The Importance of Identifying Characteristics Underlyingthe .docx

The Importance of Identifying Characteristics Underlying
the Vulnerability to Develop Alcohol Use Disorder
Ismene L. Petrakis, M.D.
The article by Gowin et al. (1), in this issue of the Journal,
describes a study evaluating characteristics that represent
risk factors for the development of alcohol use disorder. The
authors carefully examined a large sample of healthy social
drinkersusingan innovative laboratoryparadigmandfoundthat
family history of alcoholism, male sex, and impulsivity—when
combined—were associated with high rates of binge drinking
during the laboratory paradigm.This study documents different
patterns of alcohol exposure within individual drinking ses-
sions. The findings suggest that those with characteristics as-
sociatedwith a higher risk of developing alcohol use disorder
experiencedhigheralcoholexposurewithinsessions.Theau-
thors conclude that young social drinkers at risk for alcohol
usedisorderhavemarkedly different patternsof drinking and
encourage the evaluation of bingedrinking in clinical settings as
a potential indicator of vulnerability to alcohol use disorder.
This study is quite timely, and its publication for a wide
psychiatric audience is important given the recently docu-
mentedincrease intheprevalenceofalcoholusedisorder.Over
the past decade, there has been a dramatic increase in rates of
alcohol use, high-riskdrinking, and alcohol-related conditions
(2).Thisdespite scientificadvances intheunderstandingof the
underlying neurobiology (3), genetics (4), and treatment of
alcohol use disorder (5). The high rates of consumption with
the resultant medical consequences and socioeconomic cost re-
present a public health crisis. Thefinding that high-risk drinking
is on the rise suggests that understanding factors that influence

problematic drinking patterns and targeting high-risk groups
should be a priority for health care professionals.
The present study does exactly that. It extends the exist-
ing literature about risk factors associated with vulnerability
for alcohol use disorder. The risks of developing alcohol use
disorder include a strong family history of alcoholism (6), sex
(6), and impulsivity (7). Research on understanding the
mechanisms of these underlying risks has focused on altered
subjective response to alcohol in the laboratory, for example,
basedon familyhistory (8), impulsivity (9), andgenotype (10).
Nevertheless, conflicting results have been reported (11), and
discrepant hypotheses on the relationship of subjective re-
sponse to family history have been proposed (8). In addition,
it is hard to control for other factors, and some studies have
suggested that drinking history, rather than family history,
is the important factor determining alcohol response and
subsequent risk (12). Furthermore, subjective response may
or may not lead to differences in drinking patterns outside of
laboratory settings.
This study extends previous findings in two important
ways. First of all, the authors have simultaneously evaluated
several different previously identified factors. Results from
this study suggest that the risk factors are additive, which is
both intuitive and important when considering a complex
disorder such as alcohol use disorder. More importantly,
however, the authors have evaluated these risk factors per-
taining to actual patterns of drinkingor alcohol exposurewithin
a controlled laboratory setting. These data would be hard to
collect outside a laboratory setting, given the limitations of
self-
report of alcohol use and the introduction of other factors that
might complicate results. Given the recent epidemiologic
findings, results suggest-

ing that family history is
related to alcohol exposure
and binge drinking, rather
than subjective response,
indicate that binging may
be a more meaningful clin-
ical phenomenon.
The methodology of
this study deserves to be
highlighted. There aremany paradigms used in research that
provide a platform for understanding factors thought to be
important to vulnerability and relapse; these include sub-
jective effects of alcohol, alcohol consumption patterns, and
related phenomenon such as craving. Paradigms using oral
alcohol administration, including self-administration, while
ecologically valid cannot control for factors such as variable
absorption and metabolism (13). The novel paradigm used
in this study is a self-administration intravenous paradigm,
whichcontrols for interindividualdifferences, andeliminates
cues (which may be both a strength and a weakness) and is
thought to reflect pure pharmacologic effects. This paradigm
has been used to test bothmedication and genetic effects (14,
15). It has the potential to be an important tool in medication
development, as a way to test novel compounds before con-
ducting larger clinical trials.
There are several limitations of this study that should be
acknowledged.Theeliminationof factors that influencedrinking
are also a weakness, since expectancy, taste, and environmental
cues influence drinking in a “real-world” environment. As such,
The high rates of
consumption with the
resultant medical
consequences and

socioeconomic cost
represent a public
health crisis.
1034 ajp.psychiatryonline.org Am J Psychiatry 174:11,
November 2017
EDITORIALS
http://ajp.psychiatryonline.org
this paradigm loses someecological validity. As the
authorspoint
out, the cross-sectional design is a limitation, and they suggest
that longitudinal work would be an important next step when
evaluatingwhether thedrinkingpatternsnoted in the laboratory
are associated with long-term risk of the development of alco-
hol use disorder.
Despite these limitations, the undertaking of well-designed,
laboratorystudies identifyingriskfactorsforthedevelopmentof
alcoholusedisorder issorelyneeded.Despitedecadesofworkin
the alcohol-related field, findings have not influenced actual
behavior asmeasured by the prevalence of alcohol use disorder
or of alcohol-related medical consequences. As the treatments
developed have modest efficacy and poor uptake (16), efforts
toward preventing the development of alcohol use disorder
could have important benefits. The authors make the clinical
point that binge drinking may be an indicator of vulnerability
and should be assessed. This perhaps should be taken a step
further, since evidence is mounting that there are clinical
characteristics that influence risk. There is sufficient evidence
to support a good clinical evaluation that includes the assess-
ment of other factors such as family history and impulsivity as
possible risk factors, which may lead to binge drinking and

increase the risk. It is important for the scientific community to
developassessmentsandinterventionsthatcanbedisseminated
widely to evaluate and address alcohol use-related disorders.
AUTHOR AND ARTICLE INFORMATION
From the VAConnecticut Healthcare System,WestHaven, Conn.,
and the
DepartmentofPsychiatry, YaleUniversity School
ofMedicine,NewHaven,
Conn.
Address correspondence to Dr. Petrakis ([email protected]).
Dr. Petrakis has servedasaconsultant toAlkermes.Dr.
Freedmanhas reviewed
this editorial and found no evidence of influence from this
relationship.
Accepted August 2017.
AmJPsychiatry2017;174:1034–1035;doi:
10.1176/appi.ajp.2017.17080915
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Addictions as Emotional Illness: The Testimonies of
Anonymous Recovery Groups
Paula Helm
To cite this article: Paula Helm (2016) Addictions as Emotional
Illness: The Testimonies
of Anonymous Recovery Groups, Alcoholism Treatment
Quarterly, 34:1, 79-91, DOI:
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Addictions as Emotional Illness: The Testimonies of
Anonymous Recovery Groups
Paula Helm, PhD
Department of Political Theory, Goethe Universität, Frankfurt,
Germany
ABSTRACT
Participants in recovery groups from a variety of addictions,
following the Alcoholics Anonymous model, identify with each
other as suffering from a common “illness of the emotions.”
This study analyzes metaphors used to describe the patterns
and dynamics of this emotional illness and recovery, derived
from the personal writings and testimonials of group partici-
pants. Ways in which the participants discover alternate ways
to deal with their emotional illness other than manipulating it
to an active addiction are also explored.
KEYWORDS
Addictions; emotion illness;
alcoholics anonymous;
recovery groups; personal
writings and testimonials;
anonymity

Introduction
Mutual support-groups are one of the most striking phenomena
in the field
of addictions therapy. Mutual support groups are
nonprofessional, self-orga-
nized groups that follow the approach of Alcoholics Anonymous
(AA). In
those groups people who suffer from various kinds of addictions
meet to
address not only their symptoms of their illness but also the
deeper emo-
tional roots of their condition. In doing so, they understand
addiction not
only mentally and physically but experientially. This level of
understanding is
germane to the process of recovery as it addresses a disease
induced and self-
imposed emotional isolation that is born out of a fear of facing
the pain and
suffering associated with one’s disease.
In the recovery groups, participants develop the ability to face
themselves
and the reality of their destructive behavior seen through the
eyes of another
with the same condition. Yet, before the group experience,
participants fear
this pivotal moment. This fear of seeing the reality of their
disease in the eyes
of another dooms these individuals. Based on this insight,
participants of
early AA groups developed a new category to describe their
alcoholism as an
“illness of the emotions” (Alcoholics Anonymous [AA], 1957,
p. 239) they

called it. Using this category they could identify with each
other on a deeper
CONTACT Paula Helm, PhD [email protected] Department of
Political Theory, Goethe Universität
Frankfurt, Room 3. G 039, Theodor-W-Adorno-Platz 6, 60323
Frankfurt am Main, Germany.
The author approved the manuscript and this submission. The
author reports no conflicts of interest.
ALCOHOLISM TREATMENT QUARTERLY
2016, VOL. 34, NO. 1, 79–91
http://dx.doi.org/10.1080/07347324.2016.1114314
© 2016 Taylor & Francis Group, LLC
level other than just a behavioral level, finding solace in the
commonality of
their suffering and breaking through their isolation.
Analyzing groups that understand addiction as an illness of the
emotions
adds to our understanding of the multidimensional character of
addiction.
The focus of this article is on emotional illness as an essential
component of
substance use disorders. Using an ethnographic approach the
aim of this
study is to capture patterns of emotional illness, identified by
studying the
groups themselves as well as personal stories, which
participants’ author as
part of their therapeutic process. In their personal writings they
reflect not

only on their disease but also on their recovery. An analysis of
group rituals
and personal stories of the participants identifies not only
patterns of emo-
tional illness but also of emotional recovery as recounted in
group settings.
Method
A 2-year imperial study was undertaken to identify and collate
patterns of
emotional illness and recovery as recounted in recovery groups.
Two primary
sources were identified:
(1) Personal testimony archived by recovery groups such as AA,
Narcotics
Anonymous (NA), Sex Addicts Anonymous, Overeaters
Anonymous,
and various autobiographic writings that have been published by
the
groups.
(2) Personal participatory observation by the author in the
recovery
groups in New York and in Germany.
Sample
The sample comprises a heterogeneous mixture of 50 narratives,
between
1930 and 2013, including members of different groups, of
varying ages,
genders, and cultural backgrounds. The sample consists of
unpublished
narratives, written for the purpose of creating a moral inventory

and taken
from trademarked texts of 12-Step networks; the source texts
were on loan
from each group’s World Service Office (WSO). Metaphors
used to express
and define emotional illness and recovery were collected from
members’
autobiographic writings and personal testimonies. The
narratives over the
years were studied to determine which elements of the narrative
structure
remained consistent despite cultural and historical changes.
Because all the stories of the sample conform to one specific
narrative
structure that addresses the taking of a moral inventory of one‘s
internal
experience, examples from single stories can be quoted to
represent an
archetype. The authors themselves call the way they structure
their narratives
80 P. HELM
a “formula” (AA, 2003). This formula was developed in the
1930s when the
founders of AA collected participant narratives designed to
tease out the
typical patterns of emotional reactions to varied stimuli. The
following quote
from a letter from Bill W. to Bob S. captures this trend and the
origins of a
narrative “formula”:

It might be a good idea to ask people to write their own stories
in their own
language and at all the length they want to cover those
experiences from childhood
up which illustrate the salient points of their character.
Probably emphasis should
be placed on those qualities and actions which caused them to
come into collision
with their fellows. The queer state of mind and emotion, the
first medical attention
required, the various institutions visited; these ought to be
brought in. (. . .) There
ought to be descriptions of the feelings when he met our crowd,
his feeling of
hopelessness and the victory over it, his application of
principles to his everyday
life, including domestic, business and relations the problems
which still face him,
and his progress with them; these are other possible points.
(AA, 1935–1939,
Bill W. letter to Bob S., 1938)
The formula extracted from the stories collected during the
following months
serves as an emotional compass, a compass helping to “make
sense of
otherwise confusing sequences of experience” (AA, 1935–1939,
Bill W. letter
to Bob S., 1938).
In this article, quotes taken from an overall sample of 20
unpublished
documents and 30 published documents, all following the
original for-
mula, are used to exemplify the patterns of emotional illness
and

recovery.
The author also used data for analysis and reference based on
ethno-
graphic insights gathered during one year of participant
observation of
mutual support groups in New York and Germany. The author
identified
herself as a researcher in open meetings conducted by
Overeaters
Anonymous, Underearners Anonymous, Sex Addicts
Anonymous, AA, NA,
and Al-Anon Family Groups.
Analysis
To get insight into the dynamics of emotional illness and
recovery process an
empirical investigation was conducted, that combined two
different
approaches:
(1) For analyzing the concepts of emotional illness indicating
the different
areas of addiction and recovery within the autobiographic
writings, a
method was applied that works through coding and decoding
meta-
phors. The method was developed by Lakoff and Johnson
(2003). It
focuses on how people express subtle emotional processes by
project-
ing commonly used metaphors on to psychological and
emotional
ALCOHOLISM TREATMENT QUARTERLY 81

platforms. As a first step in developing an initial system of
categoriza-
tion, an open-coding pass was applied on all the text materials
of the
sample. As a second step, new codes were added whenever a
new
metaphor arose that did not fit into any of the previously
created
categories. After classification, all codes were clustered
thematically
using affinity diagramming.
(2) Turner’s ritual-theory (Turner, 1969, 2000) helps us
understand the
manner in which mutual support interacts with patterns of
emotional
illness. The common rituals practiced in the groups were
studied
following this model. The model concentrates on those
ritualized
sequences that, despite the different locations, sizes, and topics
of the
groups, were repeated each and every time. This focus enables
us to
identify the substantial factors in a group setting that empower
people
to communicate their emotions and thereby allows mutual
identifica-
tion at the emotional level.
By combining both approaches, the textual analysis and the
ritual study,
six major themes of emotional illness and four major themes of

emotional
recovery were be identified.
Theoretical basis
The study embraced a subject-centered perspective (Reckwitz,
2003, p. 284).
This perspective implies that the participants themselves are
understood to
be the “experts of their own life” (Thiersch, 2002, p. 124).
Another analytical foundation of this study was one that
identified the
groups as rites of transition (Van Gennep, 1960/2010). In
analyzing the
ritualized process of change taking place within the group
participants, the
Turner model of liminality was used. This model understands
liminality as a
performativity created space where people (inter)act “beyond
the norms and
ideals of the social structure” (Turner, 1969, p. 94). Defining
the groups as
such a space, where people can experience themselves through a
paradigm
other than that to which they are accustomed, allows
nonparticipants to
understand how participation in anonymous group rituals
positively affects
the process of transition from emotional illness to emotional
health.
Barthes’ (1982) methodology provides the framework for the
critical
approach concerning the social factors of the disease of
addiction. He

advises analyzing pre- and late-modern narrative structures as
myths. His
approach to history is performative, meaning he understands the
subjec-
tive perception of reality as determined through a specific
representation
of the past, which gives meaning and creates cultural currency.
This
approach serves the purpose of determining how the exchange
of
82 P. HELM
unconscious, tacit norms influences participants, and how it
correlates to
broader mythological concepts.
Results
The result section is divided into two parts. The first part is
devoted to the
five patterns of emotional illness as found in the textual
analysis: initial crisis,
rationalizing contradictions, metaphors of fight and war, a
public and private
self, and cycles of selfishness. The second part deals with the
narrative of
emotional recovery as practiced in the groups and as
exemplified in the
autobiographic writings of participants. Four patterns are
identified: hitting
bottom, anonymity, the emotional bottom, capitulation.
Patterns of emotional illness

Initial crisis
An initial crisis is a common theme in all of the samples that
were analyzed.
These crises are described as either personal losses, or
collective events such
as war, financial crisis. Bill W.’s narrative, in 1939, serves as a
constant point
of reference for such a crisis:
War fever ran high in the New England town to which we knew,
young officers
from Plattburg were assigned. [. . .) I was part of life at least
and in the midst of
excitement I discovered liquor. (. . .) In time we sailed “Over
There.” I was very
lonely and again I turned to Alcohol. Much moved, I wandered
outside. My
attention was caught by doggerel on an old tombstone: “Here
lies a Hamshire
Grenadier who caught his death drinking cold small beer. A
good soldier is ne’er
forgot hether he dieth by musket or by pot.” Ominous
warning—which I failed to
heed. (AA, 1939, p. 1)
Bill W. describes how he uses alcohol as a comforter to avoid
experiencing
the emotional loneliness of his wartime experience and the
distress of his
subsequent postwar disorientations. Bill uses alcohol to numb
his emotional
pain and in doing so enters a downward spiral of obsession,
compulsion, and
addiction. Alcoholics like Bill W. are unable to confront their
emotional

illness and continue to pursue a pattern of life, seeking
temporary relief in
alcohol-induced forgetfulness.
Rationalizing contradictions
Another theme of contradiction and rationalization emerges
from an analysis
of the samples. This emotional conflict is again captured in the
writings of
Bill W. Upon his return from the war he was conflicted by the
demands of
leadership and of obedience. He uses the myth of the drunken
genius to
excuse his spirit of rebelliousness. Bill W., writing in 1939,
describes his
emotional confusion as follows:
Twenty-two, and already a veteran of foreign wars, I went home
at last. (. . .) I took
a night law course, and obtained employment (. . .) Potential
alcoholic that I was, I
nearly failed my law course. Though my drinking was not yet
continuous, it
already disturbed my wife. I would still her forebodings by
telling her that the
men of genius always conceived their most majestic
construction of philosophical
thought when drunk. (AA, 1939, p. 2)
He rationalizes his drinking by using the myth of the drunken
genius who
can be extremely creative when drunk. His fanciful thinking is

again captured
in the following quote:
Twenty-two, and already a veteran of foreign wars, I went home
at last. I fancied
myself a leader, for had not the men of my battery given me a
special token of
appreciation? My talent for leadership, I imagined, would place
me at the head of
vast enterprises. The drive for success was on and took me to
Wall Street. Many
lost money but some became rich—why not I? (AA, 1939, p. 2)
Like Bill W., Susan, a young member of NA finds the roots of
her illness in
her first life crisis. Her crisis is of a personal nature. It is
constructed around
the death of her father. However different the natures of Susan
and Bills’
crises, the reader finds in both stories the common thread of
disorientation:
After my father died, I did not know where to go. I felt lost.
Since my father always
told me that he was going to meet friends when going to the
pub, I started going
there too, searching for consolation. (. . .) What I found there
was alcohol. The
bottle soon became my best and only friend. (Narcotics
Anonymous, 1986, p. 7)
Susan didn’t know how to handle becoming an orphan at age 18.
Because she
had no social network, like NA or AA to direct her in her grief
work, she felt
helplessly stuck. The resulting reaction was a desperate search

for a friend,
giving her orientation. She sought solace from her emotional
pain in her new
friend; that friend was the Friend in the Bottle.
Metaphors of fight and war
An analysis of the samples reveals that metaphors of fight and
war were used
to capture the emotional illness of persons with various
addictions. The
following quotes, taken from autobiographies of participants
with different
addictions, genders, and social status, capture one more piece of
fight and war.
Jane writes in Overeaters Anonymous (2001), “I had built an
armor of fat,
protecting me frommy subtle anger against all men. This armor
was my prison”
(p. 10). Bill writes in AA (1939), “Out of an alloy of drink and
speculation I
commenced to forge the weapon that one day would turn its
flight like a
boomerang and all but cut me to ribbons” (p. 2). Bob writes in
AA (1939), “At
the end I had no more power left to fight.” Susan writes in her
personal
testimonies, “I realized I treated my addiction like an inner
enemy. Today I
know I have to welcome this enemy as friend, if I wish to stay
abstinent”
(Susan N., personal testimonies, collected 2014).
84 P. HELM

In these examples, one can see different approaches that capture
the
interior struggle of persons dealing with the emotional illness of
their con-
dition. The following questions emerge: Who is fighting against
whom here
and how to help the struggling individuals deal with the
conflict?
A public and a private self
The narratives reveal that persons with addictions deal with two
competing
notions of self: a public self and a private self. The emotional
illness of the
addiction finds full expression in the private self. Various
substances and beha-
viors are used to numb the sense of pain that is experienced by
the private self.
At the same time, the person seeks to maintain an idealized
public self. To
maintain some sense of balance between the competing selves,
the person
who is drug dependent uses destructive rationalizations, denial,
and isolation
to deal with a bipolar self. The private and public images drift
further and
further apart as the addiction progresses, producing feelings of
constant
emotional isolation and alienation. Helen, an Overeaters
Anonymous mem-
ber, describes this feeling of the two separate selves as follows:
Taking a look at my resume, my life looks just as perfection
claims. But secretly I

always thought to myself: If they knew what price I pay (. . .) if
they knew the secret
– that I can only manage to keep my perfect appearance because
I puke as soon as
I get home (. . .) nobody would trust me anymore. (. . .) I was
haunted by the fear
that if anybody would discover my secret, nobody would trust
me anymore.
Everybody would hate me. I honestly thought that way. And I
believed what I
thought. (. . .) When I started attending Meetings I made the
experience of sharing
my worst fears and secrets and being acknowledged with them.
Today I’m so
grateful because I feel that my private and my public self slowly
melt together to be
one again. (Helen S., personal testimonies, collected 2014)
This narrative illustrates the struggle between the two selves:
the public and
the private selves. Helen received social acknowledgment for
the perfect self
she displayed in public. Helen’s hidden self, the suffering self,
remains a
source of deep emotional distress that she treats with her
addictive behavior.
In recovery she discovers an ability to bring her two selves
together in a
context of healing that is promoted through her group
participation.
Cycles of selfishness
The participants also recount patterns and cycles of selfishness.
These beha-
viors are closely related expressions of an emotional illness,
such as self-

isolation and inner conflicts of self, which characterize various
forms of
addiction. This inward focus is described as “self-centeredness
and self-
pity” and again “as the root of all problems” (AA, 1939, p. 62).
This internal
obsession is offset by an outward, exaggerated expression of
competitiveness
and of self-importance. Mel T., as a woman member of
Underearners
Anonymous, captures this emotional turmoil as she writes:
I used to be a know-it-all. I was arrogant because I’m insecure.
I feel superior to
my family and to all black people (. . .) and I hate white people.
So I act like I’m
better than I believe myself to be. There is a lot of compulsive
need to prove (. . .) as
the only smart black kid at grammar school. I used to walk into
a room and feel
like the entirety of the black people were depending on me to
get it right. I think
people are out there to get me, that people are patronizing me
because I’m black
and poor and uncultured. I created an attitude of opportunity
and enjoyment that
manifest in the appearance of my clothes, my office, my teeth,
my hair. (. . .) But
when I ran into situations that showed my ignorance and small
living to the world,
I hide. I get scared and intimidated. I hide and bite. (. . .) I
create an attitude of

poverty and paucity. (. . .) I even have run from opportunities in
the past. I ignore
my inner gifts and strength. (. . .) A lot of that is dissipating
now due to writing in
the Steps teaching me to take an honest look at myself. (Mel T.,
personal testi-
monies, collected 2014)
Mel T. in this narrative captures another expression of the two
competing
selves that are encountered in addictive states. Neither self is an
authentic
one, and the conflict between the two produce profound
alienation and
isolation, expression of her interior emotional illness, her
ability to take “an
honest look at myself” at the beginning of her recovery.
Narratives of emotional recovery
An analysis of the narratives also reveals metaphors and rituals
that illustrate
the dynamics associated with recovery. These experiences
called “emotional
recovery” are closely related to the pattern of emotional illness
described in
the previous section.
Hitting bottom
Many emotional crises characterize the narratives of the group
participants
in this study (AA, 2003). “Hitting bottom” differs from the
previous crisis
that, though in themselves are painful and devastating, do not
confront the
denial of the addictive condition or open the pathway to

recovery. Rainer,
a German addicted to alcohol, captures the essence of truly
“hitting
bottom” in distinguishing the various “bottoms” he has
experienced in
the course of his illness:
My name is Rainer and I’m an alcoholic. I pray to my higher
power that the crisis I
recently went through will be my bottom. I’ve often believed
I’d hit it, but, so far, I
was doomed to be proved wrong each time. Today I write down
my life-story, a
story that I was always afraid to face. I sit down to write,
carrying the hope that
writing about my last bottom will help to make it be my last
one. (Anonyme
Alkoholiker, 2009, p. 256)
There are many narratives, which replicate Rainer’s experience,
when
analyzing these studies. They recount the desperate struggles of
persons
with addictions to break the destructive patterns of their
addictive behaviors
86 P. HELM
and to escape from their profound emotional illness,
characterized by power-
lessness, hopelessness, self-hatred, and desperation.
The narrative of Eileen, across American woman with
addictions captures

her desperate struggle to escapes from the horrors of her
addictions to
alcohol and medications:
I knew nothing about Delirium Tremens but I’d scream at the
telephone that I’d
split wide open. I knew that alcohol and I had to part. I knew I
couldn’t live with it
anymore. And yet, how was I to live without it? I didn’t know.
After pills and
alcohol I became work addicted.(. . .) I sat for a week, a body in
a chair, a mind of
in the air. I thought the two would never get together. I went to
my doctor again. I
said: “I can’t find a middle way in life. Its either all work or I
drink.” He said: “Why
don’t you try the groups?” (AA, 2003, p. 298)
Finding “the groups,” an AA group, proves to be the turning
point in
Eileen’s recovery. She finds an alternative to her destructive
behaviors
and emotional suffering by “hitting bottom” and by finding a
recovery
group where she can share her suffering in the context of
understanding
and acceptance.
Eddy T., one of the earliest members of AA, recalls his
desperate cries of
struggling with alcoholism prior to the foundation of AA, when
incarceration
or closed psychiatric wards were the only options available
(Lobdell, 2007, p.
10). Eddie T., like Helen at a much later date would find his
salvation in AA

groups after he, too, had experienced “hitting bottom.”
Anonymity
Anonymity, since the inception of AA in 1935, has been one of
the most
cherished and effective elements of the recovery process from
addictions
and, in the context of this study, from the emotional agony of
the illness.
The founders of AA and its earliest members embodied the
“attitude of
anonymity” (Desmond T as quoted in AA, 2010) by creating a
space where
group participants can freely share their most overwhelmingly
emotional
and physical agony (AA, 1939, p. 9) The group setting creates a
liminal
space, a space where Turner (1969) describes as a “space
beyond the
everyday life social structures.” Within this safe space, group
participants
are empowered by a revered ritual that enables them to reveal
their hidden
wounded selves with others who are experiencing like suffering.
A perfor-
mative potential is created where the group members can share
their
stories, by identifying themselves by their first names only
unencumbered
by the pretense surrounding their inflated egos and their public
selves that
they have created as part of their addictive behavior. The group
settings if
free of social stigmatization (Goffman, 1963) and isolation and
alienation
are breached in a setting where anonymity equates with equality

and
acceptance. The power of anonymity is captured in the
testimonies of an
early group member in Akron, Ohio.
Everybody who knew me said I was a hopeless drunk. But when
I ended up in
hospital I believe every member of the Akron Group did come
to see me. They
impressed me terrifically, not so much because of the stories
they told me, but
because they would take the time to come and talk to me
without knowing who I
was. They didn’t need to know me, they simply believed in my
potential to change.
(AAA, 2003, p. 244)
Emotional bottom
Another emotional bottom emerges as group participants reveal
more freely
by the safe liminal space afforded by the group leadings.
Discarded and
empowered by anonymity, persons who are recovering see
themselves
reflected in the stories of others. One narrator recounts she
discovered an
understanding of her illness through the story of another: “Yes,
that’s me, I’m
like that too, and if he says he is ill, then I am ill, too” (AA,
1957, p. 69).

Helen, a member of Overeaters Anonymous, identifies the two
bottoms
that she encounters in the course of her recovery.
I was raised to be no ghetto child, to hold my head up and not
act like or be
mistaken as an American black, but my story has all the
classical embarrassments
of being an American black. Ghetto parents, theft, denial,
neglect, violence,
ignorance, sexual abuse. (. . .) The process I’m going through
right now in this
program is the act of rooting out the distress, the clearing and
cleaning of my
system. However, right now, as I get to the bottom of my
distress, I believe I have
gotten to the bottom of the bottom within myself. I’ve allowed
myself to see and
feel it. (. . .) I’m embarrassed by my upbringing and the only
way to cleanse and
purge it is to write about it. The laxatives didn’t do it. I got nice
and thin, but it
never erased what happened. Nothing will erase what happened.
I just have to live
with it all now. (Helen S., personal testimonies, collected 2014)
Capitulation
The narratives analyzed in this study constantly report that
capitulation
(surrender) is a metaphor used to describe the ability to choose
another
path resulting from “hitting bottom.” As a polar opposite of the
fight/war
metaphors identified by participants as a component of their
emotional
illness, capitulation implies surrender, or radical

deconstructions of one’s
former attitudes and self-image. The process of capitulation
(surrender) is
debilitated by group rituals especially those that describe
“hitting bottom” in
the dynamics of the death and rebirth experience (Turner, 2000;
Van
Gennep, 1960/2010). Anniversaries of sobriety in AA and other
mutual
help groups are celebrated as birthdays.
88 P. HELM
Discussion
This study identifies “emotional illness” as an expression of
various forms
of addiction. Patterns of emotional suffering have been
identified from an
analysis through the writings and personal testimonies of
participants in
mutual help groups, representing the earliest experiences of the
AA groups
and subsequent groups modeled after the AA experience. Six
integrated
expressions of emotional illness are described in the Results
section
together with four corresponding patterns of recovery. In this
Discussion
section, important elements of emotional illness and of early
recovery are
identified.
Ongoing crises of an emotional nature emerge as a constant

feature in the
narratives, between 1935 and 2013, and is embraced by this
study. Persons
experiencing addictions are enabled to deal with such crises
without a
supportive network or principles that restore some sense of
inner peace.
Unable to address an ongoing state of emotional turmoil,
persons with
addictions become dependent on addictive substances or like
behaviors in
an effort to medicate their emotional suffering. This condition
is further
aggravated by isolation and alienation and by desperate efforts
to rationalize
the conflict between the contradictory sources of self-
destructive behavior
and the desire to address the cause of this profound inner
conflict. Two
selves develop as a result of this conflict, the public self that
would maintain
some semblance of normalcy and the inner self that is racked by
guilt,
remorse, and a host of other negative emotions. A cycle of self-
centeredness
and selfishness designed to conceal the inner self from the
addictive person
and others emerges. These factors allied with the other negative
forces create
a downward spiral of self-destruction.
The crises multiply and culminate in a major crisis that is
described by the
studies participants as “hitting bottom.” This experience
becomes an indis-
pensable product of recovery, when it is shared in the context of

a recovery
group. Otherwise it is yet another devastating loss and
emotional crisis in the
continuing downward spiral of self-destruction that
characterizes an
addiction.
The textual and self-testimony analysis embodied in this study
confirms
that group participants clearly identify “emotional illness” as an
essential
component of their addiction. This finding is not a novel one,
but it does
emphasize the need to maintain a consistent focus on the
emotional dimen-
sions of addiction and in the concomitant process of recovery
that addresses
the emotional illness.
The other contribution of this study is found in its identification
of
some essential qualities of the processes of change and early
recovery as
captured from the narratives of the participants. “Hitting
bottom” has a
decisive emotional element that serves as an agent of ongoing
change and
transformation when shared in a group setting. A group ritual,
influenced
by the disarming power of anonymity, creates a safe liminal
space for the

group members. The context of trust and honesty, facilitating
capitulation
(surrender), by telling ones stories in a symbolic and real way
has the
power of “performative magic” as described by Audehm (2001).
A dramaturgy is at work in the group dynamics as illness and
recovery are
described in one’s life story in terms of spiraling down, hitting
bottom, which
results in confirmative change experienced at the emotional and
spiritual
levels. As the process of rebirth is a constant feature of the
narratives study in
which the old self, with its selfish, self-centered ego is
abandoned, and a
renewed, caring and connected self is embraced. “Self-
sacrifice,” in AA
terminology, is at work in this process (AA, 1957, p. 91).
Conclusion
Metaphors and rituals are used in this study to further amplify
our under-
standing of the dynamics of change experienced by participants
in mutual
self-help groups. Emotional illness is identified as an essential
element of
addiction, and corresponding elements of recovery are also
explored.
Concentrating on and inspecting the narratives of the
participants allows
the participants to tell their stories in their own voices as they
share the
emotional devastation of their illness and the day-to-day hope
embodied

in their recoveries. This tradition of story-telling is central to
the healing
process embodied in AA and other like self-help groups (Kurtz,
1991).
This tradition, now 80 years old, has been respectfully
employed in this
study.
Acknowledgment
The author specifically acknowledges the editorial report of
Marsha Elizabeth Thompson in
preparing this article.
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AbstractIntroductionMethodSampleAnalysisTheoretical
basisResultsPatterns of emotional illnessInitial
crisisRationalizing contradictionsMetaphors of fight and warA
public and a private selfCycles of selfishnessNarratives of
emotional recoveryHitting bottomAnonymityEmotional
bottomCapitulationDiscussionConclusionAcknowledgmentRefer
ences
ADDICTION RESEARCH & THEORY, 2016
VOL. 24, NO. 2, 111–123
http://dx.doi.org/10.3109/16066359.2015.1075980
Overcoming alcohol and other drug addiction as a process of
social identity
transition: the social identity model of recovery (SIMOR)
David Best1, Melinda Beckwith2, Catherine Haslam3, S.
Alexander Haslam3, Jolanda Jetten3, Emily Mawson2,
and Dan I. Lubman2
1Department of Law and Criminology, Sheffield Hallam
University, Heart of the Campus Building, Collegiate Crescent,
Sheffield, UK,
2Eastern Health Clinical School, Monash University/Turning
Point, Fitzroy, Melbourne, Australia, and 3School of
Psychology, University of

Queensland, St. Lucia, Australia
ABSTRACT
In recent years, there has been an increasing focus on a
recovery model within alcohol and drug
policy and practice. This has occurred concurrently with the
emergence of community- and
strengths-based approaches in positive psychology, mental
health recovery and desistance and
rehabilitation from offending. Recovery is predicated on the
idea of substance user empowerment
and self-determination, using the metaphor of a ‘‘journey’’.
Previous research describing recovery
journeys has pointed to the importance of identity change
processes, through which the
internalised stigma and status of an ‘‘addict identity’’ is
supplanted with a new identity. This
theoretical paper argues that recovery is best understood as a
personal journey of socially
negotiated identity transition that occurs through changes in
social networks and related
meaningful activities. Alcoholics Anonymous (AA) is used as a
case study to illustrate this process of
social identity transition. In line with recent social identity
theorising, it is proposed that (a) identity
change in recovery is socially negotiated, (b) recovery emerges
through socially mediated
processes of social learning and social control and (c) recovery
can be transmitted in social
networks through a process of social influence.
KEYWORDS
connectedness, social
networks, social support,
social influence, mutual aid,

peer support, Alcoholics
Anonymous, communities
HISTORY
Received 3 December 2014
Revised 20 July 2015
Accepted 21 July 2015
Published online 17 August
2015
Defining recovery
As a concept that is still relatively new to alcohol and
other drug policy and practice, there is as yet no
established definition of recovery from addiction. The
Betty Ford Institute Consensus Panel defines recovery
from substance dependence as a ‘‘voluntarily maintained
lifestyle characterised by sobriety, personal health and
citizenship’’ (2007, p. 222). This position is consistent
with the UK Drug Policy Commission statement on
recovery as ‘‘voluntarily sustained control over substance
use which maximises health and wellbeing and partici-
pation in the rights, roles and responsibilities of society’’
(2008, p. 6). These definitions emphasise a process of
‘‘personal’’ transformation that is evident in observable
outcomes across multiple domains of functioning and
supported by abstinence or increased control over
substance use.
In contrast, client-led perspectives on recovery, such
as Valentine’s (2011) statement ‘‘you are in recovery if
you say you are’’ (p. 264), emphasise the importance of
the subjective experience of change. This definition is
consistent with the mental health recovery model

advanced by Deegan (1988). She argues that recovery
constitutes the lived experience of people as they accept
and overcome the challenge of disability, ‘‘recovering a
new sense of self and of purpose within and beyond the
limits of the disability’’ (Deegan, 1988, p. 54).
These two types of definitions differ, with the former
based on external and observable behaviours and the
latter on subjective states and experiences. What they
have in common is their failure to identify the mech-
anisms of change, or the social context in which change
occurs. Instead, both focus on the characteristics of those
‘‘in recovery’’ or who regard themselves as ‘‘recovered’’.
Yet, when it comes to matters of policy and practice,
knowing how to identify a person who is ‘‘in recovery’’
tells us very little about how to assist them in their
recovery journey.
The purpose of this article is to describe a conceptual
framework that explains how the transition to recovery
can occur, together with the social and psychological
dynamics that underpin it. The paper introduces a new
and key aspect of recovery, involving social identity
change and outlines how this is implicated in both the
initiation and the maintenance of recovery pathways.
Correspondence: Professor David Best, Department of Law and
Criminology, Sheffield Hallam University, Heart of the Campus
Building, Collegiate Crescent,
Sheffield S10 2BQ, UK. [email protected]
� 2015 Taylor & Francis
While there has been considerable literature on the role
of individual identity change in recovery, the role of

social identity has been largely neglected until recent
work by Buckingham, Frings, and Albery (2013)
attempted to reconcile the literature on recovery and
social identity.
To address this lacuna, in this article, we examine the
contribution of social identity processes to recovery
using the example of Alcoholics Anonymous (AA). This
program provides the basis for a strong social identity
that supplants a salient addict identity to support
recovery. In this context, we consider the role of social
connections in the recovery journey (e.g. changes in
friendship networks and group memberships), and the
resulting impact on identity and self-definition. A key
argument here is that identity change is bound up with
AA group membership and its capacity to furnish active
members with a new sense of social identity.
Recovery as a process of social group change
Existing evidence from the alcohol and other drugs
(AOD) field highlights the important role of social
groups in recovery. More specifically, a review of
evidence supports claims that simply belonging to one
or more social groups or networks is supportive for
recovery (Best et al., 2010). This emphasis is consistent
with related observations that groups and their asso-
ciated norms influence a range of substance-related
outcomes including the initiation and maintenance of
substance use (Hawkins, Catalano, & Miller, 1992),
attrition from treatment (Dobkin, Civita, Paraherakis, &
Gill, 2002), as well as risk of relapse following AOD
treatment (Hser, Grella, Hsieh, Anglin, & Brown, 1999).
Additional support for this argument comes from a
study of 141 cocaine-dependent individuals by Zywiak

et al. (2009). This found that patients who had better
treatment outcomes typically had larger social networks,
more frequent contact with their social network and an
increase over time in the proportion of people in their
social network who did not use any substances, including
alcohol. In other words, amongst people with problems
relating to cocaine use, those with the best outcomes
were more socially connected, particularly with social
groups whose norms were not supportive of continued
substance use.
Further evidence for the centrality of social processes
in recovery is provided by Litt, Kadden, Kabela-Cormier,
and Petry (2007, 2009). In this randomized controlled
trial, people who completed residential detoxification
from alcohol were randomly allocated to either standard
aftercare or to a ‘‘network support’’ intervention
that involved developing a relationship with at least
one non-drinking peer. Compared to standard aftercare,
those who added at least one non-drinking member to
their social network showed a 27% increase at 12 months
post-treatment in the likelihood of treatment success
(defined as being without alcohol 90% of the time).
Furthermore, this increase in the likelihood of treatment
success emerged despite no pre- to post-treatment
change in the number of people who drank alcohol in
their social network. This suggests that it was the
addition of non-drinking peers that accounted for
improved outcomes.
Increasing the availability and appropriateness of
recovery-oriented social networks may also be crucial
to long-term recovery from addiction. Beattie and
Longabaugh (1999) reported that whilst both general
social support and abstinence-specific support predicted

abstinence at three months post-treatment amongst
formerly alcohol-dependent people, only social support
for abstinence predicted longer-term abstinence (at 15
months post-treatment). Similarly, Longabaugh, Wirtz,
Zywiak, and O’Malley (2010) found that greater oppos-
ition to a person’s drinking from within their social
network predicted more days without alcohol use both
during and after treatment, and fewer heavy drinking
days post-treatment. In addition, less frequent drinking
within the person’s social network predicted more days
without alcohol use during and after treatment. Based on
this, the authors concluded that transition to sustained
recovery was underpinned by a move from a social
network supportive of problematic drinking to one
supportive of recovery. In addition, Zywiak, Longabaugh,
and Wirtz (2002) found that, while alcohol-dependent
patients with larger networks and a higher proportion of
non-drinking network members showed better long-
term treatment outcomes, these effects were moderated
by the patient’s frequency of contact with the social
network (this being taken as an index of their investment
in that network).
Frequency of contact with a recovery-oriented social
network is important because it determines exposure to
both recovery values and processes (Longabaugh et al.,
2010; Moos, 2007), and the creation of a social envir-
onment in which an emerging sense of self as ‘‘non-
using’’ or ‘‘in recovery’’ can be nurtured and shaped by
the norms, values and expectations of the group (Best,
Ghufran, Day, Ray, & Loaring, 2008; Best et al., 2012).
Furthermore, the benefits of social support for recovery
(which may take the form of information or practical
assistance, emotional support and a sense of belonging)
appear to be dependent on the degree to which those
providing support are perceived to be relevant, similar

and connected to the self. Thus, support is likely to be
most effective (i.e. most likely to be welcomed and taken
112 D. BEST ET AL.
on board) when those who provide it are seen to embody
a shared sense of identity (i.e. as ‘‘one of us’’; Jetten,
Haslam, Haslam, Dingle, & Jones, 2014; Haslam,
O’Brien, Jetten, Vormedal, & Penna, 2005).
In line with this reasoning, research with adolescents
has found that the negative effects of support for
continued substance use coming from substance-using
social networks are reduced when adolescents do not see
members of these networks as similar to themselves.
Conversely, the positive effects of recovery support from
non-substance using social network members are
enhanced when adolescents rate these network members
as similar to themselves (Vik, Grizzle, & Brown, 1992).
Based on this, researchers have concluded that the degree
to which adolescents perceive members of their social
network as similar to themselves moderates the impact
of social network support on their recovery, as well as
their risk of relapse post-treatment.
Recovery as a process of identity change
The idea that identity change is central to recovery was
first advanced by Biernacki (1986) who argued that, in
order to achieve recovery, ‘‘addicts must fashion new
identities, perspectives and social world involvements
wherein the addict identity is excluded or dramatically
depreciated’’ (p. 141). Building on this theme, McIntosh
and McKeganey (2000, 2002) collected the recovery

narratives of 70 former addicts in Glasgow, Scotland and
concluded that, through substance misuse, the addicts’
‘‘identities have been seriously damaged by their addic-
tion’’ (McIntosh & McKeganey, 2002, p. 152). Based on
this, they argued that recovery required the restoration of
a currently ‘‘spoiled’’ identity.
In a critique of this conclusion, Neale, Nettleton, and
Pickering (2011) contend that the notion of a spoiled
identity is pejorative and that it neglects the range of
alternative identities available to individuals across
different social contexts (e.g. as father, daughter, neigh-
bour, etc.) and overemphasises the salience and primacy
of the identity associated with substance misuse. More
recently, Radcliffe (2011) extended the argument around
multi-faceted identity in a paper on recovery from
substance abuse among pregnant women and new
mothers. This argued that participants’ motivation for
recovery occurred in the context of an emerging
‘‘maternal’’ identity, which is often perceived to be
‘‘spoiled’’ in the eyes of health and welfare professionals
as a consequence of the mothers’ substance abuse. Yet,
for women who currently or formerly abused a sub-
stance, their pregnancy provided a turning point, or
‘‘second chance’’, allowing them to construct a ‘‘normal,
unremarkable and un-stigmatised motherhood’’ identity
that supported their transition to recovery (Radcliffe,
2011, p. 984). Based on this, Radcliffe argued that shared
narratives of recovery, and recognition of the legitimacy
of alternate identities by others, were crucial for the
stability of the mothers’ recovery.
Through such work it can be seen that both Biernacki,
and McIntosh and McKeganey, hold to a conceptualisa-
tion of identity that emphasises a particular identity

related to substance use. This ignores other identities
that the person may hold, the wider social context of
groups they may belong to and the impact of their social
network on substance-related behaviour. In this regard,
the value of taking a social identity perspective – as we
do in the social identity model of recovery (SIMOR)
outlined below – is that it avoids framing addiction and
recovery in moralistic terms, as the ‘‘un-spoiling’’ of a
spoiled identity. Instead, it frames recovery as involving
changes in a person’s social world that coincide with
changes in a socially derived sense of self, thus
broadening appreciation of the ways in which recovery
can occur.
The social identity model of recovery
The SIMOR applies the Social Identity Approach to the
process of recovery from addiction. This model frames
the mechanism of recovery as a process of social identity
change in which a person’s most salient identity shifts
from being defined by membership of a group whose
norms and values revolve around substance abuse to
being defined by membership of a group whose norms
and values encourage recovery. This emerging sense of
self is shared with others in recovery, thus strengthening
the individual’s sense of belongingness within recovery-
oriented groups. This emerging social identity is grad-
ually internalised, so that the individual comes to
embody the norms, values, beliefs and language of
recovery-oriented groups. This, in turn, helps the
individual shape and makes sense of changes in
substance-related behaviour, and reinforces the new
social identity.
Social identity model of recovery (SIMOR) builds on
two complementary theories – Social Identity Theory

(SIT) and Self-Categorisation Theory (SCT). SIT pro-
poses that, in a range of social contexts, people’s sense of
self is derived from their membership of various social
groups. The resulting social identities serve to structure
(and restructure) a person’s perception and behaviour –
their values, norms and goals; their orientations, rela-
tionships and interactions; what they think, what they
do, and what they want to achieve (Tajfel & Turner,
1979; see also Haslam, 2014). SCT explains not only
when and why groups come to define the self, but also
SOCIAL IDENTITY AND RECOVERY 113
how particular individuals achieve standing within the
group. The theory argues that increased status within a
group is achieved as individuals become increasingly
representative of a group, and that representativeness is
achieved by embodying perceptions and expectations of
what in-group members have in common, and of what
distinguishes them from relevant out-groups (Turner,
Hogg, Oakes, Reicher, & Wetherell, 1987).
In this way, groups not only provide a sense of
belonging, purpose and support (Cruwys, Dingle, et al.
2014; Dingle, Brander, Ballantyne, & Baker, 2012;
Haslam & Reicher, 2006; Jetten, Haslam, & Haslam,
2012a, 2012b), but also provide a basis for social
influence (Turner, 1991). As noted earlier in discussing
the influence of social networks on adolescent substance
use, individuals are more willing to be guided by others
when those others are seen as ‘‘one of us’’ rather than
‘‘one of them’’. As Hogg and Reid observe, in these
terms, social influence can be understood as ‘‘the
internalisation of a contextually salient in-group norm,

which serves as the basis for self-definition, and thus
attitude and behaviour regulation’’ (2006, p. 14).
The extent to which one’s sense of self is derived from
membership of a group will have a range of conse-
quences for both perception and action. According to
SCT, the extent to which a given social identity comes to
define the self in a particular environment arises from an
interaction of two factors: accessibility and fit (Bruner,
1957; Turner, Oakes, Haslam, & McGarty, 1994). The
accessibility of a given social identity will tend to be
higher if it has been a basis for self-definition and
behaviour in the past, particularly in a similar social
environment (Millward & Haslam, 2013; Peteraf &
Shanley, 1997). The fit of a given social identity arises
from meaningful patterns of perceived intra-group
similarity and inter-group difference in the situation at
hand, such that the relative differences between
those defined as ‘‘us’’ (the in-group) are perceived to
be smaller than the differences between ‘‘us’’ and ‘‘them’’
(the comparison out-groups). In a recovery context, this
means that a recovery-based social identity is more likely
to become salient to the extent that individuals consider
themselves to be relatively similar to other recovery
group members and to be relatively different from the
members of groups engaged in substance abuse.
One previous study that provides evidence of these
processes at work involved the observation of British
students transitioning from home to university life (Iyer,
Jetten, Tsivrikos, Postmes, & Haslam, 2009; Jetten, Iyer,
Tsivrikos, & Young, 2008). In this, students were found
to be more comfortable in assuming a ‘‘university
student’’ identity, and thus adjusted more successfully
to university life, if this identity was compatible with

their other social identities, both in the present (because
the new identity fitted with values and beliefs derived
from the other groups of which they were members) and
in the past (because the new identity was more accessible
due to a similar social identity having previously been
enacted in a similar environment). This meant that the
transition to a new ‘‘university student’’ identity proved
particularly challenging for those students for whom this
identity was incompatible with previous and existing
group memberships, something that tended to be more
true for students from working-class families where
education was less valued.
This analysis suggests that challenges in recovery from
addiction are likely to be experienced when a recovery-
based identity is fundamentally inconsistent with social
identities that have previously been enacted, or where the
person starting their recovery journey maintains involve-
ment with, or commitment to, any group (including
family) whose values and beliefs incorporate active
substance abuse. In this way, the social identity approach
offers an explanation for the beneficial effects of group
membership found in previous research (Best et al.,
2012; Zywiak et al., 2009). However, it can neither be
assumed that all the groups to which individuals belong
have a positive impact on physical and psychological
wellbeing (Haslam, Reicher, & Levine, 2012; Jetten et al.,
2014), nor that they all promote healthy behaviours
(Oyserman, Fryberg, & Yoder, 2007). As groups are
strong determinants of self-definition (Turner, 1991),
strong affiliation with a group that is discriminated
against and socially excluded due to involvement in
deviant norms and activities (e.g. groups of injecting
drug users) may also increase group members’ health
vulnerability and reduce subjective wellbeing and self-
esteem (Schofield, Pattison, Hill, & Borland, 2001). Social

exclusion and stigma around addictive behaviours may
also lead using group members to identify more strongly
with one another, seeing themselves as different
from any other social group and thereby reinforcing
membership.
However, as SIMOR highlights, this need not prevent
recovery, provided there is a basis from which to develop
or strengthen other group memberships that support
recovery. In particular, if a person self-categorizes as a
member of a recovery-oriented group comprising former
users, they will internalise the shared characteristics of
the group as part of the self, and this new self-
categorisation will typically involve distancing them-
selves from, and diminishing identification with, using
groups due to their inconsistency with the characteristics
of the recovery group.
This means that when (and to the extent that) people
come to define themselves in terms of a recovery-based
114 D. BEST ET AL.
social identity (i.e. as ‘‘us in recovery’’), their behaviour
will be informed by the normative expectations asso-
ciated with that identity (e.g. avoiding environments and
people associated with substance abuse). Their identifi-
cation with a recovery group will shape their under-
standing of substance-related events (e.g. an offer to go
to the pub with friends) and their response to it
(rejection on the grounds that it would put their
recovery at risk). In sum, group memberships exert
influence on individuals through the transmission of
social norms, which are internalised and thus shape

subsequent attitudes and behaviour. Identification with
the group increases exposure to its norms and values, as
well as receptivity to them. This increases the likelihood
the group’s norms will be integrated into one’s own sense
of self (who I am).
Once salient, such positive social identities act as
resources that support psychological health and adjust-
ment (Jetten, Haslam, Iyer, & Haslam, 2009; Jetten et al.,
2014). Along these lines, there is evidence that
internalised group memberships become personal
resources that support positive adaptation to change in
times of life transition (Jetten et al., 2009, 2014). For
example, Haslam et al. (2008) found that life satisfaction
among patients recovering from stroke was greater for
those who belonged to more social groups before their
stroke, and who retained more of those group member-
ships following their stroke. In addition, the formation of
new group memberships following a traumatic event has
been found to predict fewer symptoms of traumatic
stress over time, after controlling for individual differ-
ences in post-traumatic symptoms at baseline (Jones
et al., 2012). This is because, to the extent that people
identify with them, groups provide a basis for a sense of
belonging, meaning, support and efficacy (Cruwys,
Haslam, Dingle, Haslam, & Jetten, 2014; Haslam,
Jetten, Postmes, & Haslam, 2009), and social identities
provide a reservoir of social resources that the individual
can draw on in their recovery journey. An emerging
recovery-based social identity can also help to make
sense of new decisions around situations and groups
associated with the previous using lifestyle and may also
contribute to a sense of self-efficacy that reinforces the
utility of the recovery-based identity and increases the
perceived desirability of recovery group membership.

By applying a social identity approach, recovery can
be conceptualised as involving the emergence of a new
sense of self, encompassing a history of substance abuse,
yet embedded within new, health-promoting social
groups. Here, recovery is seen not as a personal attribute
that can be observed and measured (Best & Lubman,
2012), but rather as a socially mediated process,
facilitated and structured by changes in group
membership and resulting in the internalisation of a
new social identity. This social identity exerts influence
on individual values, beliefs and action and is reinforced
and made more salient by successful use in challenging
situations.
Factors that maintain recovery are primarily social;
recovery involves moving away from the using social
network and actively engaging with an alternative social
network that includes other people in recovery.
However, it is important to note that the factors that
initiate recovery often relate to becoming tired with one’s
lifestyle, and these can often be brought to a head by a
crisis event (Best et al., 2008). Indeed, although not
highlighted in the literature, there is also the possibility
that changes in social identity may in turn accelerate the
process of becoming ‘‘tired of the lifestyle’’.
Clearly, there are challenges in initiating this transi-
tion. In part, these can arise from a lack of awareness of,
or wariness of, pro-social or recovery groups, something
that can be exacerbated by the social exclusion that
results from a heavy substance-using lifestyle. Never-
theless, there is evidence that even a single positive group
experience, in the face of multiple negative ones, can
provide the necessary scaffolding to help vulnerable and
excluded individuals seek out meaningful groups and

supportive networks (Cruwys, Dingle, et al. 2014;
Cruwys, Haslam, et al. 2014). This suggests that even
deep-seated experiences of isolation can be challenged in
the process of initiating the recovery transition.
Setting the scene for initial contact with recovery-
oriented groups is one of the primary motives of an
‘‘assertive linkage’’ approach that supports individuals to
engage with various groups. Testing this approach, both
Timko, DeBenedetti, and Billow (2006) and Manning
et al. (2012) have demonstrated the benefits of using
peers to support active engagement in groups. In each of
these trials, peers linked to specialist treatment providers
acted as ‘‘connectors’’ between socially isolated clients
and pro-social groups, resulting in both increased
engagement in group activity and better substance use
outcomes. Similarly, Litt et al. (2009) reported a 27%
reduction in the likelihood of alcohol relapse in the year
following residential detoxification amongst members of
a trial group assigned to a ‘‘network support’’ condition
that involved adding one person to their social network
who neither drank alcohol nor used other substances.
The effectiveness of assertive linkage approaches points
both to ways in which the initiation of group engage-
ment can occur for excluded individuals and to the role
of the group in building resilience by promoting
engagement and a sense of belonging (Jones & Jetten,
2011). SIMOR argues that motivation to change can be
initiated through two processes. The first involves
increasing exposure to recovery-oriented groups that are
perceived to be attractive to the individual. Second,

motivation to change may also be precipitated by a crisis
event (e.g. loss of a relationship or of a job), which may
enhance the desire to change through increasing tired-
ness with a substance-using lifestyle. This may also occur
through engagement with a recovery-oriented group as
part of specialist treatment programmes (e.g. participa-
tion in 12-step meetings), or through encouragement
and enthusiasm from friends. Thus, the initial drive may
be to escape the adverse and stigmatised consequences of
a substance-using lifestyle, but the catalyst and mechan-
ism for change lies in the changing social dynamics that
an individual experiences as they transition between
using and recovery-oriented groups. This causes the
person to move away from the using groups and to
engage more actively with recovery-oriented groups.
In SIMOR, we argue that there are at least two key
phases in the recovery transition (Figure 1) although, in
reality, this process is likely to be experienced as a
gradual transition in social identity and related behav-
iours. The journey towards recovery proceeds alongside
initial exposure to recovery groups in the context of
ambivalence towards an existing social identity linked to
active substance use. This transitioning occurs as a
recovery-based social identity becomes more accessible
and increasingly salient and as the using identity, while
still salient and accessible, starts to diminish. As the
sense of identity associated with recovery-oriented
groups stabilises, becoming highly accessible and salient,
the using identity diminishes in salience and relevance.
The new recovery-oriented social identity may take
time to develop as this requires a fundamental shift in
group memberships, values and goals that occurs
alongside growing recognition of the incompatibility of

this identity with the values of the using group. Indeed,
this may explain why rates of relapse are so high early in
recovery. Nevertheless, if factors prompting initial
attraction to a recovery group can overcome its perceived
incompatibility, participation in the recovery group may
offer new values and norms that ‘‘fit’’ with the individ-
ual’s recovery aims.
The transition to a maintained state of stable recovery
(represented on the right of Figure 1) involves ongoing
involvement with recovery-oriented groups whose mech-
anisms of impact include social learning and social
control thereby shaping social identity. Here, the salience
and stability of a recovery-focused identity will grow as
the individual becomes actively engaged in recovery
groups. Moreover, as this identity becomes internalised
the influence of using group values and norms signifi-
cantly diminishes. In response, the recovery-focused
identity becomes the more accessible and meaningful
social identity, thus supporting recovery maintenance.
The result of this entire process is a transition in social
identity – from one that is predominantly using based to
one that is recovery-focused. The latter is then sustained
and maintained through active participation in recovery-
oriented group activities. While the identity associated
with substance use is not altogether lost or discarded, its
salience diminishes as the ‘‘fit’’ of the new recovery-
based identity increases and that of the substance use-
based identity diminishes. Over time, this reduces the
likelihood of the using-based identity providing a basis
for behaviour.
A similar process of social transition has been
highlighted by Longabaugh et al. (2010) in predicting
increased abstinent days from alcohol. SIMOR is also

consistent with evidence reported by Buckingham et al.
(2013) that both substance users and smokers are more
RECOVERY INITIATION
Ini�al exposure to recovery groups;
a�rac�on to and gradual engagement
with new recovery group
RECOVERY MAINTENANCE
ac�ve par�cipa�on in recovery group;
salience of recovery-focused iden�ty
increases
USING
GROUP
stable recovery
SOCIAL IDENTITY CHANGE
ac�ve use
USING
GROUP
NON-USING
GROUP
NON-USING
GROUP

early recovery
USING
GROUP RECOVERY
GROUP RECOVERY
GROUP
NON-USING
GROUP
NON-USING
GROUP
NON-USING
GROUP
NON-USING
GROUP
Figure 1. A schematic representation of social identity
transition in the course of recovery from addiction.
116 D. BEST ET AL.
likely to remain abstinent if they identify strongly with a
recovery group. In other words, as former users come to
identify more strongly with recovery-oriented groups,
and less strongly with using groups, their likelihood of
sustained recovery increases.

More recently, Frings and Albery (2015) have
developed a Social Identity Model of Cessation
Maintenance (SIMCM), which draws on previous
research showing that therapeutic group interventions
that create a sense of shared identification are the basis
for cure or, in the present context, recovery (Haslam
et al., 2010, 2014; Jetten et al., 2012a). Like SIMOR, this
model highlights the importance of social identity
processes in recovery maintenance, but approaches this
from a social cognitive perspective, positing that attend-
ing group therapy generates a recovery identity for each
individual within the group and, through this group
identification process, that an individual increases their
self-efficacy to maintain recovery. The model assesses
this in the context of group therapy for addiction, seeing
this as a vehicle through which to promote a positive
recovery-based identity that individual members can
draw on in negotiating their current lifestyle.
This is a significant contribution to the field, and is
complementary to the SIMOR model we are proposing,
but with a difference in emphasis. While both models
emphasise the importance of group membership and
identity to recovery, SIMOR focuses on social identity
transition within a changing social context, drawing on
social identity theorising from a systemic, rather than an
individual, perspective to explain how this transition
occurs. Second, SIMOR highlights the point that
structured recovery groups, such as AA, are not the
only source from which a person can develop a recovery-
based identity.
The role of structured groups, compared with infor-
mal groups such as friendship groups or social groups, is
an area that will need further exploration in both the

SIMCM and SIMOR models. For SIMOR, we argue that
engaging with informal non-using groups can result in
similar positive recovery outcomes to structured groups
and, as informal groups can be formed based on any
shared experience, preference, goal, activity and so on,
there are more of them, offering a greater variety in
experiences, and allowing for multiple sources of support
in the recovery transition.
Third, SIMOR highlights multiple phases within the
recovery process, recognising that group memberships
are continually being negotiated and proposing that
shifts in social identity may well be initiated prior to a
conscious investment in recovery. Consequently, SIMOR
suggests a transition in social identity is being negotiated
throughout the recovery process and is consolidated
during recovery maintenance. The strength of our model
may therefore lie in its contribution to framing how the
change process may work.
Social identity model of recovery (SIMOR) draws on
social identity approaches to understand how recovery is
initiated, produced and maintained whilst also recognis-
ing, and accounting for, the possibility of relapse. Thus,
while SIMCM makes an important contribution by
recognising the central role that social identity and group
process play in addiction treatment outcomes, SIMOR
builds on this analysis by characterising recovery tran-
sition in terms of an interplay between memberships of
various groups, some of which promote non-using or at
least non-harmful using, norms over addictive using
norms and examining how these dynamics play out in
the process of social identity change. The evolution of
both SIMCM and SIMOR are key to emphasising the
central role that social identity plays in recovery and

each suggests key areas for further empirical research.
Alcoholics anonymous: a model of effective
social intervention for alcohol abuse
If this model accurately represents the social identity
transition in recovery, then the social processes identified
as critical in recovery from addiction should be evident
in successful recovery group-based, peer-driven pro-
grams. In this regard, AA offers an appropriate test case
as it provides the most widely available community
support programme for problem drinkers (Kelly &
Yeterian, 2008). AA is a mutual aid organisation for
peers to support each other to overcome an addiction to
alcohol, based on 12 steps and 12 traditions that
members work through over time (e.g. Step 1 requires
members to admit that they are powerless over alcohol).
AA is used as a case study for the current paper because,
with more than 2.1 million members and 100,766 groups
in 150 countries, it is the mutual aid recovery group with
the largest membership and the strongest empirical
evidence base. Nevertheless, we would draw obvious
parallels to other mutual aid groups (such as Narcotics
Anonymous and SMART Recovery) as well as other
peer-based recovery groups and services.
Meta-analytic reviews report a positive association
between AA participation and abstinence, as well as
reductions in substance-related health care costs
(Tonigan, Toscova, & Miller, 1996). The efficacy of AA
involvement in supporting recovery is also evident across
a diverse range of populations (Emrick, Tonigan,
Montgomery, & Little, 1993; Moos & Moos, 2006). In
addition, and in line with SIMOR’s theoretical analysis,
higher rates of attendance at AA meetings have been
associated both with greater rates of abstinence from

alcohol and an increase in the number of non-drinking
friends (Humphreys, Mankowski, Moos, & Finney,
1999).
Such evidence suggests that the process of categorising
oneself as a member of a group that values abstinence
provides a plausible explanation for the efficacy of the
recovery model promoted and utilised by AA. Put
simply, AA offers a positive recovery-based social
identity that is accessible for members to use as a basis
for self-definition. This identity is largely defined by the
norms and values of AA’s prescribed social behaviours
and traditions, which are laid out in the AA ‘‘Big Book’’
(Alcoholics Anonymous, 1939) and that are discussed in
many AA meetings. This is reinforced by a shared lexis
(‘‘fake it till you make it’’, ‘‘one day at a time’’, ‘‘rock
bottom’’ etc.), the deployment of which denotes associ-
ation with AA and fosters identification with the group.
The frequent deployment of the AA lexicon may be
indicative not only of internalisation of a recovery
identity but also may imply some level of implicit
identity (Frings & Albery, 2015). Indeed, 12-step fellow-
ships may be unique in containing a range of rituals and
practices that serve as warrants of membership and that,
when enacted, clearly convey engagement with and
adherence to, the ideology outlined in the Big Book. In
serving to embed the recovery identity, such rituals and
practices are likely to have significant implications for
perceptions and recognition of group membership and
hence for the sustainability of a recovery-based social
identity. Furthermore, AA promotes meaningful and

pro-social behaviour by emphasising the need to make
amends and to help others as central to the recovery
journey (Humphreys, 2004).
In this regard, it is noteworthy that many of AA’s
prescribed practices are inherently social. New members
are encouraged to seek out ‘‘sponsors’’ (people in
recovery themselves who act as personal guides for the
recovery journey) and to speak to as many ‘‘experi-
enced’’ members as possible. Accepting that one is
powerless over one’s use of alcohol and therefore in
need of support, the sharing of one’s own story and the
structure of the sponsor system all serve to generate
active engagement and membership, thus binding
individuals to AA on an ongoing basis. Furthermore,
the principle of ‘‘keeping it by giving it away’’ speaks to
a process whereby individuals protect their own
ongoing recovery by helping others around them
achieve this as well. A substantial proportion of the
efficacy of AA in supporting recovery is therefore
achieved not merely through attendance itself but
rather through active participation at meetings (Kelly,
2013), thus embedding members within the group in
ways that encourage them to embody and live out the
group’s norms and values.
In addition, higher levels of engagement in AA-related
helping activity (e.g. helping to organise meetings, taking
on administrative roles and so on) have been associated
with greater abstinence, and lower levels of depression, at
1 and 3 years follow-up (Pagano, Friend, Tonigan, &
Stout, 2004; Zemore, 2007). Expanding on this, Pagano,
White, Kelly, Stout, and Tonigan (2013) found that
active helping in AA meetings was associated with
greater abstinence at 10 years follow-up compared to

standard professionally delivered alcohol treatment
interventions. In other words, the more members are
immersed in the activities and roles of the recovery
group, the more they benefit from their membership of
that group.
SIMOR as a basis for understanding AA efficacy
The impact and effectiveness of AA can readily be
explained from a social identity perspective. To recap,
the principal tenet of the social identity approach is that
individuals internalise group characteristics as elements
of the self (Turner et al., 1987) and that social identities
become increasingly salient as a function of their
meaningfulness and successful application in everyday
situations and activities. In these terms, it is the
perception of the self as belonging to a group that
provides the foundations for self-definition in social
terms (Turner et al., 1994).
In AA, new members’ initial attendance is said to be
precipitated by ‘‘hitting rock bottom’’ (Alcoholics
Anonymous, 1939). As Best et al. (2008) note, this is
typically understood as a culmination of the adverse
effects of their drinking reaching a crisis point, and it is
this understanding that provokes early engagement with
recovery groups. When first attending AA, new members
are greeted by existing members, who encourage them to
commit time and energy to active engagement in the
group. New members actively engage by attending 90
meetings in 90 days, by finding a sponsor to guide them
through the 12-step program, by ‘‘working’’ the 12 steps,
and by speaking to established members (recovery
elders) both during and after meetings. In this way, the
efficacy of AA for new members can be seen to result
partly from the availability and support of recovery role

models who are established members and who provide
identity-based leadership by seeking to exemplify the
norms and values of AA (Haslam, Reicher, & Platow,
2011). Established members are encouraged to ‘‘keep it
[their sobriety] by giving it away’’ and do so by engaging
with and encouraging new members through formal and
informal mentoring, assisting them to actively engage in
118 D. BEST ET AL.
AA meetings and support. By having a sponsor and
identifying a ‘‘home group’’, new members are incorpo-
rated into the social world of AA. This facilitates the
internalisation of the norms and values of the 12-step
fellowship and the adoption of an AA-based social
identity.
The foregoing analysis is consistent with the work of
Moos (2007), who has argued that one of the effective
elements of mutual aid groups like AA is the availability
of opportunities for social learning provided by the
observation of group members who are further into their
recovery journeys. Moos goes further to argue that it is
not just role models that AA offers but also an implicit
expectation that new members will learn and conform to
the group’s norms to achieve and maintain membership,
a process he refers to as ‘‘social control’’. In addition,
opportunities for social learning by observing and
imitating the recovery behaviours of more experienced
peers in recovery promotes the development of coping
skills, and positive attitudes, beliefs and expectations,
that support sustained recovery.
In line with SIMOR’s emphasis on the changing

structure of identity-based networks, Kelly, Hoeppner,
Stout, and Pagano (2012) also found that it was the
influence of AA engagement on social network change,
together with increases in abstinence self-efficacy, that
were crucial to recovery from alcohol addiction. This is
reflected in the literature around social networks and
recovery. As discussed earlier, individuals who form new
social networks with non-substance using peers are more
likely to sustain abstinence (Best et al., 2011; Kelly et al.,
2012), and those who report larger social networks and
greater frequency of contact with their social network
show more positive outcomes post-treatment (Zywiak
et al., 2002). As the individual cultivates their recovery-
based social identity through immersion in AA activities
and internalisation of AA values, so the social identity
associated with their using group is diminished
(Buckingham et al., 2013).
The established importance of social network sup-
port for long-term recovery (Best et al., 2012; Dobkin
et al., 2002; Litt et al., 2009; Longabaugh et al., 2010;
Pagano et al., 2004) speaks to the underlying effect of
social influence and social control on the transmission
of recovery behaviours (Best & Lubman, 2012). More
specifically, individuals are only likely to take on board
the values, goals, messages and support from networks
of people with whom they can already identify.
Without a basis for shared identification, there is little
motivation to engage with well-intentioned others, a
point that underscores the central role of social
identification in achieving such influence. As outlined
in our model, there is an established role for assertive
linkage to recovery and other pro-social groups (Litt
et al., 2009; Manning et al., 2012) led by either peers or
professionals. Nevertheless, more work is clearly needed

to assess the impact of such interventions on percep-
tions of support and the growth of recovery capital
(Cloud & Granfield, 2008).
There are also critical practice implications for
professional and peer services relating to the import-
ance of assertive linkage to community groups. For
many alcohol and drug users who have lost or broken
their ties with recovery-supportive networks and who
do not have access to recovery groups, assertive linkage
in the form of practical support (e.g. providing
transport) and emotional support (e.g. encouraging
and accompanying people to recovery meetings) is
essential. This has important implications for treatment
services engaged in recovery planning as it highlights
the need to initiate active engagement with recovery-
oriented groups, and to provide concrete advice and
support around the process of transitioning from using
based to recovery-based groups.
Social identity model of recovery (SIMOR) also offers
an approach that is complementary to specialist alcohol
treatment in targeting social and contextual factors that
are inadequately addressed by pharmacotherapies and
many psychological interventions. For policy makers, the
implications of the SIMOR approach relate to the need
to enhance acute therapies and promote social engage-
ment strategies that can help initiate and sustain
recovery-supportive lifestyles in the community, both
during and after formal treatment. And, while the
example we have used to illustrate the current model
focuses on alcohol recovery, similar issues of social
identity change and assertive linkage to supportive
community groups apply not only to addictions to
other substances, but also to other forms of social
exclusion and stigma, such as those associated with

obesity, homelessness and mental health problems such
as anxiety and depression (Crabtree, Haslam, Postmes, &
Haslam, 2010; Cruwys, Dingle, et al., 2014; Cruwys,
Haslam, et al., 2014).
There are also research implications related to the
generalisability of the model in terms of individual
differences and addiction-related factors. For example,
one emergent research hypothesis might be that those
who are not actively engaged in social groups, who are
introverted or who avoid group situations may be less
receptive to, or find less relevance in, interventions
promoting social identity change. A second empirical
question that arises from such an assumption is whether
the model is less applicable to the experiences of those
who are not involved in using in groups, and instead
use in isolation (as with people who drink heavily at
home alone), or to those who have little engagement
with recovery supports in group-based social situations
(e.g. those who manage their recovery through individual
psychotherapy or medication only).
The limited evidence from assertive linkage studies
would suggest the SIMOR model is similarly applicable
to a range of experiences. Cruwys et al. (Cruwys, Dingle,
et al., 2014; Cruwys, Haslam, et al., 2014) have found
little evidence that individual differences (e.g. in extro-
version) explain substantial variation in responsiveness
to group-based interventions. It is possible that people
whose addictive behaviours do not lead to social
exclusion or stigmatisation (as may be the case with

some less problematic or entrenched drinkers) may have
limited motivation to consider a social identity transition
as suggested in the SIMOR model. At the same time, the
model presented in Figure 1 provides an important basis
for empirically testing the effects of identity salience and
fit at varying phases of recovery. Those still actively
using would be hypothesised to identify more strongly
with using groups, while those in an early phase of
recovery would be more likely to report a diminishing
using identity in tandem with a growing recovery-based
social identity. The transition to a recovery-based social
identity should then be considerably more salient by the
time the individual achieves stability in their recovery.
These various issues also raise wider questions about
the testability of the model. Our sense is that these are
best addressed through empirical work, and indeed some
of this is already underway with this population. In two
existing papers based in drug and alcohol therapeutic
communities (Beckwith, Best, Dingle, Perryman, &
Lubman, 2015; Dingle, Stark, Cruwys, & Best, 2014),
the authors have demonstrated that new entrants whose
identification with the therapeutic community increased
in the first 2 weeks of treatment (which related to a
decrease in using group-based identity) had significantly
better retention and completion rates. Similarly, better
post-treatment outcomes were observed among partici-
pants who reported stronger recovery-based social
identities following discharge from treatment. Both
these studies demonstrate the predictive importance of
a social identity shift in the recovery transition. Another
longitudinal study is currently underway across four
therapeutic communities in Australia that will further
assess the impact of group belonging and social identity
change on recovery pathways whilst controlling for other
possible explanations (e.g. individual differences, addic-

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