A curious and dynamic dance revolves around the definition of recovery from mental health disorders in the 21st century. On the one hand, consumers of mental health services tend to define recovery as the presence of positive behaviors and mental states – known as the salutogenic model – while members of the scientific and medical communities tend to define recovery as the absence of disease and negative mental states – known as the pathogenic model. In order to reconcile and synthesize these two disparate points of view into a workable, useful, and inclusive definition, a group of researchers, spearheaded by Helene Provencher of Laval University (Quebec City, Quebec, Canada) and Corey L.M. Keyes of Emory University (Atlanta, Georgia, USA) propose a comprehensive definition of recovery under the label complete mental health.
First explored in the 2005 article “Mental illness and/or mental health? Investigating Axioms of the Complete State Model of Health” and expanded over the course of the past decade in close to a dozen related, follow-up studies, the idea of complete mental health – and its relationship to recovery from mental health disorders – is novel in that it recognizes the following:
- The absence of the symptoms mental illness does not automatically mean positive mental health.
- Positive mental health does not require the total absence of the symptoms of mental illness.
Instead of viewing positive mental health and mental illness as mutually exclusive states of being, Provencher and Keyes consider them as “two separate continua rather than the opposite ends of a separate continuum.” It’s important to note that while these initial studies focus on mental health disorders such as depression, schizophrenia, PTSD, and mood disorders, the value of the complete mental health model applies with equal validity to recovery from addiction and substance abuse disorders. Professor James Jackson (University of Michigan) elucidates the transfer of this Provencher/Keyes model to include recovery from addiction and substance abuse disorders in the 2016 publication Measuring Recovery from Substance Use or Mental Disorders:
“…one commonality between substance abuse and mental disorders…is that people with substance abuse problems often have cravings that could be described as conceptually similar to symptoms. In both cases, such a craving may be fine as long as the person is not acting on it.”
Both professional substance abuse counselors and individuals in active recovery from substance abuse disorders know cravings are not the only persistent symptom-like phenomenon challenging successful recovery. Counter-productive psychological coping mechanisms such as denial, anger, and rationalizing not only contribute to continued substance abuse prior to recovery, but also follow the recovering addict throughout life and often lead to relapse. Recovery does not mean the total absence of these life-interrupting coping mechanisms; rather, recovery means having the awareness, self-efficacy, and practical tools to identify and counter these mechanisms as they recur over time.
Substance Abuse Recovery: Process and Outcome
Recovery from addiction and substance abuse disorders is complex. It’s tempting to measure recovery with a single, yes/no criterion wherein abstinence signifies recovery and indulgence in intoxicants signifies non-recovery or abuse. However, substance abuse counselors and individuals in recovery alike identify this black-and-white approach as a reductive oversimplification that ignores the subtleties and nuanced challenges involved in creating a life free of substance abuse.
Relapse is a reality, yet relapse does not always mean a total collapse of the recovery effort. Nor does it mean a return to square one. The functional truth is that recovery is a non-linear process filled with advances, setbacks, successes, and failures. It includes in-between periods that are neither highs nor lows. The lifelong process of recovery happens on a dynamic continuum, and the precise location of an individual in recovery on that continuum rarely remains fixed. A recovering individual responds to the stresses and gifts of daily life with relative degrees of efficiency. Hard days are as much a part of recovery of good days. Navigating the extremes while maintaining a commitment to the process is the hallmark of a sustainable approach, as opposed to a static mindset that relegates an individual to a restrictive binary with sobriety on one side and substance abuse on the other.
An Multi-Faceted, Inclusive Model of Recovery
The complete mental health model advocated by Provencher and Keyes allows for the non-linear nature of recovery from addiction and substance abuse, and accommodates the formation of an analog for the two features of complete mental health previously described:
- Abstinence alone does not automatically mean complete recovery.
- Recovery does not require the absence of addiction-related symptoms.
Abstinence is, of course, the ultimate measure of sobriety, yet for individuals struggling with addiction, recovery means more than abstinence. It means the restoration – or in some instances, the discovery – of a way of life that supports happiness, health, and well-being. The model designed by Provencher and Keyes integrates a pre-existing model of mental illness described by Liberman and Koplewicz with their own model of positive mental health. The combination of these two models results in a multi-dimensional rubric containing six states of relative and interconnected positive mental health and disruptive mental illness, ranging from an initial state of being non-recovered from mental illness and languishing to a final state of being recovered from mental illness and flourishing:
- Non-recovered and languishing. This phase is characterized by severe impairments in mental health and extreme symptoms of mental illness.
- Non-recovered and moderately mentally healthy. This phase is characterized by fewer symptoms of mental illness combined with moderate levels of positive mental health.
- Non-recovered from mental illness and flourishing. This phase is characterized by the significantly reduced presence of the symptoms of mental illness, combined with concrete and identifiable attributes associated with positive mental health and flourishing.
- Recovered from mental illness and languishing. This phase is characterized by the absence of the symptoms of mental illness, combined with an absence of the attributes of positive mental health.
- Recovered from mental illness and moderately mentally healthy. This phase is characterized by the absence of the symptoms of mental illness, combined with moderate levels of positive mental health.
- Recovered from mental illness and flourishing. This phase is characterized by the absence of the symptoms of mental illness, combined with high levels of positive mental health.
[For the purposes of this article, the states are described here in sequence, whereas the rubric created by Provencher and Keyes situates them on an x/y axis, with the x axis representing the mental health continuum, and the y axis representing the mental illness continuum]
Substance abuse therapists and individuals struggling with substance abuse will immediately recognize the value of this expanded view of recovery. It asks both to understand that the process of recovery – the goal of which is complete mental health – is neither wholly salutogenic nor wholly pathogenic, but a combination of the two. It also asks those therapists and individuals to understand that recovery is neither solely a process nor solely an outcome, but again, a combination of the two. It gives therapists the tools to identify a client who’s abstinent, yet displaying mental health behaviors that may lead to relapse, and provides the vocabulary to discuss what they see with their client. It gives individuals in recovery the means to understand that it’s possible to be sober, abstinent, and diligently following a recovery program, yet still experience negative emotions and signs of poor mental health.
The Intersection of Theory and Practice
The Provencher/Keyes model gives treatment professionals the groundwork for situating traditional and complementary therapeutic modes side-by-side in pursuit of a greater whole: complete mental health. Awareness and application of the model particularly benefits individuals with co-occurring disorders, in that an array of therapies can be deployed – with the six states of recovery as a guide – to address both addiction and mental health disorders simultaneously. For many therapists and individuals in recovery, the Provencher/Keyes model verifies what they know already: recovery can be a messy process, filled with peaks and valleys. What works for one individual might not work for another, and what works one day for one individual might not work the next day for the same individual. The ability to bolster a recovery plan in one area, ease off in another, and stay steady in still another is something experienced practitioners and those in recovery have cultivated for decades. Until recently, however, these types of tweaks, and the insights that instigate them, have been a matter of instinct and the result of experiential knowledge – not the result of standard prescriptive practice. The introduction and adoption of a model that integrates the salutogenic and pathogenic theories of recovery into an adaptive, holistic, inclusive, and seamless whole unites theory and practice in a way that gives individuals in recovery a greater chance of therapeutic success, and ultimately, more options on the path to personal well-being and total mental health.