What factors might contribute to facilitating recovery from addiction in a recovery community? Insights into this issue can be gained from a piece of research that Lucie James and I conducted back in 2007/8 that involved a qualitative analysis of the views and experiences of clients on the highly regarded RAPt (the Rehabilitation for Addicted Prisoners Trust) treatment programme in one male and one female prison in the UK.
The RAPt treatment programme was a three-phase, abstinence-based 12-Step programme conducted over approximately 16 weeks. It aimed to facilitate cognitive, emotional and behavioural changes in inmates, so that they were less likely to use drugs and alcohol, and to reoffend, when released from prison. Our research was focused on identifying the processes that led to such changes.
1. Study Participants
A total of 15 males and 15 females, who had a long history of substance use problems and criminal offending, participated in the study. For the women, 11 of them described crack/cocaine or opiates as being their drug of choice. The average time they had been using their drug of choice was 15.6 years. Twelve of the men named crack/cocaine or opiates being their drug of choice, and they had used this drug on average for 20.6 years.
Subjects participated in semi-structured interviews—by Wired In colleagues Lucie James and Sarah Davies (now Sarah Vaile, Founder of Recovery Cymru)—that covered their experiences and views prior to entering the RAPt programme, on the programme, and since completing the programme (where applicable). Transcripts of the semi-structured interviews were analysed with Grounded Theory.
Participants in this study described being desperate for help in tackling their substance use problem before they entered the RAPt programme. Many felt that they couldn’t give up using/drinking on their own. For some, this belief came from repeated failed attempts at ceasing use; for others, their low self-esteem left them feeling that they were not capable of achieving their goal alone.
Study participants believed that this treatment programme was life-changing. They had decided to stop using drugs and try to ensure that this decision was maintained once they left prison. They found that a wide variety of elements operating within the treatment programme were critical in helping bring about the cognitive, emotional and behavioural changes occurring in themselves. They emphasised the importance of the programme focusing on all aspects of their lives, not just their problematic substance use.
2. Grounded Theory Analysis
Four inter-related themes were derived from the Grounded Theory analysis, labelled: ‘Belonging’, ‘Socialisation’, ‘Learning’, and ‘Support’. Each of these themes impacted on a fifth theme, ‘Personal Change’, comprising two key components, motivation to change and self-esteem.
Belonging: On the RAPt treatment programme, inmates met other people with similar experiences and realised that they were not alone. A sense of belonging helped them to open up and share their thoughts and experiences. It enabled them to build trusting relationships, leading them to feel more able to be honest with themselves and others.
Belonging to a group of people who had similar experiences and problems, but who were successfully changing their emotions, thoughts and behaviours, as well as feeling more confident they would address their substance use on release, also enhanced the participants’ motivation and self-belief in overcoming addiction. It facilitated the learning of new skills revolving around improved communication and better quality interpersonal relationships.
Socialisation: Participants got to know and relate to other people on the programme, and share thoughts and experiences. They learned that they were not the only one to have certain experiences and beliefs—also, to ask for and give help, and listen to and provide feedback. They became more able to trust, be honest, respect others, and learn about themselves. They began to feel they could talk to their counsellors and peer supporters.
Study participants described how their self-esteem and confidence increased as they learnt more social skills and became better at interacting with other people. The development of social skills contributed to an increased self-awareness, an understanding that participants needed to change their previous destructive thought and behavioural patterns, and a belief that they could leave their old lifestyles behind and work towards a more positive future.
Learning: Learning about the disease model of addiction and admitting to being addicted helped to change self-image, as participants no longer blamed themselves for their prior destructive behaviours. Understanding that they would have to abstain from all substances if they were to attain the goal of recovery led to significant changes in the participants’ thinking.
[NB. It is not necessarily learning about the disease model per se that is important here. It is likely that learning about another addiction model or combination of models as an explanatory framework would likely have been as important. The person must understand and relate to the model—it must be believable and ‘actionable’ to them.]
During the Step-work, participants began to see how out-of-control their lives had become and how their substance use had impacted negatively on others. They were helped to come to terms with, and let go of, their pasts and focused on a positive future free of substance use, a process which was facilitated by understanding and utilising the concept of a Higher Power.
As they learnt about addiction, themselves and their capabilities, the participants became more motivated and determined to change and abstain from substance use. Meeting other people who had gone through the same stages also helped to motivate and give hope that recovery was attainable.
Participants began to understand the relationships between their drug use and their thoughts and behaviours. They learnt a great deal about recognising certain thoughts, feelings and behaviours, and became better ‘armed’ to deal with any potentially destructive thoughts or behavioural patterns.
Support: Support was a key factor in the perceived success of the RAPt programme, and in the changes that the participants saw in their thinking and behaviours. This support came from various sources—staff, peers, peer supporters, family members—and involved different aspects of the programme, e.g. group therapy, one-to-one counselling, family conferences, Fellowship meetings.
In addition, the participants developed the ability to offer support to others, which helped boost their confidence and made them feel like a valued member of the group. Support was paramount in enabling and encouraging the participants to open up about their thoughts and experiences, and let go of the past and focus on the future. The participants received positive feedback at every step they made towards developing their new lives, and this reinforcement helped to boost self-esteem and confidence.
Personal Change: The participants frequently referred to their self-esteem and confidence, and to their motivation to change. Other research has shown that these are critical elements influencing a person’s ability to overcome their substance use problems and find their path to recovery.
In the present research, a variety of elements related to the themes described above enhanced self-esteem and increased the participants’ motivation, and confidence in their ability, to change. These elements included aspects related to the socialisation process and belonging, the education programme, and the feedback and support available from various sources.
Seeing others doing well in the programme and in Fellowship meetings also played a significant role in enhancing hope and motivation to change.
The interviewees emphasised that a critical element of the success of the programme was that attention paid to all aspects of the participants’ lives, not just their substance use issues. The programme showed participants that their problematic substance use stemmed from issues that occurred in their lives. This completely changed the way that many viewed themselves, as they had previously thought that it was their own fault that they couldn’t stop taking drugs/alcohol.
Participants also obtained a better understanding of themselves, and the relationship between their thoughts and behaviours, and were taught how to divert potentially destructive behaviours. This all enhanced self-esteem and helped them become more confident in their ability to abstain from substances.
As they implemented what they had been taught during the Step-work, they saw the positive changes that this made, and this acted as a further reinforcement to change. Many of the participants described beginning to like themselves and understand who they really were. Seeing oneself differently (in a positive sense), and liking oneself, are powerful facilitators of recovery.
One final aspect of personal change emphasised by interviewees was that programme participants must want to change, and must work hard if change is to occur. Many of the clients described periods of emotional distress occurring during the programme, which they considered an important part of the change process.
A more in-depth description of this research can be found on this website.
It is very likely that these same factors—’belonging’, ‘socialisation’, learning’ (or ‘understanding’) and ‘support’—operate in recovery communities to enhance self-esteem/confidence and motivation to change, and thereby facilitate recovery from addiction.
The photograph above, taken in Cowbridge (Wales) in 2007, shows Lucie James (Left) and Sarah Vaile (née Davies), the two Wired In team members who conducted the interviews in the prisons. Lucy did the Grounded Theory Analysis and wrote the report for RAPt.