Introduction

It is well understood that Veterans and those in active duty strongly identify with their brothers and sisters at arms and experience common struggles associated with the throes of military service. They obtain a sense of purpose, belonging, and connectedness when in the presence of other Veterans, notably because they are part of a larger social group (Walker et al., 2012; Gorman et al., 2018). When disconnected from such groups, individuals are likely to feel unpleasant emotions (e.g., loneliness and loss of identity; Burnell et al., 2017). Such experiences can lead to the use of maladaptive attempts to cope with the loss of connections (e.g., substance use) to reduce their unpleasant emotions. In this way, addiction can be understood as a means of attempting to alleviate unpleasant experiences in lieu of healthy connections and bonds. This article offers a new understanding of addiction through the lens of the fundamental human need to belong. A therapy group with Veterans seeking treatment for substance use disorders (SUDs) was utilized with the aim to provide psychoeducation and cultivation of skills necessary for reestablishing and sustaining meaningful social bonds with others to mitigate substance use was created.

Individuals with Substance Use Disorders

It has been reported that individuals diagnosed SUDs are seven times likely experience higher rates of recurring loneliness and report loneliness as a concern five times more frequently when compared to the general population (Ingram et al., 2018). It is well understood in the literature that an aspect of resumed use of substances has to do with the interactions between interpersonal (e.g., relationship quality) and intrapersonal (e.g., negative affects) factors (Witkiewitz & Marlatt, 2007).  SUDs, and more generally, addiction, has been conceptualized by some as a method of compensation for inadequate psychosocial integration (i.e., social connectedness and belonging; Alexander, 2010). Given that social isolation has the potential to lead to pervasive feelings of loneliness (Haslam et al., 2019), and feelings of disconnection, isolation, and loneliness are common experiences amongst people in recovery from addiction (Ingram et al., 2018), there appears to be connection between problematic substance use and a disconnection from social relationships. Studies that investigated social connections in relation to abstinence from alcohol indicate that having a large circle of supporting social relationships can be predictive of abstinence (Hunter-Reel, McCrady, & Hildebrandt, 2009). Moreover, social group relationships, belonging, and shared social identities have been found to have positive outcomes on recovery from SUDs (Ingram et al., 2020; Best et al., 2015; Dingle et al., 2015; Haslam et al., 2005).

Veterans, SUDs, and Disconnection

It is common knowledge that alcohol consumption is a common aspect of military culture (Ames & Cunradi, 2004). Additionally, exposure to combat among military personnel is associated with higher rates of alcohol and substance misuse (Jacobson et al., 2008). Calhoun et al., (2008) found that Veterans with low levels of social support are more likely to partake in heavy alcohol consumption with high levels of social support operating as a protective against heavy drinking. Also, when working with Veterans, Burnell et al. (2017) found that social support from peers is acknowledged as a protective factor against loneliness and social isolation due to a shared sense of identity. To further build a relationship with SUDs, ex-service personnel, and difficulties associated with loneliness and disconnection, many Army Veterans from the United Kingdom report having trouble when transitioning from the military to civilian life following military service (Walker, 2012).  Such finding is similar to research conducted in the United States, which found that disruption in identity was linked to difficulties with reintegration in civilian life, lower life satisfaction and less improvement in social support over time when compared to those who do not perceive a disruption in identity (Mitchell, Frazier, & Sayer, 2020). Feelings of loneliness, isolation, struggles to relate with civilians and losing touch with comrades following their return from deployment  and separation from the military have been found to have implications to their mental health (e.g., alcohol and substance use; Gorman et al., 2018; Walker, 2012). Such difficulty poses serious threats to their identity and frequently require additional work to establish post-service identities and relationships (Walker, 2012). While some experiences of service are more similar to civilian life than others, variables associated with reintegration, connection, and belonging are dynamic and complex (Walker, 2012).  Some variables that could be indicative of potential disruptions in identity and reintegration difficulties include individuals who spent a significant duration of their early adulthood in the military (Mitchell, Frazier, & Sayer 2020); unplanned ideas of their future home life, denial of the anticipated loss of belonging from comrades, and rigid and distinctly perceived differences between themselves and civilians (Walker, 2012). Awareness of such variables when meeting Veterans could provide insight into the difficulties that make individuals more susceptible to maladaptive attempts to cope (e.g., substance use) with disconnection, perceived lack of belonging and missing social identity.

Possible Treatments Based on Social Identity/Connection for Veterans with SUDs

Given the abundance of literature on SUDs and detachment from meaningful connections (i.e., loneliness), the therapist conducted a group therapy project as part of a post-doctoral fellowship requirement. The group centered on cultivating and deepening social relationships in recovery with Veterans struggling with SUDs was deemed appropriate. Given social challenges (e.g., stigma, relational stress) often faced by individuals struggling with SUDs (Ingram et al., 2020), and the difficult transition from active duty to civilian life, traumatic experiences, and loss of belonging (Gorman et al., 2018), relational challenges faced by Veterans (e.g., loneliness, isolation, and difficulties relating to civilians; Wilson, Hill, & Kiernan, 2018) are often magnified.

A seven to eight session group focused on Veterans, addiction, and fostering skills to further understand and reestablish interpersonal relationships was created and loosely inspired by Groups for Belonging (see Ingram et al., 2020) and adapted for the Veteran population. Groups for Belonging was a feasibility study that offered a 6-session group-based intervention meant to reduce loneliness among a SUD residential population through cultivation of a sense of group connectedness. While groups for belonging focused mainly on Social Identity Theory, that is, fostering group connectedness through the ‘sense of self’ brought about by group memberships. This was the basis for which they sought to treat loneliness among those recovering from substance use with a specific focus on stigma, fear of rejection and mistrust.

Participants

A convenience sample of Veterans seeking SUD treatment in both residential and outpatient settings were given informed consent regarding the nature of the group project’s aims. Measures were administered to assess both pre and post group addiction severity, levels of social connectedness, loneliness, and hope. While a small sample size was analyzed due to the addiction treatment environment (e.g., admissions, discharges, difficulties attending the full sequence of sessions, etc.), a complete sample size of N=11 participants  (n=5 outpatient, n=6 residential) was obtained for the study.

Group Structure

The Reconnection Group was a seven-session group focused on various areas of addiction recovery, understanding the links between addiction and relationships, psychoeducation regarding the functions of emotions and the role such emotions play in relationships, understanding what they value in relationships, how to foster new social identities protective against resumed use, and overcoming barriers to social connection.

Session 1: What is addiction: Psychoeducation regarding the biological (genetic), psychological (behavioral), social (interpersonal), spiritual (religious) theories of addiction are provided. The fundamental human need to belong and the concept of humans as a social species with the need to bond and connect are introduced

Session 2: Understanding the link between relationships and addiction: Participants are provided with three types of relationships (e.g., supportive to recovery, impaired due to substance use, and risky to recovery in addiction recovery. They collaboratively work to understand how through their substance use, supportive relationships have reduced in number, while impaired and risky relationships have increased. They are provided with paper to construct a social map of their world and asked to classify and quantify the types of relationships they are surrounded by. This helps to facilitate understanding of the influential impact others have on their ability to recover.

Session 3: Understanding the function of emotions and managing loneliness: Psychoeducation regarding the importance of emotions as information about their interactions with others and the environment and to understand their function, and how to cope with them adaptively, rather than something to escape is provided. Emotions are understood as pleasant or unpleasant experiences, not positive or negative. Loneliness is highlighted as a common unpleasant emotional experience by those experiencing addiction and in early recovery, and its function indicates to the experiencer to find their way back to meaningful and supportive relationships (e.g., a need to connect and belong).

Session 4: Valued relationships:  Psychoeducation regarding the differences between breadth (e.g., numerous in quantity, shallow, superficial, acquaintances, and potentially risky) and depth (e.g., deep, meaningful, supportive, intimate and long lasting) relationships are explored and provided. Open discussion as to the qualities and values of depth relationships is completed and the importance of relationships of depth in addiction recovery is explored.

Session 5: Reconnecting with others: Psychoeducation regarding the ways in which stigma drives disconnection in relationships. Introduction of social identity to connect with new relationships and overcome stigma is provided. The importance of shared values and group membership to reduce the impact and frequency of unpleasant emotional states (e.g., loneliness), connect to a tribe, and expand their supportive social support network is provided. Their shared identities as Veterans struggling with substance use drives a means and source of connection while in the program. The importance of adopting a recovery-oriented identity and letting go of a substance using identity is openly discussed. Veterans are then asked to identify social groups or social identities that are consistent with their values, and can utilize to remain consistent in their recovery, foster new relationships, and lasting bonds.

Session 6: Fostering new connections: Veterans are asked to identify groups they plan to become a part of to sustain their recovery. Further clarification regarding social groups, social identity and rekindling impaired relationships are discussed. Individual values and the values viewed as important in relationships are highlighted as crucial building blocks for the establishment of new and healthy connections.

Session 7: Overcoming barriers to social progression: Open exploration regarding the factors that may impede in their ability to be successful in cultivating new relationships (e.g., fears of negative evaluation, rejection, mistrust of showing feelings, and lack of self-acceptance) and are gently confronted. Discussion of the importance of patience for the self, and fostering healthy bonds/attachments to ward off unpleasant emotions, instead of maladaptive attempts to cope (e.g., substance use) . Lastly, self-compassion is highlighted, noting that recovery is a journey, and the 12^th step of recovery (e.g., giving back to help others) is highlighted as a means to further connect with individuals struggling in their recovery.

Findings

Although there was not statistical significance found among this sample, the mean differences between pre- and post- measures showed a reduction in substance use severity (a decrease in use and risk factors, and an increase in protective factors); a reduction in levels of loneliness; an increase in social connectedness, as well as hope. The Veterans also reported numerous positive qualitative changes following the group’s conclusion (e.g., “I feel so much closer to the people in here now. I got chills learning about the other members, chills in a good way though.”) What is important here is that Veterans benefitted from approaching addiction recovery through a lens of establishing meaningful interpersonal relationships based on shared social identities, experiences of stigma, and struggles with addiction.

Five Tangible Takeaways

• Groups based on fostering interpersonal and social connections in the context of treatment of SUDs is crucial for sustaining recovery in the long term.
• Loneliness and isolation are risk factors for substance use.
• Helping Veterans to foster a sense of social connection and healthy bonds to each other through shared social identity (e.g., Veterans in recovery) may decrease risk factors associated with substance use.
• Helping Veterans to feel more connected to their emotions (pleasant and unpleasant) and other supportive and meaningful relationships may be an avenue that warrants further exploration.
• Given the nature of the project, research into reducing loneliness through social connection and the relationship to substance use should be conducted.

Summary

Approaching recovery with an understanding of addiction as an unhealthy attempt to bond (i.e., a relationship with a substance due to disconnection from relationships and an attempt to escape unpleasant emotional experiences such as loneliness and loss of identity) can shed new understanding of how we consider those struggling with substance use. Therefore, groups based on fostering a sense of belonging, connection, and meaningful relationships can provide a new conceptual framework for understanding the struggle with substance use for frequently stigmatized populations (e.g., individuals and Veterans diagnosed with substance use disorders). Cultivation of skills that facilitate and enhance interpersonal connections and relationships through delivery of psychoeducation and understanding of the struggle associated with loneliness and addiction, can provide a welcomed alternative to the frequently isolate journey of recovery: the social model of addiction recovery.

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Justin Trapani, PsyD

Justin Trapani completed his Bachelors of Science in Psychology at the State University of New York College of Oneonta in 2013 and obtained his Masters of Arts in General Psychology at Adelphi University in 2015. He then completed his Psy.D. in clinical psychology with an emphasis in psychodynamic psychotherapy at Nova Southeastern University in 2021. He is currently a staff psychologist within the North Florida South Georgia Veterans Healthcare System.