We identified eight emergent themes from the data that reflected how African American women in sustained natural recovery described their process of change: (a) focused on the drug; (b) engagement in risky behavior; (c) desire to be free; (d) Damascus Road experience; (e) plea to higher power; (f) geographical cure; (g) self-liberation in commitment; and (h) developing abilities to help others through new associations. We maximized narrative descriptions of each theme with supportive participant quotes and developed a figure to overlay their lived experience of change in the recovery process with TTM (see Fig. 1).

Fig. 1

Natural recovery stories through the lens of the transtheoretical model

Focused on the Drug

In the theme, focused on the drug, participants chronicled their preoccupation with acquiring, using, and recovering from substances, as well as the socializing activities rooted in their use experiences. They described the connectivity between increasing instability in their lives and the diminished desire to refrain from substances. For many participants, the instabilities felt drastic as their addictions exponentially became more severe and all-consuming, immersed in drug-scene culture. For example, Mercy described a binge experience:

I remember staying up for like three or four days. I learned to smoke by myself because I would have more and I would take my time and smoke because I would be tweaking. I was hearing and seeing something from somebody.

She further described a night in which her high left her out of touch with reality, experiencing a euphoria:

I remember we liked this courtyard that we used to sit in and get high. I had some crack and the guy put some dope on it and I hit that, they called that chase the dragon. I was so high that I was walking in the middle of the street with my stem. They said, “Put the stem out before the cops come.” I'm like, forget the cops, I'm looking at the stem and that was a high that I will not forget.

The euphoria could not be separated from the growing instabilities that made drug use all-consuming, and participants described times when the consequences of use were disregarded. Tracey relayed her loss of control:

It changed my life so quickly. The life I lived wasn’t a thing that I liked to do, it was nothing I had ever done, you know? It took me away from myself and I had no control…I would just get up at 4:00 in the morning and sit in the car waiting for the man to bring me drugs that could have killed me.

This participant’s comments highlight both the great lengths she went to in order to acquire substances and the unpleasant experience of lacking the agency to direct her life.

With respect to drug culture and the social environment, Scorpio declared, “And once I started doing it then I liked it. You know? I just got hooked on it. Because they [friends] had to do it every day and I was right there with them every day.” Her misuse seemed to be sustained by her network of friends and absorbed much of her attention. Patricia initially called herself a “weekend junkie,” but as her habit began to escalate, she described, “And that’s the worst thing in the world to have as a habit on heroin. You dream about the drug day and night.” Thus, preoccupation with the substance takes on an extreme form, where other life activities suffer and a person feels powerless.

Engagement in Risky Behavior

Connected to the heightened focus on drugs, participants described the normalization of various risk-taking behaviors within their substance use lifestyle. Participants’ lived experiences reflected how the risky behavior supported their access to drugs. Lorraine recounted, “I felt powerless over the drug, and I just sat there using, shoplifting, doing everything I could do to support my habit.” Three participants described engaging in prostitution and dating drug dealers to support their habits. Mercy shared, “I was doing drugs and sometimes tricking for them drugs.” Saundra stated, “So you get caught up in that life and you start doing things you normally wouldn’t do and you would even sleep with people that had the drugs. That’s how life went.” Furthermore, Edna recounted her experience of dating a drug dealer, “I left the relationship with my baby’s father only to enter another unhealthy relationship with a big-time drug dealer because I thought, he can supply me with more drugs to support my habit.” In these examples, access to drugs was a major driver in decision-making, sometimes with clear tradeoffs to safety and security. Saundra recalled how she was introduced to selling drugs by her boyfriend; when her weekly drug habit began to escalate, she then started selling drugs:

Because the guy I was seeing, that’s what he did and I was telling him about how I didn’t have. I needed money, I need to make extra money or whatever, and he said, “if you do this, take this, sell it, and what you make from it, this is what I expect you to give me every week.” So, I took and I sold it and I gave him what I made and so I did it every week. People would come to my house and get it [the drugs]. I never got big time, I kept enough selling so that I could support my habit.

Participants looked back on these behaviors as straightforward and born of necessity and also expressed some self-judgment and regret in their recollections.

Desire to be Free

All eight participants shared their initial desires to leave the lifestyle of addiction; many rooted in the unsustainability of the risks required to maintain their habits. Several participants described how it was vital to “first admit that you need help and that you have a desire to change.” Lorraine acknowledged that although she attempted inpatient and outpatient substance use treatment and Narcotics Anonymous (NA) meetings, she did not have a sustained desire to change:

At one time, even though I kind of thought I would have wanted to be free from the addiction, I really wasn’t, I really wasn’t ready. I tried treatment, inpatient a couple of times, it did not help, and so I still continued just to use, use, and use.

Among the lived experiences, participants noted that their early desires to be different were intertwined with struggles and relapse. For example, Scorpio expressed that she started to take small steps toward “straightening up” her life. However, she continued to struggle and acknowledged that she “prayed on it and when I first prayed on it, it didn’t work.” In this quote, the participant acknowledged how desire is an important precursor to change but not sufficient. As the desire to recover increased and the addiction continued, she experienced disappointment that her spirituality did not immediately transform her life situation.

Damascus Road Experiences

Nearly all participants described how initial desires to change did not sustain a recovery lifestyle, and that a significant life event dramatically led to a more sustainable road to recovery. For the participants, this significant moment was often inseparable from their spiritual beliefs; therefore, researchers named the theme Damascus Road experiences. The theme is inspired by the story of Saul in the Bible in which he lives a persecutory life until a life-changing spiritual experience on route to Damascus shifts his lifestyle to that of serving God as the Apostle Paul (King James Version Bible, 2022, Acts 9:3). Participants vividly described their Damascus Road encounters including death threats, interactions with police, prison, near-death experiences, and diagnosis of cancer. For example, Edna stated:

I owed him so much money, I found out that he started scheming and plotting a hit on me. At that time, violence was terrible around DC. We had shootings 5-6 times a day, people were being found dead in the hood and near wooded areas for owing people money for drugs. I was afraid for my life. I had owed this guy a lot of money and I mean a lot, the habit was so bad that I couldn’t even afford the $20.00 rent that I had to pay.

Tracey reported her Damascus experience occurred on Valentine’s Day when a drug dealer gave her a bag of methamphetamine, acid, and THC. She owed the “wake-up” experience to the Lord:

All of a sudden, my body felt like it was on fire. I looked at that man and he looked like Satan and I looked at the walls, you know how they have in a hotel, they have the wall, the light on the wall, it looked like it was a fire torch and the bed looked like hell. I was burning up, I got so sick, he had to take me and put me in cold water. He took me home and I did not look back…I felt the Lord was telling me to wake up, wake up, wake up.

For the participants in the current study, the powerful Damascus Road experiences required them to surrender within their call to live in Christ. Participants indicated that if it were not for these experiences, they probably would have continued to misuse substances.

Plea to Higher Power

As participants embarked on their natural recovery processes, they described their lives as chaotic, unpredictable, and destructive. Because spirituality played a significant role in the lives of participants, all eight acknowledged making a plea to their higher power to help “set them free” from their addiction. All eight participants reported histories of involvement in a church community as children; however, they steered away from religious practice in adulthood. In this theme, participants described their reconnection with God in their early recovery processes. For example, Edna strikingly recounted her experience of communicating with God:

I will never forget that night. I was walking the streets high as a kite, and I prayed to God and told him that if he would save my life I promise that I would serve him and nobody else. I remember staying in bed for a few days because I was depressed, and I needed to find a way out.

Moreover, Lorraine highlighted her plea:

I began to get tired and this was close to the twelfth year [of using crack/cocaine]. So, I just, you know, I prayed and I told the Lord that I was ready to give up the cocaine usage because my daughter would be the last one that would go into the system.

Similarly, Saundra awoke from a binge thinking “I can’t do this no more. I'm awake and jittery and you say, “Lord, if my heart just slows down, I won’t do it no more.” Calling on God in these early moments of change seemed to assist participants in taking the next step in their recovery. In other words, the reconnection to their spirituality became an important resource as they began to envision a new lifestyle for themselves.

Geographical Cure

In the theme, geographical cure, participants described how physical relocations to new communities were necessary for their recovery process. For example, Scorpio expressed that she moved from a “drug-infested” neighborhood and relocated with her sister where the drugs were not as prominent in the community. For several participants, the geographical cure also put physical distance between them and individuals who engaged in substance use. Emma expressed how she left a small country town and moved to an urban area:

I didn’t allow myself to be around people that use that stuff. I was around people and had to ask myself, “Do I want to stay in this little country town, small town and be caught up with everything or move on?”

Mercy recounted moving to New York City, after being released from prison in a southern state, where she began dating a “knucklehead” and relapsed, describing herself this time as a “responsible addict.” In this case, the geographical cure ended with social isolation, not benefiting her recovery.

As participants’ narratives illustrated, substances were concentrated within their living environment. Within their stories, it was evident they found it difficult to escape the issues that plagued family members and friends. Participants described how disconnecting from those who were using substances became essential in their recovery. In addition, participants shared the importance of relocating from their neighborhoods that were immersed in drug culture.

Self-Liberation in Commitment

Within this theme, participants described embracing their self-liberation and conscious decision to remain committed to their recovery lifestyle. For example, Scorpio explained how she continually decides each day, “not [to surround] myself in that environment. Staying away from people you know that would bring that.” Her sobriety is connected to her self-liberation from people, places, and triggers. The Damascus Road experiences remain influential in their continued commitment to live in recovery with several participants noting their involvement in church ministry. For example, Tracey further recounted how the Damascus Road encounter was symbolic and revelatory for her to “get in place.” She conveyed that God got her attention and took the craving away and that she did not have to complete NA meetings. She said, “But I thank God and I didn’t have to do the steps, I was stepping to the cross.” Further, all eight participants acknowledged the unyielding relationship between their hope in a higher power and their long-term recovery. Based on participants’ narratives, having a committed lifestyle and being socially liberated were essential in their change process.

New Associations

For our participants, the geographical cure, although useful in the initial change process, was not sufficient for sustainable recovery. Participants described that long-term recovery blossomed from new associations and relationships cultivated in their new communities. For instance, Lorraine acknowledged: “I just changed, met new people, stopped hanging out in the clubs and the streets, started going to church, and staying home being a mom.” Participants described developing healthy friendships, establishing new associations with biological family members, and building relationships with a church family. For example, Edna described re-establishing family bonds, “We lived with my uncle and his wife for about one year until I was able to get on my feet.” Participants recalled reunification with parents and children, a part of their lives that had been disrupted while addicted to substances.

In particular, participants expressed how engaging in relationships with the intention to help others plays a meaningful role in their recovery sustainability. For instance, Saundra acknowledged, “When I realized that I was ready to change, I moved in with my grandmother. Two of my oldest children moved with their father and my youngest child stayed with me and my grandmother and I got rid of the boyfriend.” Saundra shared, as a result of no longer being involved in the drug scene, she began to find refuge in her family as evidenced by establishing new associations with family members, specifically her grandmother.