‘Recovery capital’ in addiction treatment: What is it, and why is it important?

Recovery from substance dependence, and making the necessary changes to one’s lifestyle and skills to support this, can take time — and is different for every person.

One of the key strategies for treating substance dependence is to determine what factors will help the person in their recovery. These factors can be personal, social, environmental or community-related, and can include personal health, social networks, housing, transport, employment, and cultural support. These things are what is known as “recovery capital”.

A key role for the clinician in the early stages of assessment is to determine the person’s circumstances and what their goals are for their life and their journey away from substance dependence. The clinician has an important role as a resource at all stages in the recovery journey, to ensure the person is aware of the various supports and strategies which may be available as part of their recovery capital.

The road to addiction

The use of addictive substances can progress from casual use, to hazardous use, through to a significant substance-use disorder or addiction.1 For many people, the road to addiction can start in their formative years.2 Over a decade ago it was reported that 90 per cent of New Zealand adolescents would have used alcohol before age 14 years.3

According to more recent figures, of young people aged 14-15 years, up to 30.3 per cent have used alcohol, 7.9 per cent tobacco and 7.8 per cent cannabis.4

For some, substance use can contribute to the development of co-morbid mental health issues.5 In the United States, 37 per cent of people who have problematic alcohol use, and 57 per cent of people with problematic use of other substances, also have at least one diagnosable mental health disorder.6

Effects of continued harmful substance use can include physical injury, cardiovascular disease, cancer, liver cirrhosis, brain damage, mental health problems, foetal alcohol spectrum disorders, respiratory disease, and oral health issues.7 There are also social, financial, occupational, spiritual and legal complications associated with severe substance misuse and addiction.8, 9, 10

People on the trajectory towards a substance-use disorder can start to lose their links to the resources they need to have a full and productive life. This is why restoring those links to their recovery capital — the internal and external resources which help a person recover from the grip of a substance use disorder — is so important.11

Using a harm-reduction approach

Both abstinence and harm-reduction approaches are used in substance addiction treatment in New Zealand.

Under the harm-reduction model of treatment, participants are not required to completely abstain from substance use at the start of their treatment, but are helped with strategies to minimise the harm their drug use causes themselves and others around them. Through a therapeutic relationship with health professionals, they are helped to set goals, and change damaging behaviour. 12

This approach is not only helpful for the individual, but also for society as a whole, bringing more people into treatment who, for whatever reason, are not ready to abstain. It thereby eases stresses on communities, reduces transmission of diseases, and takes pressure off health and justice systems.13

The harm-reduction ethos is reflected in New Zealand health programmes  such as nicotine replacement,14 opioid substitution15 and drug testing.16, 17

Part of the harm-minimisation strategy in New Zealand for opioid addiction is the opioid substitution treatment (OST) programme,15 and embedded in the OST philosophy of treatment is the concept of recovery.18 Recovery capital has been identified as a key component in addressing opioid dependence and is specifically mentioned in the Ministry of Health’s OST guidelines.18

What is ‘recovery’?

There is no universally agreed definition of “recovery” from addiction – whether as a process, lifestyle or end-goal.19, 20, 21 However it has been usefully described in this way: “Recovering from addiction is more likely seen in people motivated to change and it requires mastering effective coping, stress management, and reinforcement skills”.22

According to other researchers,23 the concept of recovery has been adopted from the mental health consumer movement, and involves “a more personal sense of recovery—involving a process of learning how to manage daily life in the presence of, or within the limitations imposed by, an ongoing disorder”. This does not have to mean total abstinence — rather identifying the barriers to change and addressing those.

Recovery has also been defined as “… the ways in which persons with or impacted by a mental illness and/or addiction experience and actively manage the disorders and their residual effects in the process of reclaiming full, meaningful lives in the community”.24

Recovery from addiction is a process that involves a person identifying and using resources and supports that will enable them to improve their quality of life. Some elements of recovery are summarised in the table below.21

Table 1: Elements of recovery from substance misuse

Core elements of recovery	Other common elements of recovery
Having capacity for growth and development.	Being able to enjoy life.
Being honest with oneself.	Handling negative pressure or feelings without problematic substance use.
Taking responsibility for personal change.	Contributing to family, community, and self.
Reacting to pressure in a balanced way.

Recovery from substance use has been described as both a process20, 23, 25, 26, 27  and a lifestyle28 and is not undertaken in isolation from other aspects of the person’s life.

Recovery can be a lifelong and at times turbulent process.

It can be a lifelong29 and at times turbulent process30 which involves addressing many interrelated factors in the person’s life. Recovery capital can serve as a lens to help the person identify both assets and barriers that need to be addressed in their recovery process.30

Recovery capital can be divided into specific domains – social capital, physical capital, human capital and cultural capital – these are defined in Table 2 below.30, 31, 32

Table 2: Domains of recovery capital

Recovery capital domain	Definition
Social capital	The resources a person gains as the result of their network of relationships.
Physical capital	The financial and economic benefits a person gains from interacting and engaging in the real world.
Human capital	The human attributes, such as knowledge and skills, positive general and mental health, and other traits which allow the person to function in society.
Cultural capital	The norms of belief and behaviour which enable a person to meet their own needs and exploit opportunities for development and progress within their own cultural group.
Community capital	Societal attitudes, supportive policies and resources that aid recovery from substance use problems.

Behaviours required to maintain recovery are different to those needed to initiate recovery.33, 34 Initial work, such as reducing substance use and addressing any urgent consequences of prolonged or dangerous substance use, tend to overshadow other longer-term goals such as healthy eating, physical activity and meaningful work which help to maintain recovery.34

Programmes such as fitness and education enhance clients’ social engagement and and help build social capital,35 while stable employment is another significant positive influence.36

Negative recovery capital

Situations which hamper or put at risk a person’s recovery are described as “negative recovery capital”.31 Examples include where a person belongs to a culture where drug use is tolerated, and/or expected, or where the person is engaging in criminal activity with frequent incarceration (or the risk of incarceration).37, 38

Other barriers to recovery could include untreated mental illness, lack of transport to attend appointments or employment, criminal history and associated discrimination, ongoing financial stress and poor income, and lack of accommodation.

Patton and fellow researchers describe negative social capital as the “pains of recovery” — factors which hamper the person’s progress away from substance addiction. These are outlined in Table 3 below.39

Table 3: Recovery capital and ‘pains of recovery’

Domain	Early recovery: recovery capital	Early recovery: the pains of recovery	Sustained recovery: recovery capital	Sustained recovery: the pains of recovery
Personal		Uncovering unresolved trauma. Low self-esteem. Uncovering other addictions. Navigating a new self/world. Purposeless/hopelessness.	Living a life beyond that which was envisioned. Post-recovery identities.	Fluctuating levels of self-esteem. Mental health issues. Relapse.
Social	Mutual aid groups – gaining new friendships and tools for recovery.	Family trauma and tensions. Cutting off drug-using friendships.	Stable and supportive romantic relationships. Family reconciliation. Social networks (via work, education, and recovery groups).	Ongoing family trauma.
Community		Unsecure housing. Unemployment and menial jobs. Negative experiences with professionals. Stigma.	Stable, secure accommodation. Discovery of purpose. Fulfilling employment and promotions.

There is significant work to be done in the early stages of recovery. The person needs to determine their life goals, including what needs to be done to reduce and ideally abstain from substance use.

They must also identify and address the triggers which lead them to substance use in times of stress – rather than using other problem-solving techniques.

Health professionals have a role to play in this process. Table 4, below, outlines a model of recovery which incorporates three key perspectives – recovery experiences, the processes of recovery, and recovery-oriented clinical practice.40, 41, 42, 43

Table 4: Major themes of recovery40

Context	Themes and sub-themes
Recovery experiences	Experiences of being normal. Respecting and accepting oneself. Being in control. Recovery experienced as intentional. Recovery experienced as material and social.
Processes of recovery	Recovery processes as step-wise, cyclical, and continuous. Process involving steps forward and steps backward. Process involving all aspects of one’s life. Recovery as everyday experiences. Struggling to achieve or remain in a normal, ordinary life. Accessing resources, possibilities, and enjoyment. Recovery as relational. Developing and maintaining supportive relationships. Accessing supportive environments. Engaging in relational hope.
Recovery-oriented practice	Helping and supporting. Being helped on one’s own terms. Timely helping. Creative and collaborative helping and supporting. Applying helpful actions. Helping for different needs. Collaborating and relating. Relational characteristics. Characteristics of professionals in collaborative relationships. Organisational conditions and strategies. Identity integration in practice. Promoting individual identity. Promoting strength-oriented identity. Generating hope through nurturing and helping. Supporting service users to become hopeful. Generating hope in the context of difficulties.

It is important to understand that when a person has been under the influence of addictive substances for some time, this will have gradually changed their behaviour. They will need to readjust to a lifestyle where normal is being without the influence of addictive substances.

This type of behaviour change is likely to take time, and is not a linear process — the journey towards recovery may be filled with advances and regressions.

Recovery potential varies significantly across individuals and populations, and different people value aspects of recovery differently.44, 45

The key element of clinical practice when assisting someone on their journey of recovery is recognising that everyone is unique and what works for one person may not work for another.

In clinical practice, assessment of a person’s recovery capital is best undertaken in the early stages of screening, to establish the level of intervention they may need. For example, an individual, even if they have a severe dependence problem, may also have a high potential of recovery capital. And an individual with a dependence problem of low severity may also have high potential recovery capital and thus may only need brief intervention.32

The key element of clinical practice when assisting someone on their journey of recovery is recognising that everyone is unique and what works for one person may not work for another. Therefore, the clinician must engage with the person and understand their particular circumstances, including any barriers towards making positive changes in their life. Recovery is unlikely to be successful where there are significant barriers, whether they be personal, interpersonal, environmental, social, or societal.

For the health professional, positive engagement with the person is key. Where the clinician develops a therapeutic alliance with the person, and seeks regular feedback from them, they are able to jointly identify desired outcomes and change the direction of treatment direction as needed.46, 47

An important part of the clinician’s role is to be a resource at all stages in the recovery journey, to ensure the person is aware of the various supports and strategies which may be available as part of their recovery capital.

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* Brent Doncliff, RN, MN, FCNA(NZ), is a mental health nurse with 40 years’ experience in health care. He has worked as a clinical practitioner, nurse educator and nurse manager, and is currently clinical nurse manager with Te Whatu Ora/Health New Zealand – Te Tai o Poutini/West Coast Region. He is a Fellow of the College of Nurses Aotearoa (NZ) and a member of DANA – the Drug & Alcohol Nurses of Australasia.

Disclaimer: The ideas and opinions expressed by the author in this article are not intended to imply that they are (or are not) in any way part of the philosophy or operational procedures of Te Whatu Ora/Health New Zealand – Te Tai o Poutini/West Coast Region. They are solely the expressions of the author, based on literature research and consolidation, collective experience, and wisdom.

• This article was reviewed by Anthony O’Brien, RN, MPhil, PhD, associate professor of nursing at the University of Waikato.

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