Professor of Addiction Medicine at Harvard The good news is that recovery may be right around the corner. Don’t give up hope

Dr. Kelly is professor of psychology and the Elizabeth R. Spallin Professor of Psychiatry in Addiction Medicine at Harvard Medical School — the first endowed professor in addiction medicine at Harvard.

He is also the founder and director of the Recovery Research Institute at Massachusetts General Hospital, a Harvard teaching hospital, ranked first in psychiatry in the United States in 2024–25.

Dr. Kelly is a founding member and the inaugural president of the American Board of Addiction Psychology. He has published over 200 peer-reviewed articles, reviews, chapters, and books in the field of addiction medicine.

In 2022, the National Council for Mental Wellbeing recognized Dr. Kelly with its Lifetime Achievement Award.

In the interview, Dr. Kelly explains whether it is possible to recover from addiction, whether sustained abstinence is necessary, what role religion and spirituality play in the prevention and treatment of substance use disorders, and whether twelve-step programs, such as Alcoholics Anonymous, help in addiction recovery.  

Before we dive in, some readers reviewing your bio might wonder how can a psychologist hold a professorship in psychiatry?

Yes, it's a bit unusual. It's because there's an endowed professorship in addiction medicine at Harvard Medical School, which I was fortunate to have been bestowed with. But I'm a clinical psychologist, and a professor of psychology as well.

Recovery Research Institute describes addiction as "a primary, chronic, neurobiological disease influenced by genetic, psychosocial, and environmental factors." How significant is genetic predisposition in addiction?

Roughly half the risk for addiction is conferred by genetics. So, some of us are more susceptible by virtue of our DNA, while others are more protected. For example, a genetic predisposition can lead some people to experience a greater reward from the same level of exposure to, say, alcohol. Some individuals may have a more profound experience during initial exposures, whereas others might find it aversive. And that degree of reward and reinforcement one receives is partly genetically modulated.  

Can we identify genetic risk before addiction develops?

The problem with genetics is that people who are at risk often do not realize they are receiving this extra reward. They should be aware of their family history. If there has been addiction in the family, they are at a four- to eight-fold increased risk of developing an addiction. We should educate these individuals and help them make better choices. They can still develop an addiction, but the clinical course is usually much shorter if they have been informed about their genetic risk.

What are psychosocial and environmental factors, and how do they compare in strength to genetic influences?

They are extremely powerful. When you think about substance use disorders or behavioral addictions like gambling, you have to have access to the drug. Without that, you have zero prevalence. That’s how powerful environmental factors are. Drug accessibility, availability, and price are major factors that influence consumption and the onset of these disorders. Again, this is modulated by genetics, but environmental conditions play a significant role.

There are, of course, other risk factors that influence vulnerability, including epigenetic effects. These are changes that occur early in human development and can turn genes on or off, affecting the risk of addiction. Risk factors include anxiety, depression, trauma, and adverse childhood experiences such as neglect. These can influence the development of changes in the central nervous system and increase vulnerability to addiction.

So psychosocial and environmental factors can turn on or off genes that increase the risk of addiction?

Yes, exactly. Arguably, most of the risk is conferred by environmental factors. For example, the age at which you're first exposed to alcohol or other drugs can significantly influence your risk of developing an addiction. The period between ages 10 and 20 is where the greatest risk occurs. You can think of addiction as an epigenetic, psycho-biological, dynamic disorder that is strongly influenced by the environment over time in both onset and sustained remission and recovery. 

Are there protective factors against addiction? Can they counterbalance risk factors, including genetic predisposition?

Absolutely. Preventing exposure is one example, for instance through parental monitoring. Parents who are more involved, who ask their kids where they're going, what they're doing, and whom they're with, who monitor their consumption, and who have a stricter attitude toward underage use of alcohol or other drugs, provide a strong protective factor. The more protective parents are about their child’s exposure to alcohol or drugs, the lower the risk of addiction.

For example, when it comes to alcohol use disorder, if someone is exposed before the age of 15, their lifetime risk is about 25 percent. If the exposure happens after the age of 21, the risk drops to around 4 percent. That’s a big magnitude difference. 

But we are still talking about accessibility, aren’t there other protective factors?

Of course, there are. Positive mutual attachment between parent and child is a very important protective factor. Peer factors, such as pro-social group norms and positive relationships, also play a role. There are also factors other than the family and peer group. Religiosity, employment, and academic competence are also very helpful in protecting against the development of addiction.

The WHO states that no amount of alcohol consumption is entirely safe or risk-free. What qualifies as low-risk drinking, and how likely is it for addiction to develop within these limits?

It’s very unlikely to develop alcohol addiction if you stick to low-risk drinking limits. However, the definition of a standard drink varies internationally. In the U.S., a standard drink contains 14 grams of pure ethanol, while in many other countries it contains 10 grams. In the U.S., a standard drink is equivalent to approximately 330 milliliters of beer at 5% alcohol, 150 milliliters of wine at 12% alcohol, or 44 milliliters of hard liquor at 40% alcohol. 

For the U.S., low-risk drinking means no more than 7 standard drinks per week for women and no more than 14 for men, with a limit of no more than 1 drink on any given day for women and 2 drinks on any given day for men.

Low-risk doesn’t mean no risk. There are two other independent pathways through which substance use can cause harm, aside from addiction: toxicity and intoxication. Toxicity can lead to conditions such as cancer or liver disease, while intoxication can result in accidents, which may cause serious injury or death. Both types of harm can occur without a person ever becoming addicted.

Your institute focuses on recovery research. What do you mean by addiction recovery?

Recovery is a term that refers to a person's ability to function after having suffered from a substance use disorder. It is quite a broad term that includes improved physical, psychological, and social well-being and health, to the point where one is able to function well without the harmful consequences of addiction.

But if addiction is a chronic disease, doesn't that mean there’s nothing to recover from?

If you think about the term chronic disease and look up what it means, chronic does not necessarily mean it's lifelong. It can mean a condition that lasts longer than just a few weeks.

We know that most people who meet the criteria for alcohol or other drug addiction in their lifetime will eventually achieve full and sustained remission. That is to say, they will recover from it. In the United States, it is estimated that about 72 percent of people who have met the criteria for an alcohol/drug disorder in their lifetime will eventually achieve full remission.

The achievement of full sustained and stable remission may take several years and multiple attempts. In the most severe cases, it might take four or five attempts, while in less severe cases, it may take just one or two. But most people do recover.

Are you saying that addiction is chronic, but not necessarily a lifelong disease?

That’s correct.

Some alcoholics may be reluctant to seek treatment because they fear they will never be able to drink in a controlled manner again. Is lifelong abstinence necessary for recovery from alcohol addiction?

It depends. We know that abstinent recovery is the most stable form of remission. If you are in remission and not drinking at all, you are more likely to remain in that state one or two years later.

Some people with less severe addiction, and/or those who have more recovery capital, are more likely to achieve non-abstinent recovery. That means they can remain in remission while still drinking to some degree without experiencing significant problems. However, non-abstinent recovery is less stable, and individuals in this category are more likely to relapse into a full disorder.

How common is non-abstinent recovery?

It's common. In the United States, research shows that 54 percent of adults in recovery report continuous or current abstinence. This means that 46 percent, which is nearly half of adults in recovery, report some level of current substance use. Again, abstinent recovery is more stable and is associated with the best functioning, but people who are able to cut down or use another substance without problems also improve greatly in their functioning too.

Some people with addiction want to be able to have a beer with friends later in life. How do we determine whether non-abstinent recovery might be a suitable option?

I think most people with addiction, at some point, would like to be able to drink alcohol again without returning to harmful use. The question, of course, is whether they can do that. Those who repeatedly fail to regulate their drinking, whose brains have changed more extensively and intensively, and who always end up intoxicated, they need to abstain.

For others, non-abstinent recovery may be an option. As a clinician, I would work closely with the patient to see whether they are able to regulate their drinking. If they are not, I would advise full abstinence sooner rather than later.

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The idea that recovery requires lifelong abstinence has been a long-held view. How is non-abstinent recovery perceived among professionals today?

If the person can function in daily life and avoid getting intoxicated, or if the intoxication is not causing harm to the person themselves or to others, what’s wrong with it? If the patient has less severe addiction and less severe problems, in the U.S., most professionals would agree that non-abstinent recovery might be an option for these people.

Don’t you worry that people in abstinent recovery might take the wrong message from the notion of non-abstinent recovery, believe they are free to drink again, and fall back into addiction?

I don't think that the idea of non-abstinent recovery would destabilize people who are in abstinent recovery and who have experienced severe addiction. These are individuals whose lives were deeply affected and who had to make significant changes to recover. It is important to communicate to people with a severe history of addiction that non-abstinent recovery is not recommended for them.

What about severe relapses? If someone has been sober for 10 years but then has a two-week binge that requires hospitalization for detox, does that mean they have to start from zero again?"

You can't ever take away someone's prior experience. They still have ten years of sobriety. They can draw on that. They may broken their continuous run of days sober, but they never lose that extensive sober experience. Obviously, they were doing many things right to help themselves stay in remission. Relapses are really learning experiences and can help refine the repertoire of coping skills, for example by staying more cognitively vigilant on the recovery trajectory.

Addiction is classified as a neurobiological disease. What changes occur in the brain of someone struggling with addiction?

There are changes in the neurocircuits involved in reward, memory, motivation, impulse control, and judgment. These represent subcortical areas located deep in the brain as well as other prefrontal brain regions. All of these parts of the brain are affected by substance use, both in terms of function and structure.

In brain imaging, chronic alcoholics often show cortical shrinkage and ventricular enlargement, and there is a lot of cellular death as well. This all means the brain has reduced in size, and its function has diminished in the affected neurocircuits. The extent of the damage is correlated with the severity and duration of the addiction.

How long does it take for the brain to recover? Is it possible to reverse addiction-related brain damage?

There is some data from brain imaging studies showing that after a couple of years of abstinence, a person’s brain can resemble that of someone who has never been affected by addiction. That doesn’t necessarily mean the brain is functioning at the same level as someone who never had the disorder, but often means the brain has compensated for the damage by creating alternative pathways to maintain function.

Again, it depends on the degree of damage, but on average, most cognitive capacity can be regained. However, in nearly all cases of moderate to severe addiction, you never get back to 100 percent, but you might recover 85, 90, or even 95 percent.  So, a lot of the damage can be repaired, but it may never fully return to its premorbid extent.

What are the main pathways to recovery?

There are three main pathways to recovery. First, clinical pathways, in which people utilize clinical services to achieve remission. Others may never use clinical pathways but instead rely on mutual help resources, which are non-clinical recovery support service pathways. A third pathway, typically used by individuals with less severe and less chronic problems, is self-managed recovery, meaning recovery without any external help.

We know that the mechanisms through which people achieve remission are similar, so even for those who don’t use any external help, the process frequently involves removing alcohol or other drugs from their environment, avoiding people who are heavy drinkers or drug users, and adopting other healthy activities that can provide some of the similar rewards to drugs or alcohol.

Can you provide examples for each of those main pathways?

Of course. Clinical pathways include medication-assisted treatments, psychotherapy such as Cognitive Behavioral Therapy (CBT), and inpatient services like detox. Non-clinical pathways may include twelve-step mutual-help groups like AA or NA, peer-based recovery support, or even faith-based support groups. Self-management involves no formal services, whether clinical or non-clinical, and is sometimes referred to as natural recovery.

Again, in all three categories, the mechanisms are similar: removing the substance from the environment, changing social circles, and seeking healthy sources of reward.

Which of the pathways are most effective?

As always, it depends on the severity and how chronic the substance use disorder is. People with severe addiction or at risk of withdrawal syndrome often may require inpatient management and medication. After discharge, mutual help groups or psychotherapy, including treatment for psychiatric comorbidities such as depression and anxiety, can be very helpful in order for people to be able to sustain remission. People with less severe addiction may benefit from non-clinical pathways or from self-management.

Inpatient treatment rehabs are often offered as a first-line option for substance use disorders. How effective are they?

There hasn't been that much study on residential treatment and follow-up from residential treatment programs. The best comparative effectiveness trials have been done in the Department of Veterans Affairs. But there wasn't much evidence for residential care in comparison to outpatient models.

In the United States, since the 1990s, it's rare to find residential treatment, although they do exist, but they make up only about 20 percent of the entire treatment system, whereas 80 percent is outpatient.

That said, they can be lifesaving and very effective modes of care, especially for those unable to stop for any length of time in their natural environment and who need medical withdrawal management and stabilization in a secure and clinically supervised setting.

You mentioned that residential treatments represent only about 20 percent. What’s the proper care when it comes to treatment?

The American Society of Addiction Medicine has specific patient placement criteria, and there are different levels of care depending on various risk factors, such as the need for withdrawal management.

It depends on a number of factors, including severity, chronicity, complexity, other comorbidities, how many past attempts there have been to stop, and the risks in their current environment. All these factors come into play when deciding which level of care is recommended.

In the most severe cases, where there is very impaired control over use or serious consequences, inpatient care is recommended. Less severe, less chronic, less complex cases could attend intensive outpatient care every other day for 6 or 8 weeks, for several hours a day.

There is no rule that someone who struggles with addiction necessarily needs to go inpatient, as it depends on various factors, but there are some indicators such as those I’ve mentioned.

You mentioned "recovery capital." Can you explain what it is?

Recovery capital is a broad concept that refers to all the potential resources a person can draw on during their recovery journey. It may include family, peer support, a faith community, or a sense of meaning and purpose. Recovery capital depends on the person and reflects the individual nature of the recovery process.

You recently conducted a systematic review on twelve-step programs for alcohol use disorder. For those unfamiliar, what are twelve-step programs?

Twelve-step treatments come from the practices and philosophy of Alcoholics Anonymous, which was originally a mutual self-help program developed in the 1930s with a sequence of twelve steps that people follow to achieve remission, as well as a fellowship of peer support.

They meet and connect regularly to learn from each other about their history of addiction and how they've overcome it. That exchange of information is very powerful, as well as the strong social bonds that connect people with the same lived experience, which can be capitalized on and used as leverage to create a new, cohesive framework for recovery.

How do twelve-step programs compare in effectiveness to other treatments you analyzed?

When subjected to the same kinds of scientific standards you would apply to any other kind of intervention, it turns out that in randomized controlled trials, people with severe alcohol dependence participating in twelve-step programs such as Alcoholics Anonymous (AA) do as well as those in other clinical interventions, such as cognitive behavioral therapy, in terms of number of drinks per drinking day, percentage of days with heavy drinking, and alcohol-related consequences.

However, when it comes to continuous abstinence, people in twelve-step facilitation or AA do better. They have between 20 to 60 percent higher rates of continuous abstinence and remission across three years. We have also found that twelve-step programs are much more cost-effective for the healthcare system.

Are twelve-step programs then better than psychotherapy?

For continuous abstinence and enduring remission, yes.

Do 12-step programs offer advantages over institutional treatments?

I think they can be additive. Our clinical services obviously cost more money, and we need to think about how to use resources to maximum effect. We need to ensure that people do not die from intoxication or withdrawal syndrome. But what do we do then?

We know that addiction disorders are susceptible to relapse, not just for days or weeks, but for many years. The first five years of remission carry a higher risk of relapse compared to after five years. We need to think about what we can do to sustain the gains from the initial detox treatment.

This is where groups like AA and other recovery support groups really are unmatched, because they provide a ubiquitous, indigenous, naturally occurring recovery support service that is accessible and freely available. That is why I call AA the closest thing public health has to a “free lunch”.

Since 12-step programs reference God, does spirituality or religion play a role as a recovery mediator in this treatment?

Yes, it does. Prayer, meditation, and other spiritual behaviors can increase the chances of remission. This is not specific to AA or the twelve-step philosophy, but a universal phenomenon. Religious and spiritual coping skills have an additive effect over and above other types of cognitive and behavioral coping.

It's not for everybody, of course, but people who are able to tap into spirituality and religious practices tend to have better outcomes. One of the mechanisms through which AA specifically works is spirituality, particularly for those who are more severely addicted.

Does that mean that religion and spirituality serve as protective factors against addiction?

Yes, it is both a protective factor in terms of the risk of onset, and it can also help with the offset or remission once you have the disorder. None of these effects are huge, but they are significant, and they add up. In some groups, for example in African Americans, the spiritual and religious angle is very important. We have found that African Americans are five times more likely to say that spirituality and religion made all the difference in their addiction recovery relative to white people.

How can religion and spirituality support addiction recovery and prevent relapse?

One of the big factors in how religious and spiritual practices might prevent relapse is self-forgiveness and forgiveness of others. The feeling that you can be forgiven for what you have done is something many spiritual and religious traditions provide. God can be experienced as forgiving your past behavior, and as you make changes, the goal is that you will ultimately achieve remission.

Addiction is unlike other psychiatric conditions because patients often go against their moral values. They start to increasingly feel guilt and remorse chronically, which can lead to intense demoralization and even suicide.

When people enter early recovery, being able to forgive yourself for the things you have done and to let go of any resentment and anger you may hold toward people from the past is important. Self-forgiveness and forgiveness of others are central to many religious and spiritual traditions, but they are not as commonly emphasized in standard clinical treatments such as cognitive-behavioral therapy.

Are there other factors through which religion and spirituality can support recovery?

Meaning and purpose. They offer a different framing of one's experience through a spiritual or religious lens. For example, many people will attest to the fact that there is a purpose to their problems, that it is not just meaningless suffering, and that they can use their experience for a good purpose, passing on their experience to help somebody else. That helps patients feel good about themselves and gives them new purpose and meaning. Spiritual and religious frameworks have that embedded in a lot of their philosophy.

Religion often emphasize a rules-based "no matter what" approach. Is this effective?

We know that rule-based behavior is more powerful than contingency-based behavior.

If there is a rule in place, for example in the context of addiction recovery, that no matter what happens you do not pick up the first drink/drug and instead call a friend, or do something else – that is rule-based. Contingency-based behavior would be operating if things get really bad, then someone might allow themselves to give in and use the substance.

Religious practices usually emphasize that it is not the use itself that is inherently bad, but the state of intoxication. However, if you have a history of severe addiction, it's better to stay away from it altogether.

If you adopt a rule-based philosophy, you are more likely to stay on a sober path, but that’s a tough one. Getting support from others can you keep to that “rule” of no use no matter what happens. This also encourages learning, adoption, and use of alternative recovery coping strategies.  

When behavior is more contingent, when the mindset is that if things get really bad then it's okay to use a substance, you are more likely to give in.

Addiction is associated with stigma. How should we approach a person struggling with addiction?  

Stigma is a big one. People struggling with addiction have a lot of guilt and shame. They are individuals who are biologically susceptible to this disorder and are at increased risk for addiction. This understanding can help them begin to forgive themselves, given the biomedical nature of the brain and how it changes with chronic exposure.

We can also help family members and society at large understand that the structure and function of the brain have changed, sometimes in ways that are significantly impaired.

However, it is important to remember that genetics are not deterministic. There are still ways to prevent addiction and the need to seek help if addiction develops. Genetics should not be used as an excuse for unhealthy behavior, but it is an explanatory factor.

As people often say, “you are not responsible for becoming addicted, but you have a responsibility to get the help you need to get and stay in remission.”

People struggling with addiction often feel hopeless. What message of hope would you offer them?

I think the good news is that recovery may be right around the corner. Don’t give up hope. On average, it takes roughly two to five serious attempts to achieve stable recovery. Ask for help, seek guidance from knowledgeable clinicians, and also from people who are living in recovery and understand what you have been through.

Find a path that suits you. There is no one path to recovery. It's a matter of finding the right type of path. It could be religion, spirituality, a faith-based path, clinical support, medication, or all of those.