within any single voice” (Frank, 2012, p.35). The concept of polyphony was originally introduced by the Russian literary critic and language philosopher Mikhail Bakhtin, who used it to explore the plurality of voices in the work of Dostoevsky (Bakhtin, 1984). It serves to shed light on how stories are built up by fragments from different discursive resources, and from this perspective narratives are seen as constructed around personal experiences, while at the same time “no story is entirely anyone's own” (Frank, 2012, p.35). Polyphony in narratives has in prior research mainly been studied in relation to illness narratives, and has shown how people embrace rather than suppress contradictory plotlines and conflicting values when narrating experiences of illness and treatment (Ezzy, 2000; MacArtney, 2016). As pointed out by Törrönen (2022), illness narratives and narratives on substance use carry similarities as they often relate to forces that impact the narrators’ self-understandings. The polyphonic aspects of the identified small stories were thematised into two broad themes that summarised the main plotlines in the data: Agentic or powerless? and Chronically ill or insufficiently skilled?

Results

As will be shown, in those parts of the material characterised by polyphony, the individualistic RP ideas were formulated side by side with the more collectivistic ideals held within AA. These ideas were to varying degree more or less in tune with each other, in this way creating a narrative space within which the study participants could make sense of their experiences.

Agentic or powerless?

The polyphonic character of the stories was evident in how AA and RP narratives were combined and negotiated in relation to agency. The story below was told by Lars. He was approximately 60 years old and had experienced alcohol problems but had now been sober for a few years. He defined AA as vital for his recovery process, and he described attending meetings several times a week. However, when talking about strategies to prevent relapse, he leaned towards RP. In the story below, Lars positioned himself as a capable person, skilled in handling cravings constructively.

Lars: Because it has happened, also now in my apartment, I have sometimes felt like I did back in the days, that it could be a good opportunity to drink, for example because it is Friday. Or because something special has happened. “What the hell, I have to calm down, because this isn’t working out.” (…) So, that has happened a few times. And at these times, I have done the same thing. I have simply made sure that I have some activity to do. I can do the laundry. It will take me roughly 1 hour. “Okay, I didn’t make it in time [before the liquor store closed].” Then it has passed, for that day. The moment when it felt like a good idea [to drink] has passed (…)

In the story, references to AA ideas such as taking one day at a time were made. Lars’ story also reflected skills typically sought after in RP, where the development of strategies to handle risk situations are essential (Witkiewitz & Marlatt, 2004). Overall, and in line with what could be considered a success story from a RP perspective, Lars positioned himself as a person with profound agency. This self-positioning challenges the traditional AA narrative and its focus on powerlessness (Glassman et al., 2020). Drawing on a RP narrative, Lars presented himself as in control over cravings, and he saw the risk of relapse as manageable thanks to willpower and self-knowledge. However, while communicating assertiveness and self-confidence, Lars also, in another part of the interview, underlined the importance of attending AA meetings. Drawing on a RP vocabulary, he stated that speaking to other people with similar experiences was the most important “tool” for him; it gave him a sense of belonging.

The story below was told by Julia, a woman in her 20s who had been using different substances since a young age but had now been drug-free for almost a year. Julia defined herself as being in an early stage of recovery and stated that AA treatment had saved her life. Interviewer:

What is it that makes it possible for you to manage all this?

Julia:

It's because I have so much support. I have my sponsor, I have my meetings, I have my parents, I have the staff at the assisted-living facility. I have a safe network, and I really hope that I will make use of it. Because right now, I have so many chaotic feelings, and I am really weighing pros and cons with relapsing. There are no pros with relapsing whatsoever, and there will never be. So, I feel secure despite my insecurity, or how to put it. It's very, very hard to explain, but I know what I have to do, and I know what I can do, not to relapse. I just have to act on it.

The importance of agency was recurrently emphasised in Julia's story. She described herself as wholly responsible for her own recovery process. When pointing out what was most important to avoid relapse, Julia referred to her relations with other people (including her sponsor and other AA members) as her primal source of strength and support. However, the presence of the RP narrative was noticeable in how these relations were not defined as supportive in themselves, but rather as potential resources that Julia was responsible for “making use of”. Julia also lacked the confidence expressed by Lars. Instead of accounting for skills in handling cravings and avoiding relapse, she expressed “hopes” that she would be able to act in the right way. When doing this, Julia made references to multiple selves in a way that is characteristic of narratives produced within talk therapy contexts (Ekendahl et al., 2022). She described herself as a person who lacked control, and she made a clear distinction made between the person referred to on a story level, who “weighs pros and cons with relapsing”, and the person interacting with the interviewer, who stated that “there are no pros with a relapse”. Overall – and despite that she did not ascribe herself any high level of agency – Julia positioned herself in line with RP ideas, as a person who owns the solution to her problems.

The understanding of recovery as a personal project including individual responsibility was also communicated in the story below, told by Carina. She was approximately 50 years old and described having had alcohol problems for 10 years but had now been sober for almost a year. Carina:

I am very strict with my routines. In the morning, I pray and meditate, I have breakfast, and that is no matter what. Well, if there's a fire … But no exceptions. So, I’m very strict. And I have almost daily contact with my sponsor.

Interviewer:

Your AA sponsor?

Carina:

Yes. And I never skip meetings. The only exception is if my daughter calls me. I’m a grandmother, and if they need someone to babysit, then I’ll do that instead. That's better than meetings. But … well. I’m even more strict now.

Interviewer:

But what if you did do exceptions? What would happen?

Carina:

Then I will notice that. For example, I always bring fruit or chocolate with me. Sweets are really good if you get one of those … Because hunger is no good at all, and I’m aware of that. I have to handle it strictly. And if I haven’t eaten regularly, then it can show up [craving].

Carina described her everyday life as strictly organised around strategies aimed at preventing relapse. She mentioned praying and meditating as parts of her daily routine – something that is noteworthy, since it was the only explicit reference made to spirituality or higher powers in the material. Furthermore, other AA activities, such as attending meetings and having contact with her sponsor, were accounted for together with strategies that can be learnt through RP, for example the importance of avoiding hunger since that is something supposed to trigger cravings (Ortiz & Wirbing, 2017). Carina's story was a clear example of how RP and AA ideas are combined into a personal recovery project, where agency and responsibility are emphasised side by side with praying to higher powers.

Thus, a RP narrative strongly influenced the participants’ stories of relapse, even when explicitly referring to AA experiences. They interpreted their AA engagement through RP terms in a way that aligned with an understanding of the individual as highly responsible for the recovery process. Participants referred to meetings as “tools”, and they portrayed human relations as objects they were responsible for “making use of”. In these stories, recovery appeared as manual labour done by an active agent. Overall, this departs from how AA members, in the second of the 12 steps, are requested to accept that only “… a power greater than ourselves could restore us to sanity”. However, despite this logical inconsistency in AA's and RP's respective values and understandings, both treatment philosophies boiled down to the participants emphasising the importance of attending meetings. The potential contradiction did not seem to trouble their storytelling.

Chronically ill or insufficiently skilled?

Both AA and RP stress that the individual must stay aware of his or her problems, and never let their guard down. However, they differ regarding how this is best achieved. AA emphasises the importance of being humble and defining oneself as chronically ill, and the dangers of considering oneself “safe”. RP more explicitly focuses on developing competence to identify and handle situations and mechanisms that drive relapse.

Overall, the participants endorsed the AA idea of total abstinence as the only alternative when recovering from substance use problems. Yet, some participants also communicated an awareness that this, quite strict, definition of “relapse” may not be compatible with the view held by people in general. In the story below, Yusuf expressed an ambivalent view on whether his own choice, to abstain, was always superior when handling alcohol problems. Yusuf was approximately 50 years old. He described having had alcohol problems for 30 years but had now been sober for a few years. He had engaged in AA treatment and had a sponsor. Interviewer:

But is it a relapse to drink just one glass of wine? Do you consider all kinds of alcohol consumption to equal a relapse?

Yusuf:

No, I’m not that judgemental. But that's a view that exists within the AA circles: “Oh no, not even an alcohol-free beer!” That exists, it is like that. So … But, for a real alcoholic, it’s quite hard. To be honest, I can’t do that. I can’t have just one beer and then go home. And if I drink … if I have a beer, I tell my friends that “I will go all in”.

Here, Yusuf positioned himself as having insights into his own problems and functioning. While reluctant to give a general answer to how others should handle their alcohol problems, Yusuf stated that for him all kinds of alcohol consumption lead to relapse. At the same time, he claimed that he did not want to judge other people. He also contrasted this non-judgemental attitude with other, more categorical views flourishing in the AA collective. Yusuf both approved of and distanced himself from total abstention as the only alternative. Here, he positioned himself more in line with RP. Yusuf did not exclude the possibility that a person with alcohol problems can learn to drink in a controlled way, even though he saw himself as incapable of doing so. Overall, Yusuf presented himself as a person with self-knowledge, who had made a personal decision on how to handle alcohol. The polyphony of Yusuf's story illustrated a conflict, as he both related to the classical AA idea that alcoholics can never drink in a controlled way, but also to a culturally held norm, more compatible with RP, of letting people find their own solutions to personal problems.

Total abstinence was, for some participants, also troublesome in relation to people and situations outside AA. Ulrika was approximately 50 years old and described having had alcohol problems for several years. She was an active AA member and had now been sober for 1 year and had experienced one relapse during this time. Abstinence was not described as uncomplicated by Ulrika, but rather as a price she had to pay: Ulrika:

(…) And I have always hoped for being able to at least have a glass of wine, like at dinners. To be able to have that social … not just sitting at home. Because, I mean, my problems are at home. But to have a glass of wine, and sit down, and be like everyone else. Because, I’m so uncomfortable just sitting there, drinking water, while everyone else drinks wine. It's really hard.

Interviewer:

That they ask “why aren’t you drinking?” Or …?

Ulrika:

No, I’m quite okay with that, but I find it hard since I feel so boring. I can’t be the same person that I can be when I’m drinking. That's so much more fun. I find myself much more fun then. It's much easier to talk to people and … Well, it's not like I have any problems talking to people, but it's the feeling. I feel so boring compared with people around me …

Ulrika expressed regrets about not being like everyone else, and that abstaining from alcohol made her feel odd at social gatherings. She described sobriety as a sacrifice and referred to drinking as “much more fun” than abstaining. This deviates from the AA idea that sobriety is not only equal to abstinence, but also to finding meaning, inner peace and becoming a more authentic person (Hill & Leeming, 2014; Weegmann & Piwowoz-Hjort, 2009). Ulrika's story thus shows how people active in AA do not always embrace its basic ideas without reservations (Glassman et al., 2021). Ulrika seemingly drew instead on RP when describing her hopes of being able to drink socially. Her claim that this may be possible since her alcohol problems take place “at home” can be related to how RP attendees learn to identify places and situations as “high-risk”. Here, the polyphony of the AA and RP narratives created a space in-between that Ulrika made use of to negotiate her position as a member of the “remission society” (Frank, 1995), and to challenge the assertion that people with alcohol problems can never drink again.

Magnus was 55 years old. He described having had alcohol problems for 15 years and had at the time of the interview been sober for a few years. He reported having had a couple of relapses during this time, but also stated that he was not that bothered by cravings. Interviewer:

But what is it then that makes you want to keep attending meetings, and taking Antabuse? Because that makes me think that “well, then it must be very easy for you to stay sober”.

Magnus:

Exactly. That's the thing. That's what I’ve learnt at these meetings. That it's very fragile. You become aware of that. I mean, I’ve heard about people who have been sober for 10 years, and suddenly, they just sit there and … and relapses are often … people describe that … they can relapse after 5 years. And some people, they even die during relapses. And I mean, I’ve been fortunate, since I have calmed down after just a few days, but, well, it may not be like that the next time. And when I attend meetings, I become very aware of that. So, it helps me very much, even though I may not always reflect on it. It's like … I still can’t pinpoint why it's so very helpful to attend meetings.

Magnus compared his own experiences of relapse with others’, and stated that his relapses were relatively easy to manage. His wording, “I have been fortunate”, indicated that he did not attribute this to his own efforts, but rather saw it as a blessing. Magnus also took a humble position in relation to his problems, as he underlined that it may turn out worse “next time”. Similar to other participants, Magnus described being affected by meeting people who had relapsed despite long periods of sobriety, and that this had heightened his awareness of how “fragile” sobriety is. While this narrative quite exclusively voices the dangers of ignoring onés chronical illness, the story below, where Magnus further elaborated his view on relapse, was more clearly marked by an AA and RP polyphony. Here, Magnus accounted for how he, through monitoring his own behaviour, had gained insights into the mechanisms of relapse.

Magnus: And then I became aware of this other connection between … that every time I’ve relapsed, and this is something I found out after quite a long time, well, it was when I felt at my best. It wasn’t like I felt like crap and needed to have something because of that, to deaden anything or so. I just felt like “What the hell, I’m feeling fine, everything's working”. No, but … It's like … There's this old common saying, that “If you don’t feel well, go to a meeting. If you feel well, run!” And I think that's true. And I’m very aware of that. And that's also a tool for me. I mean, if I start to think “It's okay, I can skip this meeting” or “No, I don’t feel like it today”, then it's a risk that it just goes on like that. And what that could lead up to … I don’t even want to think about it.

Here, polyphony was present in how Magnus described that acting the way he learnt through RP – that is, identifying high-risk situations through analysing circumstances preceding relapse – had led him to conclusions highly compatible with AA, namely that being too confident and considering oneself self-sufficient was a risky illusion leading to relapse. The idea of relapse as something “planned”, and as a process that is built up gradually and often subtly before culminating in substance use, was present in several of the participants’ narratives. It can be related to the RP idea that “seemingly irrelevant decisions” – that is, decisions that could seem unimportant but anyhow lead up to high-risk situations and relapse – are critical for the individual to anticipate, identify and act upon (Dimeff & Marlatt, 1998). At the end of the story, Magnus referred to a hypothetical inner dialogue in which he, through making these “seemingly irrelevant decisions” to skip AA meetings, put himself into a high-risk situation with potentially catastrophic consequences.

As shown above, the AA and RP polyphony sometimes manifested in two parallel voices, not fully in tune with each other, in the participants’ narratives. As, for example, when Yusuf both approved of and distanced himself from the view that people with alcohol problems cannot drink with control. At other times, like when Magnus described how he analysed his behaviour and drew the conclusion that he should act in accordance with AA ideas, the polyphony was instead visible in how the two treatment philosophies contributed with separate building blocks to a personal recovery narrative.

Discussion

Defining oneself as a member of the “remission society” (Frank, 1995) – as a person who can never be completely cured from substance use problems – impacts the preconditions for storytelling, as it sets up constraints and limitations for how both past and present experiences can be narrated (ibid). As pointed out by Pienaar and Dilkes-Frayne (2017), although some addiction discourses may be pathologising they can still be useful for the individual. In light of this, the practical usefulness of the AA narrative is obvious; it offers a clear structure for organising the past, the present and the future. Still, understanding the risk of relapse according to AA principles includes defining oneself as an (sober) alcoholic or addict – a self-image that can be challenging to handle (Hill & Leeming, 2014). The participants in this study described having to be constantly vigilant, being different than people in general and experiencing a sense of belonging with other people active in the AA community. However, positioning oneself as in constant remission, different and dependent on a self-help movement, was a narrative accomplishment carried out in more than one way.

Although proceeding from classic AA principles, the participants negotiated their understandings of themselves and other people in recovery by means of an individually oriented RP narrative as well. Several relapse stories were polyphonic in combining fragments of AA and RP treatment philosophies. Some of these fragments could seem theoretically at odds. A case in point is RP's focus on personal progress through skills and agency in handling craving, as opposed to AA's emphasis on powerlessness and being dependent on a collective of other people (through meetings, interactions and sponsorship). There were also examples of stories that partly challenged total abstinence as the only way to handle substance use problems – a finding that is noteworthy since total abstinence has been pointed out as a non-negotiable in AA (Glassman et al., 2021).

A dialogical narrative perspective holds that storytelling is always carried out as a response to present, or imagined, others (Frank, 2012). From this view, what could be interpreted as inconsistencies rather illustrate that “any individual voice is actually a dialogue between voices” (Frank, 2012, p. 34). When positioning themselves in interaction with others, people can express multiple aspects of identity in ways that “do not sum up to a coherent self” (Depperman, 2015, p.370). The results of this study thus challenge the view that different types of recovery narratives are mutually exclusive (e.g., Hänninen & Koski-Jännes, 1999). AA and RP are two of the most common interventions in the Swedish substance use treatment system (Socialstyrelsen, 2018), and people with substance use problems regularly come into contact with both of them. On the one hand, the inconsistencies that exist between AA and RP philosophies are potentially troublesome for the creation of coherent personal recovery narratives. On the other hand, relating one's personal experiences of substance use and recovery with various and differing discursive resources may facilitate a flexible and dynamic self-understanding.

Taking context into consideration, it is important to acknowledge that the stories told by the participants are products of conditions and relations specific to the interview and study setting. When narrating understandings and experiences of relapse during AA meetings, RP sessions or with people with whom the participants may have developed a shared understanding, it is possible that polyphonic aspects present in this study are played down. Another noteworthy aspect, possibly related to context, is that there was only one reference made to spirituality throughout the entire material. Despite the possibility of interpreting and reformulating spirituality idiosyncratically and in non-religious ways (Bristow-Braitman, 1995; Kelly, 2017), it was mainly absent in the interviews. Since spirituality is central to working with the 12 steps (Humphreys, 2000; Swora, 2004), this is a silence worth discussing. The combination of Sweden being a secularised country and the fact that the storytelling was carried out within the framework of research may have contributed to the participants playing down spirituality. However, it is also possible that the influence of RP on the sampled stories – with its emphasis on individuality, agency and rationality – left no room for expressions of spirituality in the participants’ stories of relapse.

Conclusion

This study advances the knowledge on how personal stories of substance use and recovery are structured by treatment philosophies in ways that are diverse, context dependent and not always coherent. We conclude that personal recovery stories can simultaneously embrace apparently contradictory notions, including ideas that addictive behaviour is both voluntary and non-voluntary. In the participants’ stories, AA ideas were central, and they emphasised the importance of admitting powerlessness, being humble and drawing strength from the AA community. At the same time, drawing on a RP narrative, participants described individual strengths and efforts such as having agency, exercising self-monitoring and acquiring skills as crucial to recovery. The study is small-scale and exploratory but does suggest that we may currently be witnessing a change in the substance use recovery discourse, at least in Sweden where AA and RP are very common. This discourse seems to value pick-and-mix-principles over theoretical consistencies, and fits well within a broader cultural climate where responsibilisation and unfettered individualisation stand in a complicated and unresolved relationship with collectivism and surrendering to so-called addicting processes. These results add to previous narrative studies in shedding further light on the flexibility of the AA narrative and call for future research on the limits of this narrative's adaptability.