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Addiction Research & Theory
ISSN: 1606-6359 (Print) 1476-7392 (Online) Journal homepage: http://www.tandfonline.com/loi/iart20
Defining and operationalizing the phenomena of
recovery: a working definition from the recovery
science research collaborative
Robert D. Ashford, Austin Brown, Tiffany Brown, Jason Callis, H. Harrington
Cleveland, Emily Eisenhart, Hillary Groover, Nicholas Hayes, Teresa
Johnston, Thomas Kimball, Brigitte Manteuffel, Jessica McDaniel, Lindsay
Montgomery, Shane Phillips, Michael Polacek, Matt Statman & Jason
Whitney
To cite this article: Robert D. Ashford, Austin Brown, Tiffany Brown, Jason Callis, H. Harrington
Cleveland, Emily Eisenhart, Hillary Groover, Nicholas Hayes, Teresa Johnston, Thomas Kimball,
Brigitte Manteuffel, Jessica McDaniel, Lindsay Montgomery, Shane Phillips, Michael Polacek, Matt
Statman & Jason Whitney (2019): Defining and operationalizing the phenomena of recovery: a
working definition from the recovery science research collaborative, Addiction Research & Theory
To link to this article: https://doi.org/10.1080/16066359.2018.1515352
Published online: 07 Jan 2019.
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ORIGINAL ARTICLE
Defining and operationalizing the phenomena of recovery: a working definition
from the recovery science research collaborative
Robert D. Ashford
a
, Austin Brown
b
, Tiffany Brown
c
, Jason Callis
d
, H. Harrington Cleveland
e
,
Emily Eisenhart
f
, Hillary Groover
b
, Nicholas Hayes
g
, Teresa Johnston
b
, Thomas Kimball
g
, Brigitte Manteuffel
h
,
Jessica McDaniel
b
, Lindsay Montgomery
b
, Shane Phillips
i
, Michael Polacek
b
, Matt Statman
j
and Jason Whitney
e
a
University of the Sciences Substance Use Disorders Institute, Philadelphia, PA, USA;
b
Kennesaw State University, Kennesaw, GA, USA;
c
University of Oregon, Eugene, OR, USA;
d
University of Georgia, Athens, GA, USA;
e
Pennsylvania State University, State College, PA, USA;
f
Georgia Southern University, Statesboro, GA, USA;
g
Texas Tech University, Lubbock, TX, USA;
h
Georgia Health Policy Center, Georgia State
University, Atlanta, GA, USA;
i
North Carolina State University, Raleigh, NC, USA;
j
University of Michigan, Ann Arbor, MI, USA
ABSTRACT
A number of definitions exist for the concept of “recovery”in both the substance use disorder (SUD)
and mental health (MH) fields. Previous attempts to define recovery have not reached consensus
among experts within the field. Thus, the definition has remained diffuse at the expense of attempts
to measure and evaluate treatment and recovery outcomes. The notion of recovery as an organizing
principle between SUD and MH, collectively identified as behavioral health (BH), can be better served
by a collaborative endeavor to define the word and concept of “recovery”. The Recovery Science
Research Collaborative (RSRC), an interdisciplinary bi-annual collaboration among recovery researchers
and professionals from across the country, sought to address the definition of recovery at the inaugural
meeting in December 2017 at Kennesaw State University. The RSRC undertook this task with the pri-
mary goal of defining “recovery”for use in research –aiming to create a consensus definition that
allows recovery to be clearly operationalized and effectively investigated.
ARTICLE HISTORY
Received 28 February 2018
Revised 25 April 2018
Accepted 20 August 2018
KEYWORDS
Recovery; addiction;
substance use disorder;
behavioral health; recovery
measurement;
recovery science
Introduction
Defining phenomena and operationalizing these definitions
is key to scientific research. Without definitions that achieve
some level of consensus, researchers have no way to assess
the validity of measurements of phenomena, define out-
comes, or come to agreement on meanings and values
within a specific field. The fields of substance use disorder
(SUD) and mental health (MH) recovery have seen several
attempts at defining the word and concept of “recovery.”
National organizations such as the Substance Abuse and
Mental Health Association (SAMHSA), the American
Society for Addiction Medicine (ASAM), the Hazelden Betty
Ford Foundation (HBFF), and others have developed work-
ing definitions of recovery (The Betty Ford Institute
Consensus Panel 2007; Substance Abuse and Mental Health
Services Administration 2011; American Society of
Addiction Medicine 2013). However, various operational
weaknesses and professional lens-specific limitations from
the fields in which such definitions originate remain, and a
true consensus among the recovery field and community has
yet to be obtained.
The task of defining recovery inherently involves a large
number of stakeholders, including those delivering profes-
sional and paraprofessional services as well as peers in
recovery themselves. Inherent in a multiplicity of
stakeholders and providers, there is significant financial and
clinical stake in such definitions (Kelly and Hoeppner 2015).
The divide between professionals and peers within substance
use and mental health disorder communities has generated
tension in attempts to define recovery as well (El-Guebaly
2012). Various styles of individual recovery and the accom-
panying recovery experiences have further complicated the
issue (e.g. abstinence-based recovery, medication-assisted
recovery, natural recovery, etc.) (White 2007). These
obstacles, as White (2007) describes, have prevented an
achievement of true scientific consensus on the definition of
recovery. Overcoming these obstacles and establishing a level
of scientific consensus on the definition of recovery by an
independent panel is an essential step in advancing the rigor
of recovery research. Such a definition can then be handed
over to the larger scientific community for evaluation of use
within research frameworks. In an attempt to complete such
a task, the Recovery Science Research Collaborative (RSRC)
was convened in December 2017.
As an independent panel, the RSRC has a mission to sup-
port the direct expansion of the science of recovery and
recovery support systems. As the centerpiece of the panel’s
endeavors, the RSRC could not philosophically move for-
ward without defining recovery or adopting an official defin-
ition from stakeholder entities such as SAMHSA.
CONTACT Austin Brown abrow563@kennesaw.edu Center for Young Adult Addiction and Recovery, Kennesaw State University, 1085 Canton Pl. NW Suite
6139 B MD 6002, Kennesaw, GA 30144, USA
ß2018 Informa UK Limited, trading as Taylor & Francis Group
ADDICTION RESEARCH & THEORY
https://doi.org/10.1080/16066359.2018.1515352
The Recovery Science Research Collaborative (RSRC)
The RSRC consists of university researchers, direct practice
staff, public health professionals, and policy advisors from
institutions across the country. The Center for Young Adult
Addiction and Recovery (CYAAR) convened the RSRC
through direct invitation. Support for the RSRC meeting and
activities was made possible through philanthropic gifts to
the CYAAR earmarked for recovery science research activ-
ities. The inaugural RSRC meeting was held at Kennesaw
State University from December 3–5th, 2017 with the fol-
lowing members in attendance (alphabetical order by
last name):
1. Robert Ashford (University of the Sciences)
2. Austin Brown (Kennesaw State University (KSU))
3. Tiffany Brown (University of Oregon)
4. Jason Callis (University of Georgia)
5. H. Harrington Cleveland (Pennsylvania State
University (PSU))
6. Emily Eisenhart (Georgia Southern)
7. Hillary Groover (KSU)
8. Nick Hayes (Texas Tech University (TTU))
9. Teresa Johnston (KSU)
10. Thomas Kimball (TTU)
11. Brigitte Manteuffel (Georgia Health Policy Center,
Georgia State University)
12. Jessica McDaniel (KSU)
13. Lindsay Montgomery (KSU)
14. Shane Phillips (North Carolina State University)
15. Michael Polacek (KSU)
16. Matt Statman (University of Michigan)
17. Jason Whitney (PSU)
The primary goals of this inaugural meeting were to: (1)
reach a consensus definition of the concept and word of
recovery, (2) discuss the current state of recovery research in
the field, and (3) identify recommendations for future
research directions.
In keeping with the intellectual independence of the
panel, it was agreed that such a panel would attempt to
define recovery for research purposes, rather than adopt the
official definition from a stakeholder entity. However, it was
also agreed that such a definition should be arrived at only
after a thorough assessment of existing definitions. Through
either espousing or discarding key strengths and weaknesses
from the most current supporting data, the group was able
to produce a synthetic, but independent, recovery definition,
which could be operationalized for recovery science
and research.
Existing definitions and background
White (2007) illuminates key points about the paradigms of
recovery. As White purports, reduction or elimination of
symptomatological indices has been the classical bedrock of
previous recovery definitions. However, recovery is generally
believed to encompass far more restorative and healing
aspects than mere symptom reduction, even when primary
symptoms are mostly eradicated. Recovery, conceptualized
and defined as an ongoing process with various pathways of
deliberate and sustained growth, allows for a broader under-
standing of recovery phenomena while allowing for specific
factors to be measured. Associated measured phenomena
include social functioning, quality of life, and relief of psy-
chological distress. Moving from a deficit-based paradigm to
a more holistic, strengths-based paradigm allows growth,
rather than pathological reductions, to be the central para-
digm of recovery science. Challenges to defining recovery
also include the degree of specificity, inclusion or non-inclu-
sion of behavioral health recovery, cultural considerations,
and degrees of changes defining the initiation, sustainment,
and fulfillment of definitional parameters.
Since the early 2000s, changing paradigms around the
concept of recovery have been taken up in meaningful ways
by various stakeholders. These stakeholder groups have
attempted to develop working definitions of recovery, yield-
ing 10 relevant definitions (Figure 1).
Three leading definitions of recovery come from
SAMHSA, the American Society of Addiction Medicine
(ASAM), and the Betty Ford Institute Consensus Panel
(BFICP) (The Betty Ford Institute Consensus Panel 2007;
Substance Abuse and Mental Health Services Administration
2011; American Society of Addiction Medicine 2013). As
with any definition, each of these has its strengths and chal-
lenges. To some extent, these may reflect the position of the
institution providing the definition - government, treatment,
and clinical - and agreement reached between affiliated par-
ties, and may not serve the operational needs of rigorous
research and evaluation.
SAMHSA
In their 2011 working definition, SAMHSA defined recovery
from mental health and/or substance use disorder as: “A
process of self-directed change through which individuals
improve their health and wellness, live self-directed lives,
and strive to reach their full potential.”
An obvious strength of this definition is the holistic
implication, and the focus on striving for healthy potential.
An additional strength of the definition is its scope, encom-
passing both mental health and substance use disorder
recovery. The focus on self-directed living, health and well-
ness, and recovery as a process are all key concepts that
should be included in defining recovery. Potential weak-
nesses of this definition are the non-specific nature of the
definition. There are many processes individuals may engage
in that improve their lives, their autonomy, or their wellness.
From education to exercise, all lives are improved through
intentional processes of change, not just the process of
recovery. For an entity such as SAMHSA, whose main func-
tion is that of a governmental agency dedicated to “reducing
the impact of substance use disorders and mental health”by
providing a clearinghouse for “information, services, and
research”, such a definition may be quite serviceable and
broad so as to cast as wide a net as possible for their
intended function. Key areas of this definition were adopted
by the RSRC panel, most notably the focus on recovery as a
2 R. D. ASHFORD ET AL.
process with holistic goals that occur through self-
directed means.
ASAM
Developed first in 2005 and updated in 2013, ASAM’s defin-
ition of recovery is applicable only to substance use disor-
ders, with specific focus on the chronic disease concept of
addiction pathology. ASAM’s definition of recovery reads:
“A process of sustained action that addresses the biological,
psychological, social, and spiritual disturbances inherent in
addiction.”The definition goes on to explain “Recovery aims
to improve the quality of life by seeking balance and healing
in all aspects of health and wellness, while addressing an
individual’s consistent pursuit of abstinence, impairment in
behavioral control, dealing with cravings, recognizing
problems in one’s behavior and interpersonal relationships,
and dealing more effectively with emotional responses.”
This definition is perhaps the most specific of the three
detailed here, and touches on integral elements of wellness,
while at the same time aligning behavioral and emotional
healing as concurrent necessities. Within the ASAM defin-
ition is the conceptualization of recovery as a process which
includes multi-dimensional spheres from the biological, psy-
chological, social, and spiritual arenas. We see also the use
of sustained action or intentionality in seeking recovery as a
key fulcrum of the definitional paradigm. This sets recovery
as an actionable and intentional process of seek-
ing wholeness.
The inclusion of spiritual disturbances is also a key
strength. This provides inclusive room for spiritually-based
recovery programs and their ensuing concepts of recovery as
overcoming a “spiritual malady”through “spiritual
Figure 1. Recovery definitions. This figure documents the most popular definitions of recovery (Kelly and Hoeppner 2015; Courtesy of the Recovery Research
Institute 2017).
ADDICTION RESEARCH & THEORY 3
awakening”, and the rapid conversionary processes of the
programs such as the Christian-centered Celebrate Recovery
or Buddhist-centered Refuge Recovery. Though generally
poorly defined in recovery research, certain common ele-
ments do emerge from meta-analysis of spirituality; namely
the role of spirituality in relatedness, transcendence, and
meaning (Cook 2004). Spirituality may serve recovery by
providing comfort, the means of rectifying the past, illumin-
ation to new realities, and a coherent sense of union with
others and the universe (Drobin 2014). Suffice to say, spir-
ituality is a multi-dimensional concept with intrinsic proper-
ties that involves coping, meaning, quality of life, stress-
reduction, and health protective factors (Miller and
Thoresen 2003; Laudet et al. 2006; Park 2012). Spiritually-
based recovery constitutes a large amount of recovery expe-
riences and as such, spirituality appears to be an essential
component of the recovery process for many (Kelly et al.
2017). This aligns well with the holistic conceptualization
that recovery is a healing of the body and mind and the
seeking of balance in one’s life as an intentional act within
the recovery framework. Acts such as prayer, meditation,
yoga, and the seeking of “mindfulness”appear often within
the anecdotal and even the scientific literature on the topic
(Chiesa and Serretti 2014). Shortcomings of the ASAM def-
inition may include the overall length of the definition and
the criterion of pursuit of abstinence. While abstinence may
be the most emancipatory state of individual recovery for
those with severe substance use disorders, it is better consid-
ered a recovery outcome, but not required to consider an
individual engaging with the recovery process. Abstinence
may also remain physically and biochemically impossible for
some of the most severe cases of SUD, particularly those
involving opioid use, where opioid-agonist therapy is consid-
ered the appropriate clinical course of care.
Betty Ford Institute Consensus Panel
In 2007, the Betty Ford Institute Consensus Panel defined
recovery as: “A voluntary maintained lifestyle characterized
by sobriety, personal health, and citizenship.”This definition
has several important aspects, as it summarizes the dimen-
sions of wellness into “personal health”, while implying
community health through active engagement of
“citizenship”. Community engagement and prosocial behav-
iors may very well be characterized by the concept of citi-
zenship, as has been put forth in social models of recovery
(Best and de Alwis 2017). Again, we see the idea of self-
directed efforts to sustain or maintain a degree of wellness
illustrated in the previous definitions. The term “sobriety”is
stated to be the “criterion necessary for a recovery lifestyle”.
Similar to the ASAM definition involving abstinence, this
term is less stringent, while maintaining a focused lens of
substance use disorder specificity.
Although this definition is both compact and specific, the
reliance on a diffuse concept of sobriety may present the
same challenges as the ASAM reliance on “abstinence”.
While “sobriety”may offer more as it suggests “clear-head-
edness”rather than a specified state of abstention, this may
be misinterpreted. As outcomes and degree of emancipation
from addictive and or pathological states vary, one may be
remiss to require a completely substance-free outcome of the
recovery process. It also shares the limiting factor of the
ASAM definition in that it is narrowly focused on substance
use disorders, failing to take into account both the similar-
ities with mental health disorders, and the large prevalence
of co-occurring mental health disorders in individuals with a
primary addiction pathology (Kessler et al. 2005).
Framework for an Updated Definition of Recovery
From these leading definitions we can surmise certain basic
and fundamental elements, while setting aside certain con-
tentions and confusions in a new definition of recovery. The
first element being the role of the individual as an active
participant choosing to seek wellness. The second being the
paradigm of recovery as a state of wellness across multiple
dimensions including physical, psychological, and spiritual.
We can also anticipate the importance of engagement with a
community that upholds prosocial values and expectations
of behavior.
Individually, quality of life seems to serve as the central
operant in the recovery process. Quality of life is likely
achieved through a holistic approach to overcoming the
restraints of a pathological way of being. The relationship to
oneself, and the relationship to one’s surroundings and other
people, must be based in rational, equitable, and fulfilling
ways whereby the individual engages in servicing and receiv-
ing of mutual benefit. It is important also to note that as a
process, recovery is a verb, bringing forth the idea of action
that moves one from disordered states to states more condu-
cive of balance, harmony, growth, and health.
Noticeably missing from each existing definition is an
overt recognition that the contexts, systems, and people
involved in recovery may vary greatly across individuals and
between segments of similar groups of individuals. The role
of community for example, may predictably harm individu-
als that are seeking recovery. The role of socio-economic
factors, stigma, ethnicity, recovery pathways, and degrees of
pathological severity and organic impairment all have a
major impact on the cognizance and establishment of, the
motivation for, and the ability to maintain recovery. Any
discussion of recovery that does not account for the role of
contexts and individual experiences will ultimately
be incomplete.
Defining the concept of recovery may have wide-ranging
implications. These may include informing research endeav-
ors, improving the evaluation of clinical outcomes, program
development, interventions, and guiding future evidence-
based practices in clinical and social-based care. This paper
details the process of the RSRC in reaching a consensus def-
inition of recovery, as well as the parameters of terms
included in the final definition. In addition, we put forth
recommendations intended to assist in the process of select-
ing metrics of recovery so future research not only has a
useful definition of recovery, but empirical ways to effect-
ively measure the concept in individuals with behavioral
health disorders.
4 R. D. ASHFORD ET AL.
Methods
Process
The consensus process started with examining current defi-
nitions of recovery from leading sources such as The Betty
Ford Institute Consensus Panel (2007), UK Drug Policy
Commission (2008), Substance Abuse and Mental Health
Services Administration (2011), American Society of
Addiction Medicine (2013), and Recovery Research Institute
(2017) (see Figure 1). Discussions took place regarding the
strengths and weaknesses of each definition, especially
regarding populations left out by defining recovery in cer-
tain ways, and the reasoning for word choice and bounda-
ries involved in previous definitions. Several of these
definitions contain particularly strong points the panel
hoped to incorporate.
From the background literature defining recovery, as well
as definitions held by organizations, several strengths were
distilled and utilized. These included: (1) considering recov-
ery as an intentional, self-directed process, and (2) including
holistic elements, such as quality of life, spirituality, citi-
zenry, and community involvement. Weaknesses in defini-
tions included: (1) focusing only on substance use disorder,
rather than broader inclusion of mental health disorders
under the term behavioral health disorder; and (2) including
traits that serve better as outcomes (e.g. abstinence) than
definitional parameters. While overall outcome states may
be of value in the search for efficaciousness, particularly in
empirical research; it is important that such outcomes are
placed within the context of processes that induce glo-
bal wellness.
Construction of the RSRC definition began with linguistic
analysis of key concepts and terms that related to specific
features of recovery. Particularly, that recovery is a process
that often occurs through relationships in a multiplicity of
trajectories. Additionally, that overlap exists between mental
health and substance use disorder recovery paradigms, and
that the scope and context of recovery is influenced by cul-
tural and ecological factors.
Reaching consensus
After developing three potential definitions of recovery from
the break out group session, the full RSRC discussed the
merits of each definition separately. In this iterative process,
a final proposed definition was created with elements from
each of the three. Members of the RSRC (N¼17) then voted
non-anonymously on each definition. With light modifica-
tions to the definition after two rounds of voting, consensus
was reached on the third vote.
Results
The RSRC consensus definition of recovery
The RSRC’s consensus definition of recovery is: “Recovery is
an individualized, intentional, dynamic, and relational pro-
cess involving sustained efforts to improve wellness.”
Definitional parameters of the consensus definition
Individual terms are defined but should be viewed holistic-
ally in context of the phrase they are contained within.
Table 1 provides all individual definitions used within the
final RSRC recovery definition.
“An individualized, intentional, dynamic, and relational process”
The definitional parameters of recovery must take into
account the variance that occurs across demographic charac-
teristics (e.g. gender, race, ethnicity, disordered pathologies,
age, etc.) and environmental (e.g. social and experiential)
contexts. While recovery as a process is likely to contain cer-
tain similarities across stratified segments of the population,
it is as likely to contain mediating and moderating variables
creating an individualized process at all stages. As such,
recovery must not be constrained or limited by definitional
parameters that also seek to constrain the population
of interest.
White and Sanders (2008) stress the importance of not
imposing a dominant “organizing metaphor for recovery”
onto historically disempowered individuals and commun-
ities. Doing so not only has the potential to reenact proc-
esses of colonization, it also fails to accurately comprehend
how individuals and entire communities of people under-
stand the etiology of addiction and recovery. Allowing for
contextual variance can assist in further operationalizing the
recovery process, and the measurement of such a process,
for many populations of interest, despite the contexts in
which they exist.
None of the previous definitions went so far as to include
a parameter allowing for individualization of recovery along
differential contexts. The closest comes from Substance
Abuse and Mental Health Services Administration (2011)
Table 1. Term definitions.
Term Definition Used
Dynamic (Of a process or system) characterized by constant change, activity and progress.
Intentional Done on purpose, deliberate
Relational Concerning the way in which two or more things are related
Process A series of actions or steps taken in order to achieve a particular end
Sustained Continuing for an extended period without interruption
Efforts A vigorous or determined attempt
Wellness A state of being in good health, especially as an actively pursued goal
Individual Of and for a particular person
Social (Adjective): relating to a society and its organization, synonyms community, collective, group
Experiential Involving or based on experience and observation
Contexts The circumstances that form the setting for an event, statement or idea, and in terms of which it can be fully understood and assessed.
ADDICTION RESEARCH & THEORY 5
definition, which calls for self-direction, which is an individ-
ualized element. However, this seems to be attributed to
autonomy, rather than personal contexts.
We have also put forth here that the process of recovery
is an intentional one. This is an important distinction from
treatment and prevention services, which can be intention-
ally sought out or mandated through various means (e.g.
court-ordered, parent/guardian ordered, etc.). Recovery as
an intentional process relates to the autonomy of the indi-
vidual in choosing to engage in the process –that they are
an active partner, self-directing the desired outcomes
through formal partnership with professionals, peer-driven
communities, and fellowships, or through informal, organic
networks such as family, friends, and/or faith. While individ-
uals may unconsciously “drift”or “age-out”of substance use
disorders (White 2007) and while mental health disorders
may become naturally less disruptive as one ages, such
degrees of spontaneous remissions may lack the intentional
and conscious choice to seek wellness and therefore may not
fit within the definition of recovery presented here.
However, as natural recovery has been proposed as a process
that simply does not require the use of formal or informal
supports such as treatment or mutual-aid groups but is
likely still intentional, additional insight into this process of
natural recovery is needed. For those individuals that have
resolved a SUD without the use of external supports, it is
likely that the process is ultimately intentional and mirrors
the growth that can be expected when one is in recovery.
Borrowing from several definitions the presumption that
recovery is a process of change, rather than an outcome that
is static once achieved suggests an inherently dynamic pro-
cess. Ergo, the results of the recovery process are varied,
affect different spheres of life at different times, and are con-
stantly evolving. The rationale for recovery as a dynamic
process is exemplified by the complexities of possible trajec-
tories and outcomes, which may vary between individuals.
Outcomes of such a process are pro-social, life-affirming,
and trend toward wellness. However, the essence of recovery
is a desired movement from disordered to more ordered
states, whereby more ordered states are likely to provide a
more fulfilling, connected, and meaningful way of living,
responding, and being.
Relationships between individuals, relationships with one-
self, and relationships to institutions, ideas, and cultural
social systems are the chief wellspring from which the
pathological manifestations of substance use disorder and
related mental health pathologies tend to manifest. Families,
relationships, and systems, such as criminal justice and med-
ical, are all dragged into the realm of the pathology. Thus,
the chief platform or stage where recovery emerges is in
these same realms, but more importantly, in the recovering
individual’s relationships to themselves, others, and society.
Recovery is very much a pro-social process whereby individ-
uals become more synchronized in values, thoughts, actions,
and beliefs through their relationships to the world around
them. This is a mutually beneficial and reciprocal arrange-
ment which builds the multi-directionality needed for stable
social capital.
Previous definitions regarding recovery as a process are:
The Center for Substance Abuse Treatment (2005), William
White (2007), The Scottish Government (2008), the UK
Drug Policy Commission (2008), Substance Abuse and
Mental Health Services Administration (2011), American
Society of Addiction Medicine (2013), Kelly and Hoeppner
(2015), and the Recovery Research Institute (Recovery
Research Institute 2017). Two definitions fall on a different
spectrum, and regard recovery either as a state or outcome
that is a product of change (American Society of Addiction
Medicine 2005), or as a lifestyle typology (The Betty Ford
Institute Consensus Panel 2007).
“Involving sustained efforts”
Sustaining wellness over time is an intentional act involv-
ing such mechanisms as social support, clinical input and
modification, and ongoing efforts at self-awareness, in order
to maintain a state of freedom from pathological symptom-
atology or to reach the desired self-directed recovery out-
comes. The majority of such effort is captured in behaviors
and actions toward wellness, either directly or indirectly.
These efforts can include attending mutual-aid peer support
programs, engaging with a recovery community organiza-
tion, on-going clinical care, taking prescribed medications,
exercise, etc.
As behavioral health disorders are often categorized as
chronic in nature (National Institute of Mental Health 1987;
American Society of Addiction Medicine 2011), it is critical
that the recovery process involves sustained efforts over
time. While these efforts may indeed vary in magnitude and
frequency, given the dynamic nature of the recovery process,
it is a hallmark that some level of effort is indeed sustained
long-term for individuals.
Definitions containing elements that direct towards sus-
tained and individualized efforts are: Betty Ford Institute
Consensus Panel (2007), William White (2007), the UK
Drug Policy Commission (2008), and American Society of
Addiction Medicine (2013). This varies from other defini-
tions of recovery –including American Society of Addiction
Medicine (2005), Center for Substance Abuse Treatment
(2005), The Scottish Government (2008), Substance Abuse
and Mental Health Services Administration (2011), Kelly
and Hoeppner (2015), and Recovery Research Institute
(2017)–where sustained efforts are not men-
tioned explicitly.
“To improve wellness”
Ecological factors, intrapersonal factors, and interpersonal
factors are all involved in wellness. Given the eight dimen-
sions of wellness (Substance Abuse and Mental Health
Services Administration 2016), coupled with the propensity
for substance use disorder to cause wide ranging negative
consequences, the recovery from such would naturally
require healing and growth in multiple areas or life spheres.
Intentional efforts to enact recovery dynamics, even in areas
not typically associated with SUD is the hallmark of recov-
ery. This also includes direct efforts to mitigate and manage
co-occurring behavioral health issues which may complicate
the overall efforts toward holistic health.
6 R. D. ASHFORD ET AL.
All previous definitions contained parameters that expli-
citly mention multiple aspects of wellness though there was
variance among the included domains in the concept of
“wellness”or “wellbeing”.
Discussion
Previous attempts to define recovery have been plentiful
throughout the behavioral health field. Each attempt has
contributed toward the ever-expanding foundation of this
phenomena as conceptualized throughout the sciences. In an
attempt to provide a definition of recovery that is multi-
faceted and applicable to all sectors of behavioral health (e.g.
MH and SUD), the RSRC brought together stakeholders that
reached a consensus definition.
Of special interest in the RSRC consensus definition is
the lack of a predilection of abstinence as a necessary stand-
ard of recovery, which is similar to the SAMHSA working
definition of recovery (Substance Abuse and Mental Health
Services Administration 2011). The aim of this consideration
was driven by a desire for inclusivity. This includes encom-
passing both MH and SUD recovery, as well as varying
paths of recovery initiation and maintenance (i.e. recovery
pathways), within the definition. The field of SUD treatment
and recovery has continued to evolve, most rapidly in the
midst of the ongoing opioid epidemic in the United States.
Most recently, this has included increased visibility of alter-
native forms of recovery (e.g. opioid-agonist medications;
harm reduction; etc.), apart from the more traditional inter-
pretations of recovery that are predicated on complete
abstinence. While the current definition does not exclude
this hallmark of abstinence, which is present in many indi-
viduals’recovery process (Kelly et al. 2017), it does inten-
tionally allow for a broader set of parameters focusing on
self-defined criteria of the process, be that abstinence, mod-
eration, or medication use.
Freedom from problematic substance use is likely the pre-
ferred goal if one is seeking wellness, provided such sub-
stance use cannot be controlled or managed. In those
individuals with severe SUD, where such control or manage-
ment is not considered possible, abstinence is likely neces-
sary for this freedom at some point in the recovery process.
Thus, the aspirational goal of such emancipation from sub-
stances, when achievable, is implied through movement
towards wellness itself. Therefore, “abstinence”is perhaps
better used as a clinical or aspirational outcome, rather than
a definitional boundary to be captured by the term
“recovery”. As a dynamic process of self-directed action, it is
the movement toward wellness, rather than any single out-
come state that is of interest to research. In this view,
“recovery”may best be visualized as a process rather than
an outcome. Abstinence, as one of many outcomes that may
or may not fully occur across multiple domains of individual
wellness, is thus a potential product of the process of recov-
ery. This is especially significant when one considers related
disordered co-occurrence, and the recovery paradigm bor-
rowed from modern behavioral health. Problematic use, as
only one symptom of a larger state of disorder, like any
number of troubling symptoms related to psychopathology,
may never be fully resolved, or may occur from time to
time. Thus, the tallying of symptomatological occurrences
may fail to capture the overall picture of recovery, and
ultimately relies on a deficit-based, rather than strengths-
based evaluation.
Defining recovery in this way allows for an increased
understanding of the nuances of the process and also leads
to decreased stigma and discrimination that may be an
unintended outcome of previous definitions. Recovery, by
the very concepts that define it, will always be a movement
toward decreasing states of pathological bondage and
increasing states of wellness. It is ultimately arbitrary to util-
ize the use/non-use of specific substances as a definitional
parameter. In this way, the RSRC definition completely
avoids the categorical discussions and contentions, while
remaining focused on an overarching thematic purity of
self-directed strivings to free oneself from negative, sub-
stance-induced, or behaviorally problematic ways of being.
Recommendations for measurement of the RSRC
definition of recovery
More recent research into recovery phenomena has sought
to include the use of novel measures typically associated
with other areas of social science. Quality of life (Laudet
2011; Kirouac et al. 2017), Flourishing (Diener et al. 2010),
and cognitive function (Vonmoos et al. 2014) along with
neurological markers and priming of neurological reaction
(Dempsey et al. 2015) to cues have all been explored.
Objective measures achieved by brain scans through fMRI
and other methods have offered hope for the future of
objective measurements. Additionally, biological statistics
captured in real time through wearable technology has also
offered promise for objective measuring.
In addition to any objective biomarkers, various domains
of wellness may be evaluated along with ecological and
social benchmarks to best capture recovery experiences,
stages, and ingredients. Intrapersonal dynamics, as well as
psychological and trait-level personality integers may also be
considered as valuable methods of assessing recovery states
through psychometrics. Past studies have utilized a multi-
tude of metrics and methods to capture recovery action and
to illuminate self-reported qualities of recovery. In an effort
to capture these elements, we are providing a contextual
overview of the common qualities of recovery, and then spe-
cific measures that align with the definition of recovery put
forth in the current study.
Qualities of recovery
Four domains of recovery, along with 35 elements, were previ-
ously identified as abstinence in recovery, essentials of recov-
ery, enriched recovery, and spirituality in recovery (Kaskutas
et al. 2014). The focus of the study was to capture elements
that define the recovery experience (Kaskutas et al. 2014).
Short- and long- term recovery elements must be considered
in selecting metrics to best capture variability between individ-
ual’s experiences. Laudet and White (2008) identified several
ADDICTION RESEARCH & THEORY 7
“ingredients”associated with recovery. From their study, 12-
step affiliation and life meaning were found to be predictive of
sustained recovery. Neale et al. (2014) used online Delphi
groups to identify 15 broad categories involving areas ranging
from substance use, psychological health, physical health,
time, education/training, identity/self-awareness, and anti-
social behavior. Social identity has also been considered of
importance to recovery and may be included as a possible fac-
tor (Dingle et al. 2015; Best et al. 2016). Patient recorded out-
come measures (PROMs) and other qualitative studies have
examined subjective qualities that could be operationalized, as
well as the methods by which metrics are created through
patient input and testing, and may also be included (Neale
and Strang 2015; Neale et al. 2015).
Borrowing from behavioral health and wellness metrics,
some key areas emerge as possible factors worth measuring.
First and foremost is the development and monitoring of
key behavioral indices that indicate velocity and direction
toward wellness, and the related strategies involved in over-
coming and/or managing troubling behaviors. Basic guide-
lines of the recovery paradigm in behavioral health involve a
sense of belongingness, community, empowerment, and a
sense of agency (Sherer et al. 1982; Speer and Peterson
2000). Connectedness, hope, identity, meaning, and
empowerment (CHIME) are considered standard domains
for behavioral health recovery (Leamy et al. 2011). Finally,
stigma is a central aspect of behavioral health considerations
and as such may be factored into any measurement of
recovery processes (R€
usch et al. 2005).
It remains, though, to ask how can we measure processes
that are dynamic? The answer may not lay in what to meas-
ure, but rather how we measure. Longitudinal research
design and assessment, such as daily diary studies or eco-
logical momentary assessment designs would be preferred
strategies to capture and operationalize the phenomena.
Linkages between the phenomena that constitute the process
of recovery and the time scales on which these phenomena
vary and co-vary could provide invaluable data.
Additionally, stages of change, motivation for change, and
other factors can be considered that may capture aspects of
intentionality and effort if captured longitudinally. Relational
perspectives imply that social connections are central to the
process of wellness. As such, measures of individual differ-
ences in intrapersonal processes could be coupled with
broader social function measures to investigate the observed
relationships between individuals and how they function in
social settings. These described suggestions could serve to
effectively capture the complex and multi-level processes of
recovery. While not exhaustive, Table 2 provides an add-
itional list of useful scales and measures of recovery that
should continue to be evaluated and used when appropriate.
Future directions
This new definition of recovery brings with it multiple
opportunities to continue to support the behavioral health
field. First and foremost are the continued endeavors to
operationalize the aspects of the process so they may be
accurately measured, supported, and strengthened where
needed. While definitions of recovery have abounded, the
operationalization of the definitional parameters has lacked,
and remains a critical need within the field at large. The
current definition allows for previous measures and concep-
tualizations of recovery (e.g. assessment of recovery capital,
quality of life) to be maintained and further evaluated, while
also opening up new threads of scientific inquiry into indi-
vidualized recovery processes, wellness as the organizing
framework for recovery, and the dynamic nature of the
recovery phenomenon.
Perhaps the most beneficial future directions, and ones
that this new definition of recovery is inclusive of, is the
relational and social aspects of the recovery process. Recent
works have begun to explore the importance of relationships
and community in the recovery process (Best and Laudet
2010; Best et al. 2017) and we believe this new definition
lends support this important framework and the future
implications it holds.
Additionally, as the understanding and support of mul-
tiple pathways to recovery likely becomes greater, the indi-
vidualized recovery process will become a prominent
element. While past definitions have not excluded individu-
ality as an organizing and important consideration, this new
definition of recovery features it explicitly. The focus on
variance in the recovery process –be that due to gender
(Wincup 2016), race and ethnicity (White and Sanders
2008), culture (Jacobson and Farah 2012), criminal justice
status differences (Lyons and Lurigio 2010) etc. –is import-
ant to further explore. While mechanisms of recovery sup-
port may be similar at a population level, the focus on
individual mechanisms cannot be understated.
It remains unlikely that field-wide consensus may ever be
reached on a single definition of recovery. The efforts of the
RSRC have been undertaken in such a way that all behav-
ioral health professions, recovery activists, and recovery sci-
entists can adopt the definition in meaningful ways to
support their endeavors and work. Further qualitative study
should be undertaken to explore additional input from each
of these stakeholder groups to identify the levels of consen-
sus with the definition put forth, and equally weighted dis-
sent to the definition. It is the recommendation of the RSRC
that given the constantly evolving nature of the behavioral
health field (including recent advances in neuroimaging)
that any definition of the recovery process be continu-
ously evaluated.
Table 2. Recovery measures and scales.
Measure/Scale Citation/Source
Substance Use Recovery Evaluator (SURE) Neale et al. (2016)
Recovery Attitudes Questionnaire (RAQ-16) Borkin et al. (2000)
Recovery Self-Assessment (RSA) O’Connell et al. (2005)
Recovery Oriented Systems Indicators
Measure (ROSI)
Dumont et al. (2005)
Recovery Assessment Scale (RAS) Corrigan et al. (1999)
Illness Management and Recovery Scales (IMR) Salyers et al. (2007)
Stages of Recovery Instrument (STORI) Andresen et al. (2003)
Recovery Process Inventory (RPI) Jerrell et al. (2006)
Mental Health Recovery Star (MHRS) MacKeith and Burns (2008)
Self-Identified Stages of Recovery Inventory (SISRI) Andresen et al. (2003)
Questionnaire of Processes in Recovery (QPR) Neil et al. (2009)
8 R. D. ASHFORD ET AL.
Limitations
The current methodology drew from the expertise and
experience of a diverse set of stakeholders, however, that a
larger sample of diverse individuals was not involved in the
process, the results may be less relevant and impactful, or
missing key elements. Additionally, the removal of the use/
non-use paradigm (i.e. the reliance on abstinence from spe-
cific substances as a symptomatological and measurement
standard), is likely to lead to the removal of some objective
biomarkers and will complicate the measurement of recovery
in the short-term.
All attempts to define terms within research involve a
degree of exclusion and inclusion along dialectic perimeters.
The meanings, values, and assumptions of all language is a
constantly evolving affair. Limitations to this definition may
also involve temporaneous constrictions as treatment, medi-
cation, public health, political, and social realities evolve.
Conclusion
Definitions of recovery serve two primary purposes: (1) to
inform and evaluate treatment, prevention, and recovery
support services; and (2) to inform the underlying research
of the recovery phenomena and the individuals who experi-
ence it. Previous definitions of recovery, though plentiful,
contain several strengths and limitations inhibiting their suc-
cessful use across both purposes. The RSRC definition put
forth here has been carefully crafted by a diverse set of
stakeholders in hopes to inform the practical field of behav-
ioral health (e.g. treatment, prevention, and recovery support
services), as well as to create a definition that can more eas-
ily be operationalized by recovery researchers and scientists.
Although field-wide consensus on the definition of recovery
is an arduous process, it is necessary to continue to engage
in the process and push forward.
Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
Robert D. Ashford http://orcid.org/0000-0003-3979-1754
Austin Brown http://orcid.org/0000-0001-9958-3696
Emily Eisenhart http://orcid.org/0000-0003-4659-5911
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