SLP Insights: A conversation with Dr. Katie Witkiewitz about recovery beyond abstinence, multiple pathways to recovery and the importance of pursuing a life worth living
NOTE: Sober Linings Playbook is a personal website. Any views or opinions expressed herein belong solely to the website owner and do not represent those of individuals or organizations the owner may be associated with in a professional or personal capacity, unless explicitly stated.
[Another Note: This article discusses research and data on non-abstinent recovery. If you think you might find this topic upsetting, please stop reading here. Despite my personal experiences and preferences as a person in recovery who chooses to abstain from alcohol, I find a lot of value in keeping an open mind to new ideas and to evidence from the research literature. I also believe there is much to be gained by broadening the definition of recovery, particularly if doing so opens the doors of treatment to a wider range of clientele and invites more people to question – and to change – their relationship with alcohol and other substances. If you’re intrigued, read on!]
This month's SLP Insights interview is with University of New Mexico psychology professor Dr. Katie Witkiewitz. Together with Dr. Jalie A. Tucker of the University of Florida, Katie edited a recently released book titled, Dynamic Pathways to Recovery from Alcohol Use Disorder: Meaning and Methods.
Katie is Regents’ Professor of Psychology and a scientist at the Center on Alcohol, Substance use, and Addictions (CASAA) at the University of New Mexico. She is also a licensed clinical psychologist and has worked extensively on developing and disseminating mindfulness-based relapse prevention as a psychotherapeutic approach to treating alcohol and other drug use disorders.
“We endeavored to challenge the assumption that sustained abstinence was a necessary and sufficient condition for AUD recovery and underscored the strong empirical basis for a broadened definition of recovery that focuses on improvements in valued areas of living, functioning, and well-being. Further, we brought together experts in the field to identify and discuss new empirical research that is needed; what theories, treatments, and policies need to be reconsidered or adapted; and how this collective body of work can make a difference in helping individuals and communities.”
Dr. Katie Witkiewitz and Jalie A. Tucker,
Dynamic Pathways to Recovery from Alcohol Use Disorder: Meaning and Methods
Several years ago, I voluntarily enrolled in an outpatient treatment program seeking help for what had become a life- and career-altering problem with alcohol. It was my first (but not my last) treatment program.
Aside from memories of oscillating between viewing myself as a failure on the one hand, and minimizing and questioning whether my problem was actually significant enough to warrant treatment on the other, my recollection of the early days in treatment are not that clear. One vivid incident, however, sticks with me.
After completing a lengthy intake interview on my first day of outpatient treatment, I waited with a newcomer’s anxiety for the group counseling session to begin. The first to arrive was a young man in his 20s. He asked to speak to the counselor privately. When the pair emerged from a small office, the counselor led him to the door and said she hoped he would come back “when he was ready.” When the door closed behind him, the counselor revealed to me that the young man had admitted to drinking earlier in the day. As a result, she had to terminate him from the program. Kudos to that young man for his honesty. But look where it got him.
The incident raised a lot of questions I continue to ponder:
Why would a treatment program turn away clients who struggle the most with abstinence?
If outpatient diabetes management programs don’t refuse to treat patients who struggle to maintain their fitness and dietary goals, why should “missteps” be handled differently in alcohol use disorder (AUD) and substance use disorder (SUD) treatment programs?
If treatment programs were more accepting of some level of continued use, would more people seek help?
If I had been able to access a harm reduction treatment program that allowed some level of use, would I have sought help earlier and perhaps achieved abstinence sooner?
Why does the treatment industry emphasize abstinence at the risk of excluding the larger (and potentially lucrative) segment of the market – people who want help, but for whom abstinence may not necessarily be the goal?
It was because of these questions that I became interested in Dr. Katie Witkiewitz’s work on non-abstinent recovery. When I contacted Katie to schedule the interview, I asked her to suggest some relevant reading material. In addition to the introductory and concluding chapters of “Dynamic Pathways,” she shared a 2020 article she co-wrote with several other authors titled “What is Recovery?” (Published in the National Institute on Alcohol Abuse and Alcoholism’s journal, Alcohol Research Current Reviews, Sept. 30., 2020 40:3).
Before jumping into the interview, I wanted to share some of my takeaways from the assigned reading.
We need a definition of recovery that is broader than abstinence. Witkiewitz and her co-authors raise questions about the validity of using abstinence as the sole measure of recovery. If the goal of recovery is to limit the harms and risks associated with alcohol and drug use, and to increase outcomes related to health, relationships, and careers, we need to look beyond abstinence to define and measure recovery in a manner that includes these broader measures of success. Reducing recovery to abstinence also obscures from view the possibility of non-abstinent recovery — reducing the quantity or frequency of use, adopting safer using practices and/or substituting with a less harmful substance (e.g., “marijuana maintenance”).
“A life worth living” is a phrase Katie uses frequently. As I understand it, a life worth living is both motivational and protective. A person who has been using alcohol or drugs as a strategy for addressing problems in their lives needs to be motivated by a vision of a better life that can be achieved through change. Once in recovery, achieving and maintaining a sense of connection, meaning and purpose can help to stabilize and reinforce the change. Abstinence and “a life worth living” are by no means mutually exclusive. But they aren’t the same.
In “What is Recovery?,” Witkiewitz and her colleagues examine a variety of definitions of recovery that move beyond abstinence. One example is the U.S. Substance Abuse and Mental Health Administration (SAMHSA) definition, which does not mention abstinence. SAMHSA defines recovery as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”
The treatment industry’s emphasis on abstinence keeps people from seeking help. In addition to the stigma of admitting to ourselves and to others that we have a problem with alcohol or drugs, the daunting prospect of abstaining entirely from the thing we have become conditioned to view as a solution to our problems is a barrier that keeps many of us from seeking help. Moreover, because drinking is socially accepted and ubiquitous, abstinence from alcohol can be stigmatizing in and of itself. Abstaining from alcohol signifies to others that the teetotaler is a person with a problem.
Based on personal experience, it certainly rings true to me that the requirement of complete abstinence makes it difficult to ask for help. And based on what I’ve learned from others in recovery, I believe most of us who eventually achieve abstinence have experienced a long glide path to that point. Along the way, we experiment with strategies for limiting use and reducing the potential for harm. We test the waters of sobriety before jumping in headfirst.
I achieved my first year of abstinence from alcohol five years after I first admitted to my doctor that I had a serious problem. Based on what I’ve read in the literature, my timeline seems fairly typical. I often wonder whether I might have sought help earlier or achieved abstinence sooner had I been able to access harm reduction treatment options that didn’t require an initial commitment to abstinence.
Either/or thinking about the nature of AUD and SUDs can be a barrier that prevents people from seeking help. There is a reason most of us who eventually find recovery begin our journey with a Google search for “am I an alcoholic/addict?” We look for definitive proof that we are/are not. People who determine they do not have a problem (even if they reach that conclusion by fudging the data!), are able to rationalize their decision to continue drinking or using without attempting a change.
Witkiewitz points out that recent research indicates describing alcohol use disorder (AUD) as something that exists on a continuum of severity, rather than as a binary either/or, leads to “greater problem recognition among non–treatment-seeking heavy drinkers.” This is important because leading people to view their drinking as problematic could motivate moderate drinkers to make a change. This is a good thing as even moderate levels of drinking can be harmful.
This is where I believe the “sober curious” movement has it right. Authors such as Annie Grace (“This Naked Mind”), Ruby Warrington (“Sober Curious”), Holly Whitaker (“Quit Like a Woman”) and others give people permission to question their relationship with alcohol even if they don’t define themselves as “alcoholics.”
The Sober Curious entrepreneurs (several offer fee-based programs and even coaching certification programs along with books and online communities) encourage all drinkers to examine the role alcohol plays in their lives. In doing so, they widen the treatment tent and market the idea of recovery to people who might not have considered it otherwise. It’s savvy marketing and, in my opinion, a better business model than an abstinence-only approach.
One reason the research has not shed adequate light on alternative recovery pathways is that researchers may be shining the light in the wrong direction. A tendency to focus on people in professional treatment and 12-step mutual help programs means studies of recovery have an inherent selection bias. Witkiewitz and her co-authors cite research indicating that over 70 percent of “problem resolutions” occur outside the context of treatment, that low-risk drinking is a more common outcome in untreated than treated samples, and that “individuals with more severe AUD appear to practice some degree of appropriate self-selection into treatment and may require more change attempts before achieving stable change.”
Alternative pathways may be more common than we think, but relatively unknown because the research focuses too narrowly on people with more severe alcohol use disorders who are more likely to end up in treatment programs, which almost universally emphasizes abstinence.
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The Interview with Dr. Katie Witkiewitz
The reading material helped me gain a better understanding of the work of Dr. Witkiewitz and her colleagues. It also informed the questions I asked in the interview below.
SLP: Could you elaborate on what you mean when you say there is a need for a definition of recovery that goes beyond abstinence?
KW: I think the biggest thing that we’ve known for years is that recovery is nonlinear. What we’ve known about all sorts of substance use disorders (SUDs), including alcohol use disorder (AUD), is that the most common outcome after someone makes an initial change attempt is to return to some level of use.
In the first 20 years of my career, I really steered clear of the term recovery because I just felt like I was more interested in these initial change attempts and how people worked through reducing their use or stopping drinking and what triggered them to return to heavy drinking or drug use.
I only more recently started thinking that “well maybe this is also recovery.” Maybe these experiences and these initial change attempts are recovery and maybe any positive change is recovery. I really wanted to expand our thinking about what recovery is to include this process of making positive changes. That might be harm reduction. It might be continuing to use at the same level but using in safer ways, or cutting down on the frequency of use, or stopping altogether.
All of those potential outcomes could be – and really should be – considered part of a recovery process. I’ve really been thinking more about recovery pathways and recovery processes versus “recovered or not.”
A lot of my thinking has come from clinical practice [Dr. Witkiewitz works as a clinical psychologist], but more so from seeing data and seeing pathways of people who are making change attempts and seeing these nonlinear changes that throw a person off course but ultimately they can get back on course and in a direction of positive change.
I really want the message for people who are considering a change attempt to be hopeful about recovery and about the fact that recovery is possible and that any deviation from that journey is part of the journey and is not a failure and is not something that should provoke shame or guilt or doubt, but rather is just part of a broader journey and process and pathway. I’m hopeful that this approach can destigmatize and reduce the shame and guilt and suffering that can come from a binary model of recovered or not. That’s just not what it looks like in the real world.
SLP: I’ve heard you refer frequently to what you describe as a “life worth living.” Is your point that when we only look at whether someone is using or abstinent, we aren’t focusing more broadly on other aspects of an individual’s life that may be indicators of success in recovery?
KW: I think the “life worth living” concept is really important from a couple of perspectives. One, I think it keeps us focused on the bigger picture. It’s really not about the substances we use or how much we consume. It is about that life worth living.
I’ve had clients who are abstinent and they’re miserable. They don’t connect with people because most of the people in their lives use substances or drink heavily. They’re unable to create connection with substance- or alcohol-free activities. So yes, they’re abstinent. But they’re not really living a valued life or moving in a valued direction.
I think as treatment professionals and the treatment community, by thinking about outcomes as a life worth living, it really changes our whole perspective about helping people create that life, which I think is going to be way more protective in the long run and more helpful for motivating change and sustaining change. That perspective is not only more open to various pathways, but it reorients everything you do to not just be about abstinence or reduction of substance use, but also thinking about what is filling the place [of substances] – the why.
What we hear from people validates this. That’s what they care about. They actually care about living a valued life and living a valued direction. That’s often why they come to treatment or decide to make a change. Substance use was getting in the way of it. That, I think, is the other really important piece of this expanded definition.
SLP: You raise questions about binary thinking about both recovery (i.e., abstinent vs. not abstinent) and the nature of AUD and SUDs. One of the reasons I appreciate the growing “sober curious” movement is that it invites people to question their relationship to alcohol or substances regardless of define themselves as a person an alcohol or substance use disorder.
I’m wondering whether you have thoughts on how we might move the thinking more in that direction. How do we invite more people to rethink their alcohol or drug use, and encourage more people to seek help and support even when their problems related to alcohol and substance use might not seem to be particularly risky or harmful?
KW: Absolutely. We know with some certainty that the binary model is preventing people from seeking treatment. About 80 percent of people [who could benefit from it] don’t seek treatment. About 50 percent of those don’t want to stop drinking. What the treatment industry has is not what people want.
In our most recent clinical trials, we admit people with any sort of goal. In a recent clinical trial, 80 percent of people had a drinking reduction goal. They see our ad in the paper, which is very specifically geared toward [asking people] “do you want to change your relationship with alcohol or do you want to reduce your drinking?” It’s not like “do you want to stop drinking forever?” It doesn’t require labeling of people as someone with an alcohol use disorder. It’s just “do you want to make changes to your drinking?” Everyone who comes to our study wants to change their drinking. Eighty percent want to reduce drinking, not abstain.
I love the sober curious movement and other similar recent social movements such as Dry January, Dry July, and Sober October. I’ve seen a bunch of different names for different months. I like the idea that you don’t have to declare yourself as someone with an alcohol use disorder and go to AA and never drink again, but that there are maybe alternative ways of evaluating your relationship with alcohol.
For some, maybe that’s abstinence. That’s great. Abstinence is a fabulous choice because alcohol is toxic. Any time we stop drinking completely, that’s going to be better for our health. But reductions in drinking and reductions in substance use are good for our health too. I love the socializing that’s happening around alternatives.
I really think the binary model [was developed based on] people with very severe alcohol use disorder. It grew out of psychiatrists treating people with the most severe alcohol use disorders in detoxification and inpatient settings. The reality is that the majority of people with alcohol use disorder are not severe.
Even the Big Book of Alcoholics Anonymous (AA) talks about people who need AA as the very “severely mangled lives,” that’s a quote from the Big Book. It [the Big Book] talks about how some people are able to moderate. [SLP note: The Big Book refers to “mangled” lives on p. 43 in a passage describing what leads most “alcoholics” to seek change: “Most alcoholics have to be pretty badly mangled before they really commence to solve their problems.”]
I really think there is a group – some individuals, and we are starting to understand who – that could really benefit the most from abstinence. Moderation is hard. And for some, it’s just not worth the effort of trying to reduce and moderate. It basically gets in the way again of a life worth living. Abstinence frees them and provides a life worth living.
Then there are a bunch of people who fall into this kind of less severe category of people who are able to moderate, reduce their drinking on their own, achieve a life worth living, which may include some drinking some of the time.
SLP: Do you think the category to which an individual belongs can change over time? For example, is it possible someone might enter treatment as a person for whom abstinence appears to be absolutely necessary, but over time the person is able to moderate?
KW: Absolutely. We’ve seen cases of this. We’ve also seen people who have done really well with moderation, and then something happens and they kind of lose control again, and their life is kind of a mess, and they decide they have to abstain because that life worth living is getting really messed up by drinking anything.
The idea is that these are all acceptable ways of achieving that life worth living and any positive change. Even if that positive change involves continued drinking but drinking in less harmful ways or reducing the frequency or reducing the quantity. The either/or thinking doesn’t help. It increases shame. It increases stigma.
SLP: You mention in your work that because research tends to focus on people who are in treatment or in AA – both of which tend to skew toward the more severe – we probably aren’t capturing the range of pathways to recovery. Could you tell me about work that’s being done to broaden the focus and include a wider population from which to sample?
KW: Yes. My colleague Jalie Tucker, who co-authors some of the work I’ve published, has done amazing work with natural recovering samples – individuals who have not sought treatment and have changed their drinking on their own. She has explicitly recruited individuals who identify as “resolving” an alcohol problem. That’s how she phrases it in her work.
We’ve done some recent work where we recruited a big sample of people who identified as moderate to heavy drinkers and were not interested in changing. What was really fun about this sample is that a lot of them changed even though they had no interest in changing their drinking. In meeting with the research team, reporting on how much they were drinking and reporting on the consequences of their drinking, some changed.
Those things, just taking a look at it and shining a light on the drinking and the consequences it was causing in their life, that, in and of itself, was enough to motivate some drinking reductions. Some of them even stopped drinking completely even though we were not offering treatment. We were just doing research. We were just asking them questions about their drinking.
We did neuroimaging as well – brain scans. We’re currently working on analyzing those data. We’re real excited to see what happened to these individuals who maybe reduced their drinking outside of a treatment context. Do we see some recovery of brain function in these individuals or not?
Another really important question from that work is what happens to these individuals who continue to drink really heavily and who don’t change? It’s an 18-month study, so over the course of that 18 months, are there serious brain consequences of that? We don’t think there will be. That’s going to be interesting. It just shows how marvelous the brain really is, and how resilient the brain really is.
I think more and more researchers are starting to tune into the fact that there’s this whole population of individuals who are not studied because they are not coming into the treatment system at all.
SLP: It’s interesting to me that simply increasing your research participants’ awareness (awareness of how much they were drinking, and of the consequences) could motivate them to change.
I reached a point where it became quite clear to me (and probably clearer to those around me) that I needed help. But sustaining change was really difficult for me until I discovered connection and an identity in a variety of groups bound by shared recovery experiences. I needed to find some purpose (and some fun), in the recovery journey in order to make the recovery path appear worthwhile.
Abstinence is part of my own recovery. I prefer the “choice architecture” of abstinence. In contrast to moderation, it’s liberating not to be bogged down with decisions about when, where, with whom and how much to drink. But it took me a while to get there.
For people who struggle with alcohol and substance use disorders, it’s difficult at the beginning to accept a life without the substance you’ve become conditioned to view as the solution to your problems. Abstinence was a hard sell for me at first.
KW: Yes. That’s a terrible pill to swallow.
SLP: Most of the research I’ve come across on non-abstinent recovery focuses on alcohol. Is there much work that examines non-abstinent recovery from other substances? I have my own guesses as to why there might be some reticence in the research literature. I imagine it’s easier for people to accept the idea that some people can reduce or moderate their use of alcohol – which is legal and widely socially acceptable – than it is for people to accept the idea that someone could moderate their cocaine or heroin use.
KW: A couple of years ago I co-authored a paper, led by Dr. Corey Roos at Yale University, on reductions of cocaine use among those who were in treatment for cocaine use disorder. We found that people who reduced their use to about one time per week (or four times per month) had similar functional outcomes, including psychological, employment, legal and other drug use problem severity domains, as abstainers. There’s also work on cannabis use that shows reductions in cannabis use are associated with improved outcomes.
I haven’t seen literature yet on heroin and methamphetamine. I suspect those might be substances where reductions in use might be harder. [Columbia University psychologist] Carl Hart wrote a book about his experiences with moderate heroin use over the years [the book is “Drug Use for Grown Ups: Chasing Liberty in the Land of Fear,” 2021]. Carl Hart’s own experience is, of course, anecdotal. [Even though others may share similar experiences,] it’s important to remember that the plural of anecdote isn’t data.
There’s no empirical data verifying people can reduce heroin use and methamphetamine use, but I would be relatively confident that there is a subset of people who can. I think they would have to have certain environmental supports in place and probably not a lot of co-morbid depression or anxiety where they are using the substance to medicate. But certainly, we know that people can reduce their cocaine use frequency and people can reduce their cannabis use. There’s data for those two substances showing reduction is achievable, stable, and improvements are similar to those we see in abstinence.
SLP: Within recovery communities there is significant stigma around alternative recovery pathways that don’t involve abstinence. In the case of medication assisted treatment (or even psychotherapeutic drugs prescribed to treat things like anxiety or depression) there is even disagreement about how to define abstinence or sobriety.
Within academia, or at least among researchers who study substance use disorders and recovery, do you find there is more acceptance of the idea of multiple pathways to recovery?
KW: It varies. There is a subset of researchers who have been saved through Alcoholics Anonymous, who really attribute their recovery from alcohol or other drugs to abstinence, and who also work in this area.
I’ve certainly received pushback from some academics. There was recently a critical commentary published about one of our papers. We responded by writing a commentary to their response. There was some back and forth.
I think academics do tend to be more persuaded by data. They tend to poke holes in the data or find the cases where someone does terribly with harm reduction. They tend to be myopically focused on those cases rather than the majority of people who are doing well.
Whereas in terms of my experiences with more lay audiences in public talks, or when I post about our research on social media, I think there is this very angry and defensive stance that “abstinence worked for me so it’s the only path.”
I actually had someone say that my work was very threatening for their abstinence. I found that interesting and I took it very seriously in terms of thinking about how I frame things. Obviously, I would never want to disturb someone’s abstinence pathway if that’s the pathway that’s working for them. But it also brings up for me this question of how stable are you in your life, how good is your life if even the notion that someone else out there could be successful with harm reduction is threatening? It kind of makes me wonder, does that person need more support? Are they living a life worth living? Or are they “white-knuckling” it and really on the brink of not having a life worth living?
It's definitely something I think about a lot, and that I encounter more in lay audience settings than I do in academia, but there are definitely some academics who do not like the work I do.
SLP: In Dynamic Pathways, one of the suggestions you and your co-authors offer for further research is the need to examine mutual help alternatives to Alcoholics Anonymous or other 12-Step groups.
My own pet theory is that asking whether mutual help groups “work” is akin to asking whether school “works.” There are a lot of extracurricular variables that determine success; however it is measured. And asking whether SMART Recovery or Dharma Recovery work better than AA seems like asking whether Waldorf is better than Montessori. Do you think examining differences among mutual help alternatives would be fruitful?
KW: I love this new area. Dr. Sarah Zemore has done some great work comparing AA to SMART Recovery and some other options. It seems like it really depends on personal goals and personal fit. I agree with you that any of these mutual support groups are likely to be helpful. Just like with AA, you encourage people to find a meeting or a group that fits for them, and it can take a while to find a home meeting.
I think it’s similar for other mutual help groups. If someone has found AA to not be helpful, that doesn’t mean SMART Recovery won’t be helpful. They’re very different approaches so I would encourage someone to try SMART, or Recovery Dharma or LifeRing or Women for Sobriety or other groups that are popping up online.
I think there are a lot of options out there. I think a lot of people only know of AA and I think that’s sad because there are other options. If AA doesn’t work, then maybe try a different AA meeting because as they say, “if you’ve been to one AA meeting, you’ve been to one AA meeting.”
If AA doesn’t fit, then check out these alternatives. Check out SMART. Check out Recovery Dharma. I love Recovery Dharma just because of my mindfulness work and training in Buddhist practices. There are other options out there, so I think finding a good fit is what matters most.
SLP: To be frank with you, I kind of worry about posting a piece about non-abstinent recovery on my website. I worry about reactions like the one you described from the person who suggested your work, or your talk “threatened” their recovery. I guess it’s important to frame it properly and to ground it in the research.
I do believe, however, that work on alternative recovery pathways is important. If nothing else, shedding light a range of alternatives might draw more people into treatment.
KW: For people who might be resistant, I guess I would ask them to reach down deep to when they were starting their recovery journey and think about what they would have wanted open to them at that point. Would they maybe have come along sooner if this were an option? Would they have maybe destroyed less of their life if this were an option? And why not have that be an option for someone else?
And yes. Regarding making a bigger tent. We all benefit when people are living lives worth living. Let’s try to have society be a better place even if it doesn’t fit within our definition of how we personally recovered.
SLP: Thank you so much for taking the time to speak to me about your work. I really appreciate it.
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As is often the case, when the interview was over, I was left with the feeling that I had only scratched the surface. The relatively short reading list Katie provided ahead of time generated so many thoughts and questions. But that’s the nature of discovery. There is always more.
On that note, in the final chapter of Dynamic Pathways. Witkiewitz and her co-author call out the need for further research to develop a better understanding topics including:
Criteria for defining successful recovery outcomes;
The variety of pathways into addiction as well as pathways to recovery;
How addiction and recovery vary over time and over the life cycle of an individual;
The role of social networks and “recovery capital”; and
The role gender and race play in help-seeking and utilization of treatment and mutual health groups.
In the concluding paragraph of Dynamic Pathways, Katie and her co-author, Jalie A. Tucker, offer the following: “There are many pathways to recovery…We encourage the field to embrace this heterogeneity and embark on new research, community action, and policy-making to support the many pathways to recovery.”
I can’t think of a more succinct summary or apt conclusion to this piece.
Sober Linings Playbook
The author at the University of New Mexico’s Center on Alcohol, Substance use and Addictions (CASAA)
I couldn’t resist adding another snapshot from Albuquerque — the Jesse Pinkman house from AMC’s “Breaking Bad.”