Social processes during recovery: an expansion of Kelly and Hoeppner’s biaxial formulation of recovery

Abstract Recent conceptualizations frame addiction recovery as a complex process involving changes across behavioral, physical, psychological, and social domains. These broad conceptualizations can be difficult to apply directly to research, making detailed models of individual dimensions necessary to guide empirical work and subsequent clinical interventions. We used Kelly and Hoeppner’s biaxial formulation of recovery as a basis for a detailed examination of social processes in recovery using social network approaches. We delineated how appraisal of situational risks and social network resources result in coping actions, and how repeated iterations of this process change a person’s social recovery capital over time. In addition, we incorporated the experience of interpersonal trauma and structural oppression and demonstrated how the model accommodates the complex issues often encountered during recovery. We present a measurable framework that can guide empirical testing of how social processes and social recovery capital change over time during recovery. The model presented here illuminates key factors in the recovery process that have the potential to support trauma- and social-network-informed interventions. We call for research that empirically tests this model in ways that will result in practical, trauma-informed social network interventions for people in recovery.


Introduction
Recent conceptualizations frame recovery from alcohol and other substance use disorders (AOSUDs) as a complex process involving changes in multiple domains such as use behaviors, physical and mental health, quality of life, and social relationships (White 2007;Kelly and Hoeppner 2015;Witkiewitz et al. 2020).These conceptualizations are inevitably broad and general, making them useful to explain and describe recovery from AOSUDs but difficult to apply directly to research and clinical work.Detailed, testable models of the individual dimensions of recovery will be important for guiding empirical work and subsequent clinical interventions (National Institute on Alcohol Abuse and Alcoholism 2021).
This article builds on Kelly and Hoeppner's (2015) 'biaxial formulation of the recovery construct' and presents an expansion of the social dimension of the general recovery concept.Kelly and Hoeppner posit that people experience increased recovery capital and better appraisal of and ability to cope with stressors with increasing time without substance use and that a person's level of recovery capital is related to their ability to both assess threats to their recovery and cope with those threats (Kelly and Hoeppner 2015).Their elegant combination of the theoretical frameworks of Recovery Capital and the Transactional Model of Stress and Coping, often called the Stress-Coping Model, provides a broad overview of general recovery processes.This article focuses specifically on the social processes in recovery and proposes three innovations to the framework: (1) Using social network approaches to model complex social processes; (2) Identifying testable, clinically-applicable microprocesses that shape the development of social recovery capital; and (3) Contextualizing the model by incorporating trauma as a specific stressor relevant to many people in recovery.Herein, we present the theoretical arguments for this approach and provide a detailed model of social processes during recovery.

Social network approaches
Complex social processes are inherently difficult to measure, leading many researchers to reduce them to individual attributes such as the presence or absence of support rather than examining the support a person receives from their network as an interactive, interdependent whole (Adams 2016).Some social researchers propose using social network approaches to quantify transactional and relational elements of the social environment to deepen our understanding of how barriers, strengths, and stressors within the social environment function together to promote or hinder recovery (Neal and Christens 2014;Rice and Yoshioka-Maxwell 2015;Tracy and Whittaker 2015).
Egocentric social network approaches are person-centered methods of examining the social ecology of a focal person with regards to the characteristics of the network members or alters, and the informational flow and structure of the network (Valente 2010) 1 .The structure and characteristics of the alters in a network have an important effect on the attitudes, beliefs, and behaviors of the focal person (Valente 2010), and can influence their recovery.Alter characteristics such as their substance use or abstinence, support for the focal person's recovery efforts, or engagement with formal or informal treatment are shown to affect recovery outcomes (Manuel et al. 2007;Laudet and Stanick 2010;Davey-Rothwell et al. 2011;Litt et al. 2015).Structural variableswhich measure how people in the network are connected, including things like closeness and reciprocity in relationships, network density (the proportion of possible connections between alters that actually exist), and bridging ties that connect the focal person to resources outside of the network-also affect recovery outcomes, primarily through interactions between network structure and composition (Rice and Yoshioka-Maxwell 2015;Tracy et al. 2016;Francis 2020).Social network interventions are shown to significantly reduce risks in sexual behaviors, disease transmission, and substance use in the meta-analysis (Hunter et al. 2019).
Frameworks such as the Social Identity Model of Recovery and Social Identity Mapping of Addiction Recovery examine social network characteristics and norms in relation to a person's development of identity as someone in recovery (Best et al. 2016;Beckwith et al. 2019) and are an excellent way to capture both social network and recovery capital information.

Social recovery capital
We can apply the conceptualization of social capital as a practical resource derived from a person's social environment to explain how differences in individual social resources can impact experiences in recovery (Bourdieu 1998;Granfield and Cloud 2001), and use this conceptualization to model how people in recovery use their connections to alters to maintain stability (economic, job security, etc.), reinforce a recovery-supportive ideology (group norms, common beliefs about recovery, obligations, etc.), and gain emotional support (Granfield and Cloud 2001;Reimer et al. 2008).We can also model how resources are accessed and flow through the network's structure.For example, having a lower-density network or bridging ties are both associated with higher social capital (Brunie 2009), and may be critical during times of personal transition-such as early recovery-for linking a person to new social supports and rapidly sharing norms, information, and resources (Granovetter 1973;Valente et al. 2004).
Social recovery capital can be conceptualized as the sum total of resources for and threats to recovery found in a person's social environment (Cloud and Granfield 2008).A person's social recovery capital changes as they progress through recovery (Cloud and Granfield 2008), with rapid increases in the first 6 months after entering treatment (Francis 2020), higher recovery capital following treatment (Best et al. 2015), and longer-term, more gradual increases over the first three years of recovery (Laudet and White 2008).
Social recovery capital is typically modeled with a positive range, but it is worth considering the important body of literature on negative social capital that posits that characteristics typically linked to higher social capital like strong relationships and close contact can increase health risks by isolating people from outside resources, restricting behaviors, and reinforcing risky behavior through social contagion (Portes 1998;Ehsan et al. 2019).Cloud and Granfield (2008) set social recovery capital on a continuum from positive to negative to quantify the balance and interaction of these complex and combined social influences on behavior.
While most models of social recovery capital agree that there are certain elements that support it and that the level of capital changes over time, most are less clear about specific mechanisms by which it develops and changes (Hennessy 2017;Best and Hennessy 2022).Social Identity Mapping captures some of this process as the person in recovery actively reflects on their network composition and resources (Beckwith et al. 2019), but it primarily captures a snapshot of the network rather than the process of change itself.The repeated appraisals modeled in the Stress-Coping Model provide a way to capture this change process.

The Transactional model of Stress and coping
The Stress-Coping Model posits that people perform a cognitive appraisal of threats when entering a potentially stressful situation, then appraise their own internal and external resources for coping, and finally use their appraisals of threats and resources to take action and restore internal balance (Lazarus and Folkman 1984).This process is continual and appraisals of both situations and resources change as the person gains new information or insight.
This fits well with how egocentric social network approaches quantify a person's perceptions of their network relationships (McCarty et al. 2019) and has direct links to recovery outcomes.For example, perceived alter support for recovery decreases relapse risk while perceived encouragement of substance use increases the risk (e.g.Davey-Rothwell et al. 2011).

Trauma
Trauma is a common stressor for people in recovery that fits within both models and can be captured in social network interactions and structure.Roughly one-third of people in recovery report experiencing at least one form of childhood maltreatment (Zhang et al. 2020), and some studies 1 While whole-network approaches can show how information and resources flow through the network (Valente 2010), the egocentric approach's focus on the individual's perception of their network makes it a better fit for this model.
show more than 90% of people in recovery have had lifetime trauma exposure (Gielen et al. 2012).Having higher levels of trauma is related to having more severe AOSUDs in women (Gallagher and Brunelle 2023), and this impact extends into recovery (Belfrage et al. 2023).
Positive social factors such as reconciling family situations and finding recovery-supportive romantic relationships can balance the negative impact of trauma on recovery capital (Patton et al. 2022).For example, survivors of sexual victimization report that having a supportive social network that offers empathy and belief in the survivors and healing their social patterns and relationships that reflect the abuse (e.g.reconciling with their abuser, creating new patterns of parenthood within their own families) all increase social recovery capital and perceived coping ability (Gueta 2022).

Kelly and Hoeppner's 'biaxial formulation of the recovery construct' (2015)
This formulation combines recovery capital and the Stress-Coping Model by showing that recovery capital increases with increasing time without substance use and that increases in recovery capital are related to the better appraisal of and ability to cope with stressors.Lower levels of recovery capital are related to decreased coping perception and increased threat perception, while higher levels are related to increased coping perception and decreased threat perception (Kelly and Hoeppner 2015).Their framework provides a broad view of the general recovery concept and provides a stable base for detailed exploration of how we can model recovery processes over time.

A model of social processes during recovery
Figure 1 shows a detailed examination of how the microlevel social appraisal processes that drive behaviors can be modeled using social network approaches and examines how they build and shape social recovery capital over time in the context of trauma.Circled numbers (e.g.‹) link in-text discussions of concepts to the figure.In addition, we provide examples of how the model can be applied and tested in research and clinical settings.

‹ Time
One of the primary goals of this model is to understand the process of building and changing social recovery capital over time, and, by extension, understand how people progress through recovery.Because appraising and coping with situations during recovery happens iteratively and recursively and builds on previous experience, researchers will need to consider longitudinal assessment timeframes on multiple levels from momentary to longer-term to match the theoretical model (Hopwood et al. 2022).
Longitudinal conceptualizations of recovery identify distinct recovery stages defined by changes in thinking, social connections, and behavior that can offer several general benchmarks for key recovery stages (Laudet and White 2008;American Psychiatric Association 2013;Inanlou et al. 2020;Martinelli et al. 2020): Early recovery is the first 3-12 months; sustained recovery is 1-5 years, although some set that cutoff at 3 years (Laudet and White 2008); and stable recovery is after that point.The changes represented by these recovery stages are reflected in the individual's appraisals of situations and their ability to cope.For example, someone early in recovery might appraise a social situation where others are drinking as more stressful and their social recovery capital and coping ability as low compared to someone in sustained recovery.

› Individual factors
These affect the accrual of recovery capital and the ability to effectively appraise situations and make decisions related to recovery.Some are more fixed, such as family history and genetics (McCutcheon et al. 2017), adverse childhood experiences (LeTendre and Reed 2017), the presence of co-occurring disorders (Tracy and Biegel 2006), and underlying neurological or biological conditions (Conrod and Nikolaou 2016).Others, such as developmental transitions (Tucker et al. 2020), recovery-related changes in neurobiology (Schulte et al. 2014), personality traits (Satchell et al. 2020), interpersonal style (Leach and Kranzler 2013), social skills (Best and Lubman 2012), and treatment (Porcaro et al. 2021) may change over time.

fi Situational appraisal
The person appraises: 'Is this situation a threat to me or my recovery?'Social norms and peer pressure as contained in both alter characteristics and network structure influence risk appraisal.For example, people in early recovery who formed closer relationships with peers in later recovery reported seeing problems and solutions differently (Best et al. 2021).Likewise, people are significantly more likely to initiate drinking and drink more when spending time with close friends who are also drinking heavily (O'Donnell et al. 2019).

fl Coping appraisal
Once a person identifies a situational threat, they appraise: 'What coping resources are in my social network?'This is an appraisal of their overall social recovery capital and captures both the available resources and how those resources flow within a network.Alter characteristics such as level of substance use or level of support for recovery can influence a person's coping ability when confronted with a stressful situation and lead to more or less ability to avoid relapse (Stone et al. 2016) and long-term recovery success (Moos and Moos 2007).All forms of recovery capital are often intertwined such that financial, emotional, and community support from alters all increase social recovery capital (Jurinsky et al. 2022).Alters in recovery are especially valuable sources of recovery-specific support, resources, and information about recovery that have the particular benefit to recovery capital, above and beyond those who are light drinkers or abstainers (Davey-Rothwell et al. 2011).
Whether the person perceives these coping resources as available depends on network structure.Having close, highcontact ties can be supportive of recovery (Mason et al. 2017), but this positive effect is only true when the people in the network are supportive of recovery (Eddie and Kelly 2017).Similarly, the level of network density affects the accessibility of coping resources, but whether that accessibility promotes or hinders recovery depends on alter characteristics such as support for recovery (Francis, 2020).Having a diversity of types of relationships (e.g.family, friends, case workers) can be protective against threats to recovery (Panebianco et al. 2016;Moore and Kawachi 2017), and this is likely because some of these ties represent bridging ties that can link the person to resources and gain access to those that share recovery-supportive norms.Again, these types of bridging ties only provide a recovery-supportive coping resource when the alters and ties themselves support recovery (Francis 2020).
Different expectations or norms for different settings, places, and situations can affect appraisals (Folkman et al. 1986).For example, heavy drinking may be a norm at family events but is penalized at work-social events, making a family event seem potentially riskier.Likewise, those in residential or other controlled environments typically have fewer recovery resources in their networks than those in outpatient settings (Kim et al. 2015) but may perceive themselves as being better able to cope because of the structure and resources inherent in the setting.
Finally, relationship aspects that we may see as positive, such as strength of connection or closeness can result in negative capital and a resulting perception of lower coping ability when combined with other aspects.For example, a person with strong, close relationships to people who support recovery would experience much higher social recovery capital and coping ability than someone with strong, close relationships to people who encourage substance use.

°Action
Once the person appraises their coping resources in relation to the threat, they decide, 'What will I do to cope with this situation?'Our current understanding of recovery acknowledges that abstinence, harm reduction, and substance use are all parts of recovery (Brown and Ashford 2019) and that all of these are valid coping responses in the face of a stressor.More important is the self-reflective process of growth that happens when a person reviews their-often unconscious-appraisal process and the coping actions they used to restore their internal balance and make decisions about how to change their social network or other aspects of their recovery environment.For example, engaging with support groups like Alcoholics Anonymous can facilitate network changes that increase perceived recovery capital (Kelly et al.

Coping Appraisal
What coping resources are in my social network?

Situational Appraisal
Is this situation a threat to me or my recovery?
x  2011; Martinelli et al. 2021).An appraisal can also lead to deliberately limiting or severing contact with alters they perceive as recovery-endangering or strengthening ties with those they perceive as protective (Francis et al. 2020).Such situation-specific review of social networks has proved effective in increasing readiness for change and abstinence self-efficacy when combined with brief motivational interviewing techniques (Kennedy et al. 2018).

-Trauma
The experience of trauma-particularly chronic-affects a person's entire appraisal and decision-making process.They may falsely appraise potentially recovery-endangering situations as less risky (Smith et al. 2004) or view less-risky situations as more threatening than they actually are.They may have negative appraisals of their coping ability or view their social network as an unreliable resource (Finkelhor and Browne 1985;Lazarus 1991), or see substance use as a coping strategy for trauma (Lazarus 1991).These conflicting reactions may occur in the same individual for different situations and likely indicate an impaired ability to appraise risks and balance coping reactions appropriately to the situation (Herman 1992).People who have experienced interpersonal traumas are often enmeshed in relationships that blur the lines between recovery support and recovery endangerment, making an appraisal of threats and resources challenging (Ouimette and Read 2014).For example, women in recovery report having relationships that can be simultaneously recovery-supportive and enabling of substance use, such as alters providing needed supports such as child care or money that ultimately enable them to use (Tracy et al. 2010) or having family who support recovery but have communication patterns or expectations that increase their relapse risk (Brown et al. 2015).
Systems-level traumas such as the experience of minority stress, discrimination, oppression, and marginalization also have striking impacts on individual experiences of recovery.People who identify as sexual and gender minorities report that minority stress contributes to both substance use as a coping mechanism and increased difficulty meeting recovery goals and that this is magnified for those with multiple intersectional identities (Felner et al. 2020).For example, a teen who experiences rejection from their family for their identity may perceive themselves as having few social coping resources.A gay man in recovery who experiences significant stress from discrimination may feel reluctant to seek support from members of his identity community because the only safe social meeting space is a gay bar.
Systemic racism not only impacts individual decisionmaking during recovery but also contributes to inequalities in access to resources and quality of care (Farahmand et al. 2020).For example, a Black person may experience repeated race-based bias and discrimination from multiple medical providers, leading them to discount recovery-related social support from formal treatment providers as a potential coping resource.All of this indicates that the experience of trauma at all levels is a particularly important factor to model when examining the social dynamics of recovery.

Measurement
This model is designed to be testable and clinically useful, so we wish to present an overview of methodologies that we suggest will work well with it.A full discussion of suggested methods and measurement tools is provided in the Supplemental Material.
‹ Time is an important aspect of the model and it is necessary to capture it in a meaningful way.Assessments keyed to the recovery stage show change over broad timeframes, while weekly or monthly assessments show changes within the stage.For example, more frequent assessments may be especially helpful during stages with known rapid change such as early recovery, while longer periods between assessments may be appropriate during stages with less change.In addition, momentary assessments capture the brief processes of change in appraisal and decision-making in real-time.› Individual factors relevant to recovery can be assessed at baseline and subsequent visits with simple survey measures, medical and biological assessments, chart review, and family history data.Standard biopsychosocial assessments capture much of this information in clinical settings, and clinicians can tailor their questions to capture these factors as needed.fi and fl Situational and coping appraisals can be assessed via multiple aspects.Social network analyses, including clinical tools like ecomaps, can map a person's network characteristics, structure, flow of resources, and can provide an overview of the perceived social resources and stressors within their network.Survey measures that capture stressor or coping appraisals, self-efficacy, or recovery capital are another option.Ecological momentary assessment methodologies are effective for directly capturing the micro processes of recovery-specific appraisals and building social recovery capital by repeatedly sampling a person's current thinking, behaviors, and experiences in their natural environment.°Actions done to cope with a situation can be measured as simple choice outcomes (coping strategies used, use patterns, etc.), global measures of recovery wellness, or more micro-level decisional outcomes seen in methodologies such as ecological momentary assessments.-Finally, trauma can be assessed using measures of current symptoms and trauma history.It may be important to capture specific aspects of the trauma such as childhood exposures, recovery-related discrimination, or individual-level traumatic responses to systemic-level racial discrimination in order to precisely capture the impact of such trauma on other aspects of the model.
While it is possible to capture much of this information with more traditional methods (e.g.surveys), certain technologies may be extremely helpful.Momentary assessments can be made minimally intrusive and accessible in both research and clinical settings using smart devices and similar technologies (Yang et al. 2019).Virtual reality can present scenarios that have been shown to provoke cue reactivity equivalent to natural environments, making it possible to assess appraisal processes in laboratory environments (Segawa et al. 2019).Measurement of physiological responses, central nervous system readings (e.g.EEG, MRI), and changes in physical expression or behavior could also be used to directly assess the stressfulness of various recovery situations (Mauss and Robinson 2009).

Discussion
It is important to have general conceptualizations of the recovery construct that shape our understanding of the broad processes at play, but it is equally important to develop detailed, testable models of individual dimensions of recovery to guide empirical work and subsequent clinical interventions.In addition, the heavy impact of trauma on the recovery population indicates the increasing importance of grounding our theoretical, empirical, and clinical work in a trauma-informed perspective.This article derives a model of the micro-level processes of appraising social threats and coping resources that people in recovery from AOSUDs use to build social recovery capital over time from Kelly and Hoeppner's (2015) biaxial formulation of the general recovery construct and contextualizes it with an examination of the impact of trauma.In addition, we emphasize the use of social network approaches to disentangle the complex processes that shape the progression of one aspect of recovery.Finally, we offer multiple methodological suggestions for implementing our model in empirical and clinical work.We believe that the narrower focus of this model, the clear connection to practical methodological approaches, and the trauma-informed contextualization increase the potential for translation of our theoretical work into sound empirical study and clinical interventions.

Implications for research and practice
Recovery capital is considered to be an emerging perspective in addictions research, and there is a lack of consensus on how to model and measure its concepts (Hennessy 2017).Similarly, there have been few formal incorporations of trauma theory or trauma-informed practices in empirical or clinical frameworks of recovery (Bartholow and Huffman 2021).This model presents a way to examine an individual's micro-level social processes of appraisals and actions that help them build social recovery capital (fi-°), the traumainformed context of these processes (›, -), and their recovery growth generated by them (‹).
Researchers can use the relationships, timeframes, contexts, and methodologies described in this article and the supplemental material to build research designs that address their specific research questions.For example, a researcher using the model to understand how the experience of micro-discriminations based on recovery status impacts people's appraisals of social risks and resources at different points during recovery could use a longitudinal design incorporating measures of recovery-related discrimination with momentary assessments during virtual reality scenarios to capture micro processes during different recovery stages.Researchers using social network data could examine the impact of traumatic experiences on differences in the composition, structure, and interactions within a person's network, and how that in turn affects concepts such as abstinence self-efficacy during early recovery.
Clinicians evaluate micro-level appraisal processes and coping actions as a standard part of therapy.This model places that evaluation process within the context of building social recovery capital.Clinicians can show clients concrete steps of appraisal and action that increase social recovery capital over the longer term, and help them understand the iterative nature of the process.Clinicians can capture social network data through clinical tools such as Social Identity Mapping or ecomaps and can use it to identify intervention targets and bolster clients' understanding of potential coping resources.In line with current trends in creating traumainformed systems of care (Substance Abuse and Mental Health Services Administration 2014), clinicians can also use this model to adjust their intervention strategies by providing additional information or supports around the coping process to clients with trauma experiences.This model allows the clinician to examine the interactions between the individual and the social landscape in which they are embedded in a way the reduces stigma and supports selfreflection and change.
This model also incorporates trauma as an important element that affects multiple aspects of the process of appraisal, coping, and building social recovery capital-an important addition as the experience of trauma is significantly more common for people with AOSUDs (Gielen et al. 2012), yet trauma is often excluded from models of recovery or incorporated only as a tangential component.We were unable to explore how the type of trauma (e.g.domestic violence, childhood abuse, discrimination, etc.) impacts the recovery processes detailed in the model due to minimal literature to draw from.There has been some exploration in the literature, such as a grounded-theory exploration of how complex and structural traumas interact with community supports to impact recovery for Black men (Yu 2018), and a systematic review of types of trauma, coping strategies, and substance use in American Indian and Alaska Native individuals (Herron and Venner 2022), but there is not enough literature yet to be generalizable to this model.We believe that exploring how specific types of trauma impact social microprocesses in recovery is an important area for future research.

Conclusions and future directions
The Recovery Support Strategic Initiative established by the Substance Abuse and Mental Health Services Administration has emphasized the need for treatments for AOSUDs that mobilize and strengthen the social resources available in the social networks of people in recovery, particularly in ways that are individualized (SAMHSA 2015).The model presented here illuminates key factors in the recovery process that have the potential to support trauma-and social-network-informed interventions.We call for research that empirically tests this model in ways that will result in practical, trauma-informed social network interventions for people in recovery.

Figure 1 .
Figure 1.An expansion of Kelly and Hoeppner's (2015) combined Recovery Capital and Stress-Coping model focused on social processes during recovery.