Review of the application of positive psychology to substance use, addiction, and recovery research
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Review of the application of positive psychology to substance use, addiction, and recovery research.

Krentzman A.R.
Psychology of Addictive Behaviors: 2012, in press.
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The contemporary recovery movement in addictions and the positive psychology movement in the broader field of psychological health have recently grown in prominence but almost entirely in parallel streams, yet the overlaps and possible synergies between them suggest that an integration could be a step forward in recovery from addiction.

Summary This review and conceptual analysis explores the overlaps and differences between (only briefly mentioned in this account) and research findings relating to two relatively new movements in psychology and addiction. Over the past decade, both fields independently recognised their work focused disproportionately on illness and pathology. Scholars in psychology called for the scientific study of human flourishing, which become the fast-growing subspecialty of positive psychology, while scholars in addictions research called for a new focus on recovery and sobriety, which became realised in the grassroots recovery movement.

Their similarities are in the emphasis on wellness rather than illness, and optimism that people can not only overcome pathology but develop more positive lives. However, they differ in important ways. The addiction recovery movement is a multifaceted grassroots effort led by people in recovery from substance use disorders, built on a recovery-oriented rather than pathology-oriented framework. Participants in the recovery movement work collectively to remove obstacles to treatment, support multiple paths to recovery, and make broader social systems more supportive of recovery lifestyles. The distinctive focus is primarily on macro-systemic change targeting policies, treatment systems, community resources, and social phenomena including stigma.

While the recovery movement has grass roots, positive psychology was sprouted in academic soil, but quickly spread to sections of the general population eager to improve their lives, lending it the character of a larger movement spreading beyond academia. Although positive psychology is concerned with positive organisations, its primary emphasis has been psychological change at the level of the individual. It recognises that there is more to mental health than the absence of mental illness – strengths, well-being, optimal functioning and flourishing. Flourishing individuals have been defined as "filled with emotional vitality ... [and] functioning positively in the private and social realms of their lives". Rather than seeking to overturn previous 'psychologies', positive psychology emphasises what it sees as some important but previously neglected perspectives.

Within this perspective, a positive intervention is defined as "an intervention, therapy, or activity primarily aimed at increasing positive feelings, positive behaviors, or positive cognitions, as opposed to ameliorating pathology or fixing negative thoughts or maladaptive behavior patterns". A subset of these interventions called 'positive activity interventions' can be completed without professional help. Two widely tested examples which may have potential in substance use disorders are the gratitude intervention called Three Good Things (write down three things that went well each day and their causes every night for a week) and the optimism intervention, Best Future Self (write down the realisation of all of your life dreams when in the future everything has gone as well as it possibly could).

Main findings

Recovery approaches

So far limited work on contemporary recovery approaches to addictions suggests that new recovery institutions are filling a gap left by traditional professional treatment and mutual aid groups, and that continuing care interventions may offer benefits beyond those provided by acute care.

Some of the strongest findings (because they derive from randomised trials) related to the Oxford House recovery homes where individuals in recovery live, share expenses, and provide mutual abstinence-specific social support and other forms of concrete and emotional assistance. Residents themselves manage the business of the household and there are no limits on stays. For the randomised trial researchers recruited 150 adults from inpatient units in Illinois who agreed to be randomly allocated to usual care (the control group) or to apply to Oxford Houses. Compared to the control group, over the two-year follow-up period fewer Oxford House assignees were using alcohol or drugs or charged for a recent offence and more were employed. By the end fewer than half as many (31% v. 65%) were using alcohol or drugs, a third as many were in prison (3% v. 9%), and average earnings were substantially higher. All these differences were reported as statistically significant. Additionally, at two years 27% more Oxford House assignees had their own accommodation and nine more mothers had regained or retained custody of their children.

Another set of findings from randomised trials support the recovery movement's insistence that addiction should be treated as a chronic rather than acute disorder, implying long-lasting or open-ended support. Two trials have tested so-called 'recovery management checkups', quarterly meetings between counsellors and clients that take place consistently for two or three years – longer than traditional aftercare models – and treat each follow-up as an opportunity for intervention. After improvements were made, in the later trial checkup patients were more likely than controls to re-enter treatment if needed and received more treatment, attended more self-help meetings, achieved more days of abstinence, and lived in the community for shorter periods in a state where they needed, but did not receive, treatment. [Editor's note: these and other studies have recently been reviewed, the results of which led an expert panel to argue that extended and regular monitoring of patient progress was the key component of continuing care and one with the greatest evidence of effectiveness.]

Positive psychology

How well do positive psychology interventions work? Beyond the addictions, a meta-analysis A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. of 51 randomised controlled studies of positive interventions amalgamated data from studies of healthy individuals and those suffering from depression. It found beneficial impacts in the form of moderate effect sizes A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. The most common statistic used to quantify this difference is called Cohen's d. Conventionally this is considered to indicate a small effect when no greater than 0.2, a medium effect when around 0.5, and a large effect when at least 0.8. for well-being and depression.

But a closer look at the research reveals that 'it works' would be too simple a verdict. In one body of work statistically significant differences were found when gratitude interventions were contrasted with 'hassles' conditions which ask participants to list things that irritate, annoy, or bother them, but not when they were compared to nothing intended to be an active intervention, except among groups more at risk than healthy populations. An emerging pattern suggests that those at a slight or great disadvantage, either because of illness, feeling bad, or being highly self-critical, seem to benefit more from a gratitude intervention than healthier individuals.

In respect of substance use, just one study (conducted in the UK) has applied positive psychology, in this case during group therapy of ten 14–20-year-olds attending an alcohol and drug treatment service for young people, comparing their results to a control group of ten not offered this extra intervention until later. The eight-week intervention promoted positive emotions, savouring, gratitude, optimism, strengths, relaxation, meditation, goal-setting and change, relationships, nutrition, physical activity, resilience, and growth. Compared to the controls, it led to greater increases in happiness, optimism, and positive emotions, and a much greater but (given small samples and highly variable levels of drinking) not statistically significant remission in symptoms of alcohol dependence.

Though these are the only findings specifically testing effectiveness, engagement in anti-relapse mutual aid and variables related to relapse to dependent substance use have been found to be related to key constructs in positive psychology. For example, among 126 former problem substance users abstinent for at least six months, the construct of 'hope' was strongly and positively correlated with other positive psychology constructs and with relapse-related variables including having a sense of purpose in life, social support, self-efficacy and psychiatric symptoms. The same was generally not the case however for 'spiritual transcendence' and 'flow' – the experience of losing oneself in pleasing, enjoyable activity.

In another study of 164 AA members sober for at least a year, the intensity of affiliation to AA was significantly associated with optimism, gratitude, purpose in life, and spirituality. However, this sample were relatively well-off and well educated and highly involved with AA.

These findings suggest that hope is possibly important in sustaining recovery, and are in line with findings that spiritual/religious practices are a mechanism via which AA affiliation affects drinking.

The author's conclusions

Despite tremendous growth in both positive psychology and the recovery culture, only the nine studies reviewed in this article have so far explicitly applied the discoveries of positive psychology to substance use, addiction treatment, and recovery, yet in other sectors these approaches have become prominent. The recovery movement has historically been an initiative for macro systemic change, while positive psychology has historically promoted micro interventions designed to create change at the level of the individual. Integrating the two can more comprehensively engage the spectrum of care necessary to adequately address addiction.

Thanks for their comments on this entry in draft to Amy Krentzman of the University of Michigan in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 17 October 2012. First uploaded 16 October 2012

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