Inclusion criteria.

• The study presents or substantially advance an original framework of typologies and/or themes of alcohol misuse recovery narratives.
• The framework is produced through an analysis of empirical data.

Exclusion criteria.

• The study is of narratives, but it is not possible to identify from title or abstract whether they are alcohol misuse recovery narratives
• The study is of narratives where the narrator does not have personal experience of alcohol misuse (for example the narratives are of family members of people who have misused alcohol).

Primary outcome was to develop a framework of over-arching narrative typologies (structures) and themes (content) characterizing alcohol recovery narratives which can be used by alcohol misuse support services to inform the development of future research, policy, and practice within healthcare and other settings.

Secondary outcome was to describe alcohol recovery narratives based on narrator’s age, gender, sexuality, and ethnicity.

Original author language.

Where possible the language used by original authors was preserved, while maintaining the clarity of synthesis of dimension and characteristics of alcohol recovery narratives. Where the terms “alcoholic” or “alcoholism” were used by the original authors to describe alcohol misuse, these have been retained.

The review group acknowledges the heterogeneity in language used to describe alcohol use, and the stigma associated with some commonly used terms, which itself can act as barrier to change. After thoughtful discussion between review group, we opted for the term ‘alcohol misuse’ to describe excess alcohol intake, harmful alcohol intake, drinking problems, alcohol dependence, and alcohol use disorder.

1. Genre.

Four genres from 13 studies were identified: Drama; Redemption; Drinking tale, and Identity tale (Table 3) [64, 65].

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Table 3. Description of types and subtypes of alcohol recovery stories dimensions.

https://doi.org/10.1371/journal.pone.0268034.t003

Drama has three subtypes. Melodrama: narratives that are high in emotional content and present exaggerated characters and exciting events. Comedy theatre: narratives with humorous element, which often use dramatic irony to induce laughter. Quest: narratives that take recipients on a journey in search of something (such as a successful recovery).

Redemption has two subtypes. Redemptive narratives: describes stories which centred on the idea of self-redemption, a phenomenon used to describe positive personal change after a negative experience [40]. Redemptive narratives were often shared by narrators who were in long term recovery from alcohol misuse, and who perceived they had benefited from their adversities [66]. They showed elements of difficult experience, positive self-transformation, greater improvement in general health, and had a high chance of sustained sobriety. Non-redemptive narratives: had short term recovery, lacked positive experience, had less improvement in general health, and increased risk of relapse to drinking [40].

Drinking Tale describes how sharing a narrative impacted the narrators themselves [67]. Sharing life stories helped the narrator’s recovery in five different ways; by being reminded of their painful past, reinforcing their own recovery, losing their sense of uniqueness, facilitating and improving their relationship with themselves, and eventually helping others [17].

Identity Tale comprised narratives which foregrounded characteristics in relation to their alcohol use and social context (e.g., narrator’s age, gender, sexual orientation, ethnicity). Some research specifically sought the narratives of marginalised people such as Indigenous Australians and Alaskans. Drinking behaviour and recovery varied by life stage. Associated characteristics expounded through subgroup analysis.

2. Identity.

Identity as a dimension describes self-transformation as a multistage process, distinct from the use ‘identity tale’ whereby the later highlights social, cultural, and demographic aspects. Fourteen publications discussed the importance of identity in the context of alcohol recovery. The concept of identity acquisition is a cornerstone of recovery in AA, where a person who has problems with alcohol accepts “alcoholism” as a disease and identifies as an “alcoholic” [27]. This concept of identity acquisition is not generally used in recovery outside formal treatment settings [16, 38].

The concept of identity transformation was characteristic of these narratives., Within this dimension, we identified following stages—identity renewal, identity construction, and identity formation (Table 3).

Identity renewal. During this first stage, the individual lacks a specific identity, nor is effort expended in forming one, a phenomenon described in psychological literature as “identity diffusion” [68]. Alcohol misuse causes a personal and social crisis and the person experiences fear, guilt, and shame. Participants spoke of recuperating and rebounding from “rock bottom”.

Identity construction. The ensuing stage comprises of self-nurturing where a person arrives at a point where they begin to look for help, share their situation with others and ’surrender’ to the process of recovery from alcohol misuse [59, 61, 62]. The individual goes through cognitive restructuring, whereby one starts giving up on destructive thoughts, believing in the self, commits to change and attains a new identity [38].

Identity formation. In the final stage a person accepts their renewed identity as a self-aware “alcoholic”. What followed in the narratives was affinity and group membership, adapting to their emerging new role. The narratives characterised reconstructing social identity and mending relationships and generating capacity to help others [11, 27, 53].

3. Recovery setting.

In recovery setting type two subtypes were identified ‘recovery within treatment’ and ‘recovery outside treatment’ (Table 2). ‘Recovery within treatment’ describes the experiences of a participant who was formally treated by an institution, clinicians, alcohol support workers, organisation, or a person for alcohol misuse. ‘Recovery outside treatment’ describes the experiences a participant who had minimal or no formal input from an institution, clinicians, alcohol support workers, organisation, or a person for alcohol misuse [16, 26, 38].

Recovery within treatment has following subtypes. AA narrative: was most common for recovery within a formal treatment system, the core of an AA narrative was hitting rock bottom, sharing a story, spirituality, and acceptance of the new identity as an”alcoholic” [11, 26, 27, 45, 55]. Dual diagnosis: has narratives of alcohol misuse and mental health problems, and alcohol misuse and diabetes [45, 58].

Alcohol misuse and mental health has the following narratives. Dominant cultural narrative: participants were more inclined to accept a diagnosis of a mental health problem but were resistant to the label of an “alcoholic”. Community and family narratives: participants described recover as an ongoing process involving significant others and achieving recovery by a sense of belonging, mutual aid, and sharing experiences. In both contexts mental health services played a pivotal role in recovery processes [58].

Alcohol misuse and diabetes: In these narratives all participants believed in the genetic inheritance of diabetes but not of “alcoholism”. Participants often confused symptoms of alcohol withdrawal with hypoglycaemia which resulted in erratic eating and drinking habits. The involvement of specialist diabetic services and alcohol support groups improved participant knowledge and facilitated recovery [45].

Polydrug misuse has narratives of participants who suffered childhood trauma, a strict code of keeping family secrets and denying negative feelings, resulting in multiple substances addiction. Therapeutic and self-help groups played an important role in recovery of people with these experiences [45].

Recovery outside a treatment has following subtypes. Natural recovery: narratives were less homogenous than those within treatment setting. They included internal and external influences, did not feature significant involvement of others. Participants who described natural recovery tended to disagree with labelling and did not believe sharing stories helped recovery [26, 38]. Cognitive restructuring and positive recovery capital played a key role in natural recovery [7, 38]. Emancipation narratives: described identity development through making changes in life and liberation from oppressive circumstances. Discovery narratives: in these narratives participants identified themselves being different and developed their identity by consciously expanding experiences including art and the use of psychedelic drugs such as LSD. Mastery narratives: in these narratives’ participants felt social pressure to demonstrate mastery over things like to win fights and/or drink more, alcohol misuse was seen as irrational behaviour, with recovery involving an increased awareness of a drinking problem. Coping narratives: described a lifelong struggle, difficult personal circumstances, and use diagnostic labels to help recovery [16].

4. Drinking trajectory.

The drinking trajectory describes impact of aging on drinking habits and comprises of four types (Table 3) [7, 44].

Upward drinking career describes the increase of alcohol intake in adulthood and had two further subtypes ‘mildly upward’ and ‘sharply upward’. In the ‘mildly upward’ career alcohol was part of social life and slowly increased with age. The ‘sharply upward’ drinking trajectory found to be common in women, with drinking becoming part of the person’s lifestyle in the later part of their working years.

Fluctuating drinking career describes drinking patterns which varied with time and life circumstances.

Steady drinking career describes intermittent periods of sobriety and heavy alcohol use.

Downward drinking career describes decline in alcohol consumption as the person got older. This was either mildly downward, where change was slow, or steeply downward, where change was rapid [44]. Alcohol careers can include late onset of alcohol dependence [often after specific triggers such as bereavement or retirement] with resolution shortly thereafter [7]. Dunlop et al. (2013) showed age positively correlates with improved self-esteem, general health, and authentic pride and negatively with aggression which in turn increase the chances of recovery from alcohol misuse [41].

5. Drinking behaviours and traits.

Non-alcoholic drinking type comprises narratives participants were drinking actively but in a controlled manner.

Non-alcoholic non-drinking type comprises narratives of participants who completely abstained from alcohol. In ‘alcoholic drinking’ type participants were active alcoholics. In ‘alcohol non-drinking’ type the participants were either ‘non-drinking alcoholics’ or ‘recovering alcoholics’ [27, 44].

Personality traits including antisocial, passive, prosocial, grandiose, and dishonest were commonly associated with alcohol misuse [43, 52].

6. Stages (sequence).

The commonly used alcohol recovery model has the following stages: origin of difficulty, episode of change, attainment of recovery, and ongoing struggle (Table 3) [43, 50, 58]. In these narratives triggers of alcohol use were social and cultural difficulties, norms and pressures, childhood abuse, mental health problems, a lack of belonging and numbing the pain [47, 60, 61]. As drinking progressed, physical, mental health, and social problems attributable to alcohol consumption developed, with alcohol escalating to provide escape from fear and shame. Turning points described by participants ranged from no specific event to near death experiences, embarrassment, spiritual experiences, a sense of loss, death of a family member, loss of a friend by suicide, and physical and mental health decline [56, 63]. The person described a phase of rejection and denial, but eventual acknowledgement of the problem followed by help seeking or natural recovery, then sobriety. Ongoing struggle describes the efforts made by the individual to maintain their sobriety and recovery [43]. By participating in meaningful activities, adopting a new identity, and creating positive recovery capital narrators of these stories felt they were more likely to achieve long term sobriety [7].

7. Spirituality and religion.

A lack of sense of belonging was a common theme that resonated across numerous recovery stories, and particularly in stories from more marginalised communities such as Indigenous Americans and Australians and those in the LGBTQ+ community [39, 50, 56, 60]. Spirituality and belief in a higher power was a cornerstone for recovery in the AA model [27, 45]. Participants described ‘religion’ as dogmatic, ritualistic, biased against sexual orientation and identity, and had strict codes of moral behaviour, while ‘spirituality’ as more individualistic, open, inclusive, and flexible [60]. Lack of belonging and social isolation triggered alcohol use, and support groups such as AA provided an opportunity for spiritual reconnection and f attainment of a sense of belonging and sobriety [53, 56, 59, 60].

8. Recovery experience.

Recovery experience narratives were positive, negative or both (Table 3).

Positive recovery experiences were ego ideal for participants, and improved their self-pride, empowerment, trust, and relationships. They found lost opportunities, felt more integrated into society, were happy to be alive, and enjoyed new hobbies and activities.

Negative recovery experiences were characterised as having a craving for alcohol, feeling the pressure of intense self-discipline, loosing drinking friends and social contacts, inadequate coping skills, and concomitant mental health illness. The narratives liver transplants recipients particularly offered the themes of financial and job-related issues and the impact of other comorbidities [38, 51].

Subgroup analysis.

Age. Along the dimension of age, young people, drinking habits and activities often involved peer pressure whilst socialising with friends, such as taking part in drinking games in college and as part of social status, whereas drinking habits of older individuals related to later life experiences and challenges [44, 47]. Thus, demonstrating an importance of social and cultural influences on drinking behaviours, which may influence recovery [64, 65].

Gender. Five studies reported the narratives of female participants only, these studies emphasized identity renewal, and the affective response of shame as characteristic of the recovery narrative [47, 49, 53, 55, 56]. Shame is a social and regulatory emotion that invokes self-awareness and self-other obligations [49, 56]; we also found an all-female study using shame as impetus to build relationships through help of networks. This was a common affective response that contributed toward coping when stepping out of addiction and into new identity. There was a heavy reliance on social networks, which was present in all narratives apart from Christensen and Elmeland (2015) where participants used new hobbies and activities for self-renewal. Studies with male only participants showed no distinct characteristics in the sample except the study using shame as impetus described above [26].

Sexual orientation. In the studies with participants identifying themselves as LGBTQ+, we note that spiritual awakening was more commonly sought rather than religious affiliation [56, 60]. Alcohol use was a lifestyle choice recognised by participants from the LGBTQ+ community. Building a new identity through recovery programs and networks enabled recovery and formation of new ‘productive’ relationships outside of alcohol use [56, 60].

Marginalised communities. Analysis of studies discussing the experiences of Indigenous Australian and Alaskan people’s recovery [39, 50] although showings experience of similar stages of recovery, tended to have more emphasis on elements of stereotyping, alienation, marginalisation, inequality, low wages, and the impact of sudden gaining of citizenship status and money. The recovery process was unpredictable and messy [39], and participants achieved recovery both within and outside treatments settings.

Alcohol and mental health. Analysis of studies discussing dual diagnosis of alcohol misuse and mental health problems showed participants often suffered with negative self-perceptions, including low self-esteem, lack of love from others, lack of desire to belong, anger, and shame [11, 38, 40, 43, 46, 53, 58, 59, 61]. Mental health problems often acted as a trigger to drink harmfully [61]. Common mental health problems reported were anxiety, depression, obsessive compulsive disorders, post traumatic disorders [mostly due to difficult childhoods], attention seeking behaviours, eating disorders, and emotional instability [11, 40, 43, 46, 58, 61]. Facilitators to recovery were integrated support from mental health and substance misuse services, a flexible and trustworthy relationship with care providers, individualised treatment pathways, and easy to understand step-by-step support. Whereas barriers to recovery were undiagnosed or unrecognised mental health problems, inadequate support from mental health services, underfunded services, and punitive response to alcohol misuse [58]. Participants who had negative recovery experience reported ongoing mental health difficulties comprised of anxiety, depression, and intrusive or disturbing memories. This in turn impacted longevity of sobriety [38].

Medium and high-quality studies. On performing subgroup analysis on twenty-six medium and high-quality studies most dimension types were present in the framework apart from the narratives of college drinking, indigenous Australians, and redemption.