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Addiction (2000) 95(5), 749–764. “NATURAL RECOVERY” MEETING. Natural recovery from alcohol and drug problems: methodological review of the research ...
Addiction (2000) 95(5), 749– 764

“NATURAL RECOVERY” MEETING

Natural recovery from alcohol and drug problems: methodological review of the research with suggestions for future directions LINDA C. SOBELL, TIMOTHY P. ELLINGSTAD & MARK B. SOBELL Center for Psychological Studies, Nova Southeastern University, Fort Lauderdale, Florida, USA Abstract Aims. The methodology of studies that reported data on individuals who recovered from an alcohol or other drug problem (cigarette smokers were excluded) without formal help or treatment were reviewed. Design/ measurements. Potential studies were identiŽ ed (a) through computerized literature searches, (b) by reviewing references from key publications and (c) by correspondence with researchers in the Ž eld. Studies had to (a) be in English, (b) be published, in press, or presented before the end of 1997, (c) report original results or be part of an original survey and (d) separately report respondents whose recoveries were and were not attributable to treatment. No case studies were included. Eligible studies were evaluated with respect to meeting criteria for (a) natural recovery, (b) methodological rigor and (c) reporting demographic and substance abuse history variables. Findings. Until 1997 only 38 articles (40 different respondent samples) met the inclusion criteria for this review. This small number of studies is not surprising, as natural recovery from substance abuse is a relatively new area of study. Moreover, the ma jority of the 38 articles were published in the past 8 years. For most studies, descriptions of the respondent samples at pre- and post-recovery were seriously deŽ cient. Alcohol was the most studied drug, with heroin a distant second. Low-risk drinking (78.6%) and limited drug use (46.2%) were commonly reported outcomes in natural recovery studies. Conclusions. Based on this review, future natural recovery studies should: (a) report respondents’ demographic characteristics at the time of their recovery; (b) describe respondents’ pre-recovery problem severity; (c) explore in some depth what factors, events or processes are associated with the self-change process; (d) provide corroboration of respondents’ self-reports; (e) examine factors related to the maintenance of recoveries; (f) conduct interviews with individuals who have naturally recovered from cocaine, marijuana and polydrug abuse; (g) include a second interview at a later time to examine stability of natural recoveries; and (h) require a minimum 5-year recovery time frame. Introduction Several years ago Chiauzzi & Liljegren (1993) published a paper entitled “Taboo topics in ad-

diction treatment: an empirical review of clinical folklore.” They identiŽ ed natural recovery as a taboo topic, stating that disease model advocates

Correspondence to: Linda C. Sobell, Center for Psychological Studies, Nova Southeastern University, 3301 College Avenue, Fort Lauderdale, 33314, USA. Tel: 954 262 5811; fax: 954 262 3895; e-mail: [email protected] Submitted 24th June 1999; initial review completed 19th August 1999; Ž nal version accepted 4th January 2000. ISSN 0965– 2140 print/ISSN 1360-0443 online/00/050749– 16 Ó Carfax Publishing, Taylor & Francis Ltd

Society for the Study of Addiction to Alcohol and Other Drugs

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had put forth a tautological argument that “an ability to cease addictive behaviors on one’s own suggests that the individual was not addicted in the Ž rst place. If one is not able to stop independently, then an addiction is present” (p. 306). Such thinking has not only led to an assumption that people with substance use disorders cannot recover on their own, but some have suggested that failure to seek treatment for a substance abuse problem will have fatal consequences. For example, Robert Dupont, former Director of the National Institute on Drug Abuse wrote “Addiction is not self-curing. Left alone addiction only gets worse, leading to total degradation, to prison, and, ultimately to death” (pp. xi– xii; Dupont, 1993). In a similar vein, Vernon Johnson in his book I’ll Quit Tomorrow stated “Alcoholism is a fatal disease, 100 percent fatal. Nobody survives alcoholism that remains unchecked … these people will not be able to stop drinking by themselves. They are forced to seek help; and when they don’t, they perish miserably” (Johnson, 1980, p. 1). While natural recovery or self-change is a common route to recovery for cigarette smokers (estimates range from 80% to 90% of all those who stop smoking; Marlatt, Curry & Gordon, 1988; US Department of Health and Human Services, 1988; Carey et al., 1989; Fiore et al., 1990; Mariezcurrena, 1994; Hughes et al., 1996), this phenomenon has been largely ignored for alcohol and other drugs until the last decade. For example, although only a small percentage (i.e. , 10%) of substance abusers receive formal treatment for alcohol and drug problems (Narrow et al., 1993), clinicians and researchers in the addiction Ž eld seldom encounter people who recover on their own. In addition, few members of the public believe that substance abusers can change on their own (Cunningham, Sobell & Chow, 1993a; Ferris, 1994; Cunningham, Sobell & Sobell, 1998; Klingemann, 2000). Despite this fact, the popular literature (e.g. Hamill, 1994) as well as media reports are replete with descriptions of individuals who have recovered from substance abuse on their own, including some having returned to low-risk drinking (e.g. Robert Goulet, Patrick Swayze, Johnny Carson, Pete Hamill, respectively; Goodman & Benet, 1991; Park, Johnson & Matsumoto, 1991; Rosen, Hoover & Stambler, 1991). Although case studies are not as convincing as controlled trials or large surveys, they are,

nevertheless, re ective of people’s willingness to be forthcoming about their own change process. Lastly, natural recoveries have been reported for problems other than substance abuse (neurosis: Eysenck & Rachman, 1973; stuttering: Finn, 1997). In fact, the majority of “psychological” problems people experience are never brought to the attention of mental health professionals or paraprofessionals (Toro, 1986). Instead, problems generally are shared with “natural helpers” who possess no mental health training. Since 1975 several reviews of natural recovery from substance abuse have been published. The Ž rst review identiŽ ed a handful of published studies describing natural recoveries from alcohol problems (Smart, 1975/76). That review and those appearing over the next 20 years added relatively little to our knowledge of natural recoveries other than to suggest that there was considerable variability in the types of life events associated with natural recoveries (Smart, 1975/ 76; Waldorf & Biernacki, 1982; Stall & Biernacki, 1986; O’Doherty & Davies, 1987; Fillmore, 1988; Jordon & Oei, 1989; Mariezcurrena, 1994; Blomqvist, 1996). As well, most of the identiŽ ed life events have been global in nature (e.g. changes in family milieu, friends, vocation, health, religion or social pressure). Part of the reason that so little can be concluded from these reviews is that most of the research has been exploratory (Jordon & Oei, 1989) and methodologically  awed (reviewed in Sobell, Sobell & Toneatto, 1992; Sobell et al., 1993b). Nevertheless, the recent increase in research has led to natural recovery from substance abuse gaining recognition and acceptance. Prestigious bodies such as the Institute of Medicine (1990) and the American Psychiatric Association (1994) have acknowledged that natural recovery is a legitimate and documented route of recovery. One recent review claimed to examine critically the research methodology and issues raised by natural recovery studies (Watson & Sher, 1998) and to identify new issues (e.g. recoveries across the life-span; socio-cultural, developmental and individual factors related to recovery), but was disappointing for several reasons. First, it did not comprehensively review the literature, as several references were overlooked (e.g. Robins, 1973a, 1973b; Blackwell, 1983; Biernacki, 1986; Brady, 1993; Copeland, 1995; Mariezcurrena, 1996). Secondly, the conclusions appear to be based on the authors’ perusal of the

Natural recovery review literature rather than a systematic quantitative evaluation of natural recovery studies. Consequently, conclusions of questionable validity were drawn. For example, it was stated that most natural recovery “studies have assessed primarily White, middle-aged males, and may represent recovery processes that are not generalizable to women, minorities, and other age groups” (Watson & Sher, 1998, p. 7). As will be demonstrated in the present review, this conclusion is not accurate. The present review comprehensively evaluates the methodology of natural recovery studies reported up to 1997. Strengths and weaknesses of the studies are identiŽ ed, and recommendations for improving the methodology of future studies are offered. Studies reporting on smoking cessation without treatment were excluded because, as noted earlier, such studies have already been the focus of considerable research (Davis, Faust & Ordentlich, 1984; Fiore et al., 1990; Garvey et al., 1992).

Method Studies were identiŽ ed by (a) searching Medline and Psychlit computerized literature databases, (b) reviewing references from important publications and reviews and (c) corresponding with researchers in the Ž eld. Because there are no standard or agreed-upon term(s) for describing recovery without treatment (Sobell et al., 1992), multiple search terms and their variants were employed (e.g. self-quitters, self-change, spontaneous remission, natural resolution, spontaneous recovery, untreated remission, spontaneous resolution, natural recovery, autoremission). Potential studies were evaluated for inclusion in this study by two of the investigators (LCS and TPE) based on the following inclusion criteria: (a) presented in English; (b) published or in press in a peer-reviewed journal, or presented at a professional conference prior to the end of 1997; (c) reported original results (i.e. not a review article) or part of a larger study; (d) respondents had a past history of alcohol or drug problems; (e) no case studies (e.g. Stewart, 1987; van Kalmthout, 1991) or personal accounts (e.g. Hamill, 1994) and (f) separate reporting of respondents whose recoveries were and were not attributable to treatment. Unlike state-of-the-art reviews of treatment

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studies in the addictions Ž eld (Sobell & Sobell, 1989; Breslin et al., 1997), the present review was not limited to published studies because research in this area is very new and some reports have not yet been published (e.g. poster presentations, articles in press). Studies were evaluated with respect to meeting criteria for (a) reporting natural recoveries, (b) methodological rigor (e.g. control groups) and (c) reporting demographic (e.g. age, gender) and substance-use history (e.g. recovery length, recovery type) variables. A few natural recovery studies included respondents who had attended one or two selfhelp group meetings (Sobell et al., 1992, 1993b; Tucker, Vuchinich & Gladsjo, 1994). Because these investigators speciŽ cally did not deŽ ne attendance at one or two self-help group meetings as constituting formal treatment, these studies were included in the present review. A few studies that reported data for naturally recovered respondents also included a separate group of individuals who had gone to treatment or self-help meetings several years prior to their recovery (Klingemann, 1991b; Sobell et al., 1992, 1993b; Sobell & Sobell, 1998). These studies were included because the respondents reported that treatment did not contribute to their recovery, and the authors felt that due to the minimal treatment exposure or the time between treatment and recovery, treatment did not contribute to resolution (i.e. respondents’ recoveries were essentially on their own). The present review accepts the judgement of these authors, and such studies were included in this review if they met all other inclusion criteria. Of the studies screened for eligibility, 38 met all of the inclusion criteria. These studies are listed in the Appendix. Two of the studies included two different respondent samples and are footnoted in the Appendix. Each of these reported the results of two separately conducted surveys. Thus, this paper reports on 40 different respondent samples from 38 total studies. Studies that were related to an original source article and from which additional data (e.g. follow-up reports) were obtained are identiŽ ed by an asterisk in the Appendix. Data from eligible articles were recorded using a uniform data checklist covering the following variables: (a) respondent characteristics: gender, ethnicity, education, diagnosis, reports of problem severity and consequences, problem and resolution lengths; (b) demographic information at the time of interview

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Table 1. Percentage of natural recovery respondent samples (n 5 40) reporting different study variablesa Variable Sample sizeb Year study published 1990– 97 1980– 89 1960– 79 Pre-recovery data sourcec Self-reports Collaterals Other Recruitment sourcec Advertisements Snowballing/Chain referrals Surveys Other Past treatment separated from no treatment Study location (country) USA Canada Europe Treatment deŽ ned Multiple recovery groupsd Year study conducted Collaterals conŽ rmed subjects’ Post-recovery self-reports Interviews location Interview tape-recorded Respondents paid for interviews Control group used . 1 interview with subjects over time Relapse rates

% (n) sample reporting 100.0 (40) 100.0 (38) 52.6 (20) 31.6 (12) 15.8 (6) 100.0 (40) 100.0 (40) 30.0 (12) 10.0 (4) 97.5 (39) 38.5 (15) 28.2 (11) 23.1 (9) 17.9 (7) 90.0 (36) 92.5 (37) 59.1 (22) 16.2 (6) 18.9 (7) 82.5 (33) 57.5 (23) 52.5 (21) 40.0 (16) 40.0 (16) 32.5 (13) 20.0 (8) 17.5 (7) 17.5 (7) 5.0 (2)

a

Number of studies is 38; two studies each have two respondent samples. b Mean (SD), median, and range of subjects for all studies: 140.9 (399.2), 43.0, and 5– 2456 respectively. c Multiple sources could be reported. d For example, abstinent recoveries reported separately from low-risk drinking.

and at the time of recovery: age, marital status, employment status, occupational status; (c) study characteristics: year conducted, location of the interview, country where the study was conducted, interview tape recorded, respondents paid, recruitment source, control groups used, collaterals used, sample size, sources of information used, reported treated respondents and untreated respondents, problem substance, deŽ nitions of treatment, factors in uencing the recovery, length of recovery and type of recovery. The variables assessed for each respondent sample are listed in the Ž ve tables that will be described below.

Results and discussion Table 1 shows the numbers and percentages of the 40 naturally recovered respondent samples that reported different study variables. As is evident from Table 1, reports of natural recovery studies have been increasing dramatically in recent years, with half (52.6%) published in the last 8 years. Although some studies had very small sample sizes, overall the 40 samples had a mean and median (range: 5– 2456) sample size of 140.9 and 43, respectively, suggesting that the literature is not replete with sporadic case reports, but rather represents a substantial number of cases of natural recoveries from substance abuse. Somewhat more than half (59.1%) of all studies were conducted in the United States, with 18.9% and 16.2% conducted in Europe and Canada, respectively. As shown in Table 1, self-reports of pre-recovery data were obtained from all 40 respondent samples. Almost a third (30.0%) of the samples also collected pre-recovery data from collateral informants. Self-reports, therefore, have been the major and, in most cases, the only source of information about the extent of problems before recovery. Despite respondents sometimes having to recall events from the distant past (e.g. # 10 years before the interview), fewer than half the respondent samples (40.0%) obtained conŽ rmation of respondents’ self-reports by collaterals. Although few in number, four separate studies have examined the validity of self-reports among naturally recovered substance abusers (Klingemann, 1991b; Gladsjo et al., 1992; Sobell et al., 1992, 1993b; Tucker, 1995; Tucker et al., 1994; Blomqvist, 1996; Sobell, Agrawal & Sobell, 1997). These studies, like those for substance abusers in treatment (Babor, Brown & Del Boca, 1990; Maisto, McKay & Connors, 1990; Sobell, Toneatto & Sobell, 1994), found that naturally recovered substance abusers give reasonably accurate accounts of their pre- and post-recovery drinking when compared with similar reports from their collaterals. Advertising has been the primary mode (38.5%) of recruiting participants for natural recovery studies. The next two most common avenues of recruitment were variations of “snowballing” (i.e. chain referrals, 28.2%) and surveys (23.1%). Four-Ž fths (81.8%, 9/11) of the snowballing efforts included individuals with drug problems. On the positive side, a very high

Natural recovery review Table 2. Demographic variables reported for natural recovery respondent samples (N 5 Variable Age at interview (years) Age at recovery (years) Education (years) Gender Occupation Ethnicity Employed at interview Employed at recovery Married at interview Married at recovery

% (n) of respondent samples reporting 62.5 (25) 22.5 (9) 45.0 (18) 75.0 (30) 32.5 (13) 37.5 (15) 47.5 (19) 10.0 (4) 45.0 (18) 7.5 (3)

Mean (SD) or mean % across samples b

40.5 (9.1) 34.4 (6.2)c 13.1 (0.9)d 69.4%e 38.9%f,g 69.8%h,i 60.9%j 55.3% 48.7%k 36.0%

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40)a Range 19.0– 58.2 26.7– 42.6 11.9– 14.5 0– 100 11.0– 66.7 0– 100 0– 100 0– 95.0 0– 82.3 18.0– 70.1

a

Number of studies is 38; two studies each have two respondent samples. b N 5 20; 5 did not report a speciŽ c age. c N 5 8; 1 did not report a speciŽ c age. d N 5 7; 1 did not report speciŽ c years. e % Male. f % White collar. g N 5 12; 1 did not report speciŽ c percentages. h % White. i N 5 14; 1 did not report speciŽ c percentages. j N 5 16; 3 did not report speciŽ c percentages. k N 5 16; 2 did not report speciŽ c percentages.

percentage of the respondent samples not only reported how they deŽ ned treatment (82.5%), but also separated treated respondents from untreated respondents (90.0%). Because only a Ž fth (20.0%) of all respondents were reimbursed for their participation, it is unlikely that participants falsely reported themselves as recovered for monetary reasons. Because very little is known about long-term recoveries, natural recovery studies could be very valuable for tracking the stability of recoveries over time. Disappointingly, only 17.5% of all respondent samples had more than one interview with participants and only two (5.0%) examined relapse rates among naturally recovered substance abusers. Lastly, only half the respondent samples (52.5%) reported the year that the study was conducted. Table 2 displays demographic variables reported for the 40 respondent samples. Except for gender, descriptions of respondents both at the time of recovery and when interviewed were seriously deŽ cient for most studies. Respondents’ gender was the only feature reported with regularity (75.0%) and even then, a quarter of all samples failed to report such data. Interestingly, for those studies that reported gender, the percentage breakdown (female: 30%; male: 70%) is only slightly higher than Ž gures for alcohol treatment facilities where a quarter of the clients are female (National Institute on Drug Abuse, 1992). Less than half the samples reported data for the variables of education and ethnicity (45.0% and 37.5%, respectively). One reason why some studies were coded as having missing

demographic or substance use history data is that they combined data presentations for recovered respondents with treated and/or non-recovered samples (King & Tucker, 2000). The lack of reporting of demographic information at the time of recovery is a serious shortcoming of the current literature. One might expect variables such as marital status, employment and age at time of recovery to be important for identifying factors associated with recovery and for predicting who is most likely to recover naturally. With respect to the variable of age at the time of recovery, for example, two important age-related processes are relevant (reviewed in Watson & Sher, 1998): (1) young adult recoveries: for males there is a decrease in the prevalence of alcohol problems from their 20s to their 40s that cannot be accounted for by treatment (Cahalan, Cisin & Crossley, 1969); also, it has been hypothesized that many young people “mature out” of substance abuse, an age-based form of natural recovery related to assuming adult/family responsibilities (Winick, 1962; Fillmore et al., 1988; Kandel & Raveis, 1989; Labouvie, 1996); and (2) late-life recoveries: it appears that not all alcohol problems develop early in life and that those that develop later may not be as severe and may be more predisposed to natural recovery; it also appears that across the life-span different factors contribute to as well as maintain natural recoveries (Atkinson, Tolson & Turner, 1990; Sobell et al., 1993a, 1998; Atkinson, 1994; ). Unfortunately, slightly less than a quarter (22.5%) of the studies in the present review reported age at the time of recovery.

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Table 3 shows the numbers and percentages of the 40 naturally recovered respondent samples for which different substance use history and recovery variables were reported. Alcohol has been the predominant substance of interest in natural recovery studies, with three-quarters (75.0%) of all respondent samples reporting on individuals who had alcohol problems. Heroin was the next most studied drug (22.5%). Because it is not known how well Ž ndings from one substance will generalize to others, not only are additional natural recovery studies of drug abusers needed, but particularly studies examining drugs that are currently under-represented in the literature, such as cocaine and marijuana. Another issue highlighted by Table 3 is the lack of reporting of problem severity. It is reasonable to expect that problem severity may be an important predictor of natural recovery (Sokol, Martier & Ager, 1989; Sobell et al., 1993b; Sobell, Cunningham & Sobell, 1996a) and that less severe problems may be easier to overcome without treatment. In this regard, it is disappointing that many studies (40.0%) reported no information about the severity of participants’ substance abuse problems before their natural recovery. In addition, the failure to adequately describe problem history makes it difŽ cult to compare natural recovery studies to treatment studies. Three variables related to recovery also appear in Table 3. In close to two-thirds (62.5%) of all 40 samples, respondents were asked about their reasons for recovery. Evaluating reasons for recovery is important as it has been suggested that such information could be helpful for designing better interventions for substance abuse (Sobell et al., 1993b, 2000a). Although factors supportive of maintenance of recoveries are also important, such factors were probed in less than half (45.0%) of all respondent samples. Lastly, although a majority of substance abusers report signiŽ cant barriers for delaying or not entering treatment (Cunningham et al., 1993a, 1993b), such information was sought in only 22.5% of the respondent samples. Concerning recovery type, all (28/28) of the samples reported abstinent outcomes for alcohol abusers and three-quarters (78.6%, 22/28) reported low-risk drinking recoveries. Although not as high, 46.2% (6/13) of other drug recovery studies reported limited drug use as a type of recovery.

Table 4 presents descriptive statistics for problem recovery length and substance use characteristics for naturally recovered respondent samples. For those studies that reported the problem length before recovery, the mean of 10.9 years and range of 5– 17 years suggests that respondents’ substance abuse problems were well established. Whereas most of the respondent samples (80.0%) reviewed required a minimum recovery length of at least 6 months, the median was only 12 months. Because substance use is a highly recurrent disorder (Marlatt & Gordon, 1985) and because several recent studies have suggested that stability of recovery with or without treatment does not seem to occur for at least 5 years (De Soto, O’Donnell & De Soto, 1989; Sobell, Sobell & Kozlowksi, 1995; Dawson, 1996; Jin et al., 1998), it is suggested that natural recovery studies should require a minimum recovery period of 5 years. The mean (median) length of recovery of 6.3 (6.4) years suggests that in most cases respondents’ recoveries can be considered very stable and enduring. Lastly, across all studies two-Ž fths (40.3%) of alcohol recoveries involved low-risk drinking, suggesting that such drinking is a common route to recovery among naturally recovered alcohol abusers, a Ž nding that parallels results from treatment outcome studies (Rosenberg, 1993; Heather & Robertson, 1998). For the 40 natural recovery respondent samples, Table 5 lists the percentage that reported reasons for recovery, maintenance factors and barriers to treatment. The speciŽ c reasons for recovery, maintenance factors and barriers to treatment are also listed by category and frequency in Table 5. Because of methodological differences between studies, differences in terminology, and the ways the results were presented, the word descriptions in Table 5 are somewhat arbitrary and are intended to bring together reasons and factors that appear to share a common theme. It is also important to note that because some studies used standard checklists to probe factors related to recovery, some of the frequency counts may be slightly elevated as a result of providing respondents with a set of cued responses. Of the 40 respondent samples in this review, 25 (62.5%) offered reasons for recovery. The most frequent reason involved health concerns, with 17 samples (42.5%) reporting these con-

Natural recovery review Table 3. Substance use history and recovery variables reported for natural recovery respondent samples (N 5 40).a

Substance use variable Problem recovery typeb Alcohol Cocaine Heroin Marijuana Other Study required minimum recovery length for respondents Mean recovery length Problem severity or consequences Pre-recovery substance use Problem length prior to recovery Assessment of secondary drug use and recovery Arrests/legal problems Alcohol or drug diagnosis MAST/ADS/SADD c Pre-recovery assessment time frame Respondents received psychiatric assessment/treatment DASTe Type of alcohol recovery (N 5 28) Abstinence Low-risk drinkinge Type of drug recovery (N 5 13) Abstinence Limited drug usee Reasons for recovery Maintenance factors Barriers to treatment

% (n) of respondent samples 100.0 (40) 75.0 (30) 7.5 (3) 22.5 (9) 2.5 (1) 12.5 (5) 80.0 (32) 60.0 (24) 60.0 (24) 47.5 (19) 45.0 (18) 40.0 (16) 35.0 (14) 35.0 (14) 25.0 (10) 25.0 (10) 17.5 (7) 2.5 (1) 100.0 (28) 78.6 (22) 76.9 (10) 46.2 (6) 62.5 (25) 45.0 (18) 22.5 (9)

a

Number of studies is 38; two studies each have two respondent samples. b Some studies reported on multiple recovery types. c MAST 5 Michigan Alcohol Screening Test; ADS 5 Alcohol Dependence Scale; SADD 5 Short Alcohol Dependence Data. d DAST 5 Drug Abuse Screening Test. e DeŽ nitions varied across studies.

cerns. The next most frequent reasons concerned Ž nancial issues and negative personal issues relating to substance use (e.g. negative feelings about self or embarrassment about a speciŽ c incident). Each of these reasons was cited in 12 (30.0%) samples. Other reasons included changes in the way respondents viewed their substance use (i.e. cognitive change; 27.5%), in uence from a signiŽ cant other (25.0%), family-related reasons (22.5%), socialrelated reasons (20.0%), legal reasons (20.0%) and religious reasons (17.5%). Maintenance factors were reported by 18 (45.0%) of the 40 respondent samples. Of these,

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the most frequently reported factor (13, 32.5%) involved social support or a change in social groups. SigniŽ cant other or family-related factors were the next most frequently reported maintenance factor, with 11 (27.5%) samples reporting these. These Ž ndings are consistent with the literature showing that positive family milieu or social support is the single most notable factor associated with a positive outcomes in treatment studies (Moos, Finney & Chan, 1982; Billings & Moos, 1983; Longabaugh et al., 1993; Higgins et al., 1994). Eight samples (20.0%) reported that respondents had developed nonsubstance-related interests to help keep them from relapsing, while avoidance of use substances, work-related changes and general lifestyle changes were each reported by 17.5% (n 5 7) of the samples. Additionally, religion, self-control or willpower and changes in living arrangements were each reported by 15.0% (n 5 6) of all samples. Only four of the 18 respondent samples that reported maintenance factors indicated that they used a speciŽ c time frame when asking about maintenance factors (e.g. within the Ž rst year after recovery; Sobell et al., 1993b). Nine (22.5%) of the 40 respondent samples assessed barriers to treatment. Nearly all of these (8, 20.0%) indicated that at least some respondents did not want to be stigmatized or labeled. Six (15.0%) samples reported respondents having negative beliefs or experiences with treatment, whereas Ž ve (10.0%) felt that treatment would not be appropriate due to their alcohol problem not being that severe or that it would not solve their problem. Privacy, or not wanting to share one’s problems with others, was reported by four (10.0%) of the 40 samples. Interestingly, the same constellation of reasons have been given by individuals with alcohol and drug problems for delaying entering treatment (reviewed in Hingson et al., 1982; Thom, 1986; Cunningham et al., 1993b). One of the major deŽ ciencies of natural recovery studies conducted to date is that investigators have provided very little qualitative or quantitative data with which to understand what drives and/or maintains natural recoveries from alcohol and drug problems (Blomqvist, 1996). It has been suggested that one reason this has occurred is because most of these studies have been exploratory and retrospective (Blomqvist, 1996). Unfortunately, this situation has not changed as

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Table 4. Problem recovery length and substance use characteristics of natural recovery respondent samples Demographic variable

Mean (SD) or mean % across respondent samples

Median

Range

10.9 (4.0)

11.3

5.0– 17.0

17.0 (9.1) 6.3 (2.3)

12.0 6.4

6.0– 40.0 0.4– 11.7

59.7% 40.3%

62.0% 38.0%

3.0– 100% 0.0– 97.0%

85.5% 14.5%

100.0% 0%

0.0– 100% 0.0– 100%

Problem length (years) prior to recovery (N 5 16)a Minimum required recovery length (months) for study (N 5 32)b Recovery length (years; N 5 20)c Type of alcohol recovery (N 5 26)d Abstinencee Low-risk drinkinge, f Type of drug recovery (N 5 10) Abstinencee Limited drug usee,f a

Two did not report a speciŽ c mean, but gave range answers. b Some samples did not report using a minimum recovery requirement. c Four did not report a speciŽ c mean, but gave range answers. d Two studies did not report whether the respondents’ drinking post-recoveries were abstinence or low-risk drinking. e Mean across samples. f DeŽ nitions varied across samples.

re ected by the brief categorical descriptions of recovery and maintenance processes listed in Table 5. Further, over one-third of the studies in this review failed to report any reasons for recovery, over one-half did not report maintenance factors and, remarkably, over three-quarters never asked respondents about their reasons for not seeking treatment or going to self-help groups (i.e. barriers).

Conclusions The present review found that most of the natural recovery studies with alcohol and drug abusers were methodologically weak. The majority of studies did not adequately describe respondents in terms of their demographic or substance use history backgrounds and features of their recoveries. Research in this area would be strengthened and our understanding of natural recoveries would be advanced if future studies consider the following suggestions. Studies need to report consistently respondents’ demographic characteristics at the time of their recovery. Such information will be useful in identifying variables common among naturally recovered substance abusers. Studies also need to obtain detailed descriptions of respondents’ pre-recovery substance abuse history in order to provide a clear picture of the pattern and severity of respondents’ substance use. For example, the few studies that have obtained detailed drinking

history information from respondents have suggested that the high prevalence of low-risk drinking in natural recoveries may re ect that such individuals had less severe alcohol problems (Sobell et al., 1993b, 1996a). However, whether such a Ž nding generalizes across studies can only be determined if all studies collect adequate prerecovery substance use history information. Besides pre-recovery information, factors related to the maintenance of recoveries should be explored in natural recovery studies. Further, because a number of clinical disorders are highly co-morbid with substance use disorders, assessment of co-morbid psychopathology should also occur in natural recovery studies. In a related regard, because the treatment literature suggests that substance use patterns may change over time (e.g. decreased heroin use, increased alcohol use; Biernacki, 1986; Sobell et al., 1994), it is important to gather a proŽ le of psychoactive substance use at pre- and post-recovery. For example, a recent study that assessed substance use both before and after recovery found that the respondents who had naturally recovered from a cocaine problem also reported that they continued to use alcohol at levels considered as high risk (Toneatto et al., 1999). Finally, as noted earlier, there is a very high co-occurrence of cigarette smoking among individuals who abuse alcohol and drugs. For this reason, coupled with evidence suggesting possible relationships between smoking cessation and cessation or reduction of alcohol use (Sobell & Sobell, 1996;

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Table 5. Reasons for recovery, types of maintenance factors, and types of barriers to treatment reported by natural recovery samples (N 5 40). % (n/N) of respondent samples

Variable Reasons for recovery Health-related Negative personal effects Finance-related Viewed substance use different (i.e. cognitive change) Related to signiŽ cant other Family-related Social-related Related to legal issues Religious reasons Work-related Change in living arrangements Life-style changes Fear of consequences Seeing negative effects of use on others Maintenance factors Social support/change in social group SigniŽ cant other/family Development of nonsubstance interests Life-style change Avoidance of substance use situations Work-related Religion Self-control or willpower Changes in living arrangement Positive personal attributes Finances Health Barriers to treatment Concerns about stigma, labeling, embarrassment Negative beliefs or experiences about treatment Belief that treatment is inappropriate or problem not severe enough Privacy, not wanting to share problems Financial costs Inconvenience

Ellingstad et al., 1999), tobacco use should be assessed for all naturally recovered substance abusers. Corroboration of naturally recovered respondents’ self-reports is important because respondents are being asked to recall events from the distant past. The results from studies that have examined the self-reports of naturally recovered substance abusers parallel Ž ndings from studies of substance abusers in treatment (Babor et al., 1990; Maisto et al., 1990; Maisto & Connors, 1992; Sobell et al., 1994). Generally, it can be concluded that naturally recovered substance abusers’ reports of their pre- and post-recovery and related experiences are consistent with reports from other sources (Winick, 1962; Klinge-

62.5 (25/40) 42.5 (17/40) 30.0 (12/40) 30.0 (12/40) 27.5 (11/40) 25.0 (10/40) 22.5 (9/40) 20.0 (8/40) 20.0 (8/40) 17.5 (7/40) 15.0 (6/40) 15.0 (6/40) 15.0 (6/40) 12.5 (5/40) 10.0 (4/40) 45.0 (18/40) 32.5 (13/40) 27.5 (11/40) 20.0 (8/40) 17.5 (7/40) 17.5 (7/40) 17.5 (7/40) 15.0 (6/40) 15.0 (6/40) 15.0 (6/40) 12.5 (5/40) 12.5 (5/40) 27.8 (5/40) 22.5 (9/40) 20.0 (8/40) 15.0 (6/40) 12.5 (5/40) 10.0 (4/40) 5.0 (2/40) 5.0 (2/40)

mann, 1991a; Gladsjo et al., 1992; Sobell et al., 1993b). Although the primary conŽ rmation of self-reports of natural recovery with substance abusers has been by interviewing collaterals and thorough ofŽ cial records, sometimes conŽ rmation may not be possible. For example, some studies (Sobell et al., 1993b; King & Tucker, 2000; Toneatto et al., 1999) have reported difŽ culties in getting respondents to provide the name of someone who knew them when they had their problem (i.e. in the distant past, e.g. 10– 20 years ago). This is a concern because one study reported that 10.5% (24/228) of participants initially interviewed were eliminated because of problems with collateral veriŽ cation (e.g. subject refused to provide a collateral,

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collaterals refused to be interviewed, collateral could not conŽ rm recovery; Sobell et al., 1993b). One alternative, used successfully in a recent large community intervention with problem drinkers (Sobell et al., 1999), is to incorporate reliability checks into the interview process (e.g. ask the same questions when Ž rst screened into the project and again when interviewed at a later date). Also, in order to conserve follow-up resources, collaterals from a random sample of participants could be interviewed (e.g. 10% of participants’ collaterals were scheduled to be interviewed; Sobell et al., 1996b). In addition, although a few studies have assessed family history of alcohol problems for naturally recovered participants, the results have been inconsistent (reviewed in Watson & Sher, 1998). Some studies have found no difference in family history among recovered and current alcohol abusers, whereas others have found that naturally recovered participants were less likely to have a positive history of alcohol problems. Thus, like problem severity, family history of alcohol and drug problems should be assessed in future studies of naturally recovered substance abusers as a possible factor predisposing to natural recovery. Finally, as already mentioned, more studies are needed of natural recoveries from cocaine, marijuana and polydrug abuse. Adding a second interview at a later point in time is an easy way to explore recovery stability and relapse among naturally recovered alcohol and drug abusers (e.g. Sobell et al., 1995). In a related regard, because shorter recovery intervals are likely to include respondents who may relapse and, thus, do not re ect stable recoveries, it is important to require a minimum recovery length of at least 5 years in order to avoid confusing stable recoveries with transient or temporary changes in substance use. In terms of stability of recoveries, there is a need to assess and examine where and how natural recoveries Ž t into the stages of change model (Klingemann, 2000). One problem with applying this model is that many of those who recover on their own do so spontaneously and do not report an elaborate or lengthy planning process. Further, many individuals who recover on their own do so the Ž rst time they decide to stop, a Ž nding that some argue contradicts the stage of change model where relapse is a stage that must be gone through (Sutton, 1996; Bandura, 1997; Davidson, 1998). For example, one recent study

reported that 42.9% (15/35) of their respondents “successfully resolved on [their] Ž rst attempt” (King & Tucker, 2000). Longitudinal studies with naturally recovered respondents can be used to examine how changes in alcohol and drug use are related to changes in other behaviors. In particular, changes in the use and abuse of other substances needs to be explored as there have been reports of respondents stopping one drug but increasing the use of another (Biernacki, 1986; Sobell et al., 1994). One longitudinal study of naturally recovered alcohol abusers found that when asked how they dealt with urges within the Ž rst 6 months of stopping drinking, close to one-half of respondents reported drinking non-alcoholic beverages, a quarter said they ate sweet things, and about one-Ž fth reported smoking cigarettes as well as eating food (Sobell et al., 1995). In addition, some studies have found that cessation of alcohol problems was associated with an increase in likelihood of subsequent smoking cessation (Breslau et al., 1996). As discussed previously, conventional wisdom postulates that individuals who have alcohol or drug problems cannot recover except through treatment or self-help groups. The 38 studies reviewed in this paper make clear that this aspect of conventional wisdom is not accurate. In addition, the natural recovery literature undermines another central tenet of traditional concepts of alcohol and drug problems, the notion that recovery can only occur through abstinence. More than three-quarters (78.6%) of the studies of individuals who recovered from alcohol problems reported some recoveries as involving low-risk drinking. This parallels Ž ndings from alcohol treatment outcome studies (Rosenberg, 1993; Breslin et al., 1997) and suggests that the way the Ž eld views recovery from alcohol problems is not consistent with the empirical literature and is in need of change. Although fewer studies of natural recoveries from drugs as opposed to alcohol problems have been reported, a similar pattern of Ž ndings emerges with regard to recovery type. Nearly half (46.2%) of the drug studies reviewed reported recoveries involving limited drug use. This is not surprising as controlled opiate (Zinberg & Jacobson, 1976; Zinberg, Harding & Winkeller, 1977; Blackwell, 1983; Waldorf, 1983; Klingemann, 1991b; Shewan et al., 1998) and cocaine use (Waldorf, Reinarman & Murphy, 1991; Cohen

Natural recovery review & Sas, 1994; Hammersley & Ditton, 1994; Mugford, 1995) have been reported previously. In light of such evidence, an important priority for the substance abuse Ž eld should be to develop a conceptualization of alcohol and drug problems that accommodates discontinuity over time (i.e. does not declare progressivity to be a required element of substance use disorders), and accommodates multiple pathways to recovery including moderation and harm reduction (Marlatt, 1998). Until then, it would be foolish to expect concepts that cannot explain common Ž ndings in the research literature to facilitate understanding of the etiology and treatment of substance use disorders. Other directions future natural recovery studies could take include (a) cross-cultural evaluations; to date, only one study has conducted a cross-cultural evaluation of natural recoveries (Sobell et al., 1996, 2000b); (b) meta-analyses of existing studies could be undertaken, including comparative analyses across substance use disorders, including nicotine; and (c) because this review demonstrated that low-risk drinking has been reported in three-quarters of the respondent samples, it is important for future studies to assess post-recovery drinking levels. Although the present review did not evaluate the deŽ nitions of low-risk drinking used by investigators, those levels varied from study to study. Further, future studies should ask respondents about any drinking that might have occurred post-recovery (i.e. even one drink) because several studies have found that many individuals who might consider themselves as abstinent have consumed small amounts of alcohol (Ludwig, 1985; Sobell et al., 1992; Vaillant, 1995). In fact, one large US survey reported that one-quarter of all those who had resumed low-risk drinking after once having an alcohol problem reported drinking less than once a month in the last year (Dawson, 1996). As well, respondents should be asked about any drug use that occurs postrecovery. In conclusion, unless future studies of natural recovery are methodologically sound and uniformly report basic demographic and substance use history information, it will be impossible to draw conclusions across substances. In addition, unless a minimum recovery interval is required, the conclusions drawn may be biased by being based on transient or unstable recoveries. It will also be important to identify substance related

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differences (e.g. environmental change such as moving may be an important factor in natural recoveries from heroin, but less important for alcohol) and commonalities (e.g. social support may be helpful to the maintenance of all types of substance abuse recoveries). Lastly, if one of the goals of studying natural recoveries is to understand what factors might be associated with successful recoveries and to test those factors in clinical interventions, then an in-depth qualitative understanding of what drives and maintains recovery in the absence of treatment or self-help is a sine qua non.

Acknowledgements The research presented in this paper was supported, in part, by a grant (no. AA08593) from the National Institute on Alcohol Abuse and Alcoholism. The authors also wish to thank Lisa Young-Johnson and Karen Capato for their assistance in the early phase of this pro ject. Portions of this paper were presented at the 33rd Annual Meeting of the Association for Advancement of Behavior Therapy, Toronto, Ontario, Canada, November, 1999.

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of two drinking related assessment instruments: alcohol Timeline Followback and inventory of drinking situations, Substance Abuse and Misuse, in press. SOBELL , L. C., KLINGEMANN, H., TONEATTO, T., SOBELL, M. B., AGRAWAL, S. & LEO, G. I. (2000b) Cross-cultural qualitative analysis of factors associated with natural recoveries from alcohol and drug problems, in press. SOKOL, R. J., MARTIER, S. M. & AGER, J. W. (1989) The T-ACE questions: practical prenatal detection of risk-drinking, American Journal of Obstetrics and Gynecology, 160, 863– 870. STALL, R. & BIERNACKI, P. (1986) Spontaneous remission from the problematic use of substances: an inductive model derived from a comparative analysis of the alcohol, opiate, tobacco, and food/obesity literatures, International Journal of the Addictions, 21, 1– 23. STEWART, T. (1987) The Heroin Users (London, Pandora Press). SUTTON, S. (1996) Can stages of change provide guidelines in the treatment of addictions? in: EDWARDS, G. & D ARE, C. (Eds) Psychotherapy, Psychological Treatments and the Addictions, pp. 189– 205 (Cambridge, MA, Cambridge University Press). THOM, B. (1986) Sex differences in help– seeking for alcohol problems—1. The barriers to help-seeking, British Journal of Addiction, 81, 777– 788. TONEATTO, T., SOBELL , L. C., SOBELL , M. B. & RUBEL, E. (1999) Natural recovery from cocaine dependence, Psychology of Addictive Behaviors, 4, 259– 268. TORO, P. A. (1986) A comparison of natural and professional help, American Journal of Community Psychology, 14, 147– 159. TUCKER, J. A. (1995) Predictors of help-seeking and the temporal relationship of help to recovery among treated and untreated recovered problem drinkers, Addiction, 90, 805– 809. TUCKER, J. A., VUCHINICH, R. E. & GLADSJO, J. A. (1994) Environmental events surrounding natural recovery from alcohol-related problems, Journal of Studies on Alcohol, 55, 401– 411. US DEPARTMENT OF HEALTH AND HUMAN SERVICES (1988) The Health Consequences of Smoking: nicotine addiction, a report of the Surgeon General (Washington, DC, US Government Printing OfŽ ce). VAILLANT, G. E. (1995) The Natural History of Alcoholism Revisited (Cambridge, MA, Harvard University Press). VAN KALMTHOUT, M. A. (1991) Spontaneous remission of addiction, in: SCHIPPERS, G. M., LAMMERS, S. M. M. & SCHAAP, C. P. D. R. (Eds) Contributions to the Psychology of Addictions, pp. 47– 64 (Amsterdam, Swets & Zeitlinger). W ALDORF, D. (1983) Natural recovery from opiate addiction: some social– psychological processes of untreated recovery, Journal of Drug Issues, 13, 237– 280. W ALDORF, D. & BIERNACKI, P. (1982) Natural recovery from heroin addiction: a review of the incidence literature, in: ZINBERG, N. E. & HARDING, W. M. (Eds) Control Over Intoxicant Use: pharmacological, psychological, and social considerations, pp. 173– 181 (New York, Human Science).

Natural recovery review WALDORF, D., REINARMAN, C. & MURPHY, S. ( 1991) Cocaine Changes: the experience of using and quitting (Philadelphia, PA, Temple University). WATSON, A. L. & SHER, K. J. (1998) Resolution of alcohol problems without treatment: methodological issues and future directions of natural recovery research, Clinical Psychology: Science and Practice, 5, 1– 18. WINICK, C. (1962) Maturing out of narcotic addiction, Bulletin on Narcotics, 14, 1– 7. ZINBERG, N. E., HARDING, W. M. & WINKELLER, M. (1977) A study of social regulatory mechanism in controlled illicit drug users, Journal of Drug Issues, 7, 117– 133. ZINBERG, N. E. & JACOBSON , R. C. (1976) The natural history of “chipping”, American Journal of Psychiatry, 133, 37– 40.

Appendix List of 38 articles that met criteria for inclusion in review of natural recovery studies from alcohol and other drugs* ARMOR, D. J. & MESHKOFF, J. E. (1983) Remission among treated and untreated alcoholics, in: MELLO, N. K. (Ed.) Advances in substance abuse: behavioral and biological research: Vol. 3, pp. 239– 269 (Greenwich, CN, JAI Press). BIERNACKI, P. (1986) Pathways from heroin addiction recovery without treatment (Philadelphia, Temple University Press). BLACKWELL, J. S. (1983) Drifting, controlling and overcoming: opiate users who avoid becoming chronically dependent, Journal of Drug Issues, 13, 219– 235. BLOMQUIST, J. (in press) Treated and untreated recovery from alcohol misuse: environmental in uences and perceived reasons for change, Substance Use & Misuse. BRADY, M. (1993a) Giving away the grog: Aboriginal accounts of drinking and not drinking (Canberra, Australia, Australian Government Printing Service).* BRADY, M. (1993b) Giving away the grog: an ethnography of Aboriginal drinkers who quit without help, Drug and Alcohol Review, 12, 401– 411. BURMAN, S. (1997) The challenge of sobriety: natural recovery without treatment and self-help groups, Journal of Substance Abuse, 9, 41– 61. COHEN, P. & SAS, A. (1994a) Cocaine use in Amsterdam in non deviant subcultures, Addiction Research, 2, 71– 94. COHEN, P. & SAS, A. (1994b) Ten Years of Cocaine Use: a follow-up study of 64 cocaine users in Amsterdam (Amsterdam, Instituut voor Sociale GeograŽ e, Universiteit van Amsterdam).* COPELAND, J. (1997) A qualitative study of barriers to formal treatment among women who self-managed change in addictive behaviours, Journal of Substance Abuse Treatment, 14, 183– 190. COPELAND, J. (1998) A qualitative study of selfmanaged change in substance dependence among women, Contemporary Drug problems, 25, 321– 345.* CUNNINGHAM, J. A. (in press) Resolutions from alcohol problems with and without treatment: the

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effects of different problem criteria, Journal of Studies on Alcohol. CUNNINGHAM, J. C., LIN, E., ROSS, H. E. & WALSH, G. W. (1998 January) Factors associated with untreated remissions from alcohol abuse or dependence: implications for the provision of treatment, Paper presented at the International Conference on Addictive Behaviors, Santa Fe, NM. CUNNINGHAM, J. C., SOBELL, L. C. & SOBELL , M. B. (1996 September) Recovery from alcohol problems with and without treatment in a general population survey: reasons for change, Poster presented at the International Symposium on Addictions ’96: Treatment Across the Addictions, Hilton Head, SC.* DAWSON, D. A. (1996) Correlates of past-year status among treated and untreated persons with former alcohol dependence: United States, 1992, Alcoholism: Clinical and Experimental Research, 20, 771– 779. GLADSJO, J. A., TUCKER, J. A., HAWKINS, J. L. & VUCHINICH , R. E. (1992) Adequacy of recall of drinking patterns and event occurrences associated with natural recovery from alcohol problems, Addictive Behaviors, 17, 347– 358.* GOODWIN , D. W., CRANE, J. B. & GUZE, S. B. (1971) Felons who drink: an 8-year follow-up, Quarterly Journal of Studies on Alcohol, 32, 136– 147. GRAEVEN, D. B. & GRAEVEN, K. A. (1983) Treated and untreated addicts: factors associated with participation in treatment and cessation of heroin use, Journal of Drug Issues, 13, 207– 218. GRANFIELD, R. & CLOUD, W. (1996) The elephant that no one sees: natural recovery among middleclass addicts, Journal of Drug Issues, 26, 45– 61. HARDING, W. M., ZINBERG, N. E., STELMACK, S. M. & MICHAEL, B. (1980) Formerly-addicted-nowcontrolled opiate users, International Journal of the Addictions, 15, 47– 60. HINGSON, R., SCOTCH , N., DAY, N. & CULBERT, A. (1980) Recognizing and seeking help for drinking problems, Journal of Studies on Alcohol, 11, 1102– 1117. JORQUEZ , J. S. (1983) The retirement phase of heroin using careers, Journal of Drug Issues, Summer, 343– 365. KING, M. P. & TUCKER, J. A. (1998) Natural resolution of alcohol problems without treatment: environmental contexts surrounding the initiation and maintenance of stable abstinence or moderation drinking, Addictive Behaviors, 23, 537– 541.* KING, M. P. & TUCKER, J. A. (in press) Behavior change patterns and strategies distinguishing moderation drinking and abstinence during the natural resolution of alcohol problems without treatment, Psychology of Addictive Behaviors. KLINGEMANN, H. K.-H. (1991) The motivation for change from problem alcohol and heroin use, British Journal of Addiction, 86, 727– 744. KLINGEMANN, H. K. H. (1992) Coping and maintenance strategies of spontaneous remitters from problem use of alcohol and heroin in Switzerland, International Journal of the Addictions, 27, 1359– 1388.* KNUPFER, G. (1972) Ex-problem drinkers, in: ROFF , M., ROBINS , L. & POLLACK, H. (Eds.) Life history

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research in psychopathology: Vol. 2, pp. 256– 280 (Minneapolis, University of Minnesota Press). LEUNG, P. K., KINZIE, J. D., BOEHNLEIN, J. K. & SHORE, J. H. (1993) A prospective study of the natural course of alcoholism in a Native American village, Journal of Studies on Alcohol, 54, 733– 738. LUDWIG, A. M. (1985) Cognitive processes associated with “spontaneous” recovery from alcoholism, Journal of Studies on Alcohol, 46, 53– 58. MARIEZCURRENA , R. (1996) Recovery from addictions without treatment: an interview study, Scandinavian Journal of Behavior Therapy, 25, 57– 84. MC MURRAN, M. & WHITMAN, J. (1990) Strategies of self-control in male young offenders who have reduced their alcohol consumption without formal intervention, Journal of Adolescence, 13, 115– 128. PUKISH, M. & TUCKER, J. A. (1994 November) Natural recovery from of alcoholism: contexts surrounding abstinence or moderation outcomes, Poster presented at the Annual Meeting of the American Psychological Association, Los Angeles, CA.* ROBINS , L. N. (1973a) A follow-up of Vietnam drug users (Washington, DC, US Government Printing OfŽ ce).* ROBINS , L. N. (1973b) The Vietnam drug user returns (Washington, DC, US Government Printing OfŽ ce).* ROBINS , L. N., HEIZER, J. E. & DAVIS, D. H. (1975) Narcotic use in southeast Asia and afterward: an interview study of 898 Vietnam returnees, Archives of General Psychiatry, 32, 955– 961. ROIZEN, R., CAHALAN, D. & SHANKS, P. (1978) Spontaneous remission among untreated problem drinkers, in: KANDEL, D. B. (Ed.) Longitudinal Research on Drug Use. Empirical Ž ndings and methodological issues, pp. 197– 221 (Washington, DC, Hemisphere). SAUNDERS, W. M. & KERSHAW, P. W. (1979) Spontaneous remission from alcoholism: a community study, British Journal of Addiction, 74, 251– 265. SCHASRE, R. (1966) Cessation patterns among neophyte heroin users, International Journal of the Addictions, 1, 23– 32. SOBELL, L. C., CUNNINGHAM, J. A. & SOBELL , M. B. (1996) Recovery from alcohol problems with and without treatment: prevalence in two population surveys, American Journal of Public Health, 86, 966– 972.a SOBELL, L. C., SOBELL, M. B. & TONEATTO, T. (1992) Recovery from alcohol problems without treatment, in: HEATHER, N., MILLER, W. R. & GREELEY, J. (Eds.) Self-control and the addictive behaviours, pp. 198– 242 (New York, Maxwell MacMillan).* SOBELL, L. C., SOBELL , M. B., TONEATTO, T. & LEO, G. I. (1993) What triggers the resolution of alcohol problems without treatment? Alcoholism: Clinical and Experimental Research, 17, 217– 224. SOBELL, M. B., SOBELL , L. C. & KOZLOWKSI, L. T. (1995) Dual recoveries from alcohol and smoking problems, in: FERTIG, J. B. & ALLEN, J. A. (Eds.) Alcohol and tobacco: From basic science to clinical practice (NIAAA Research Monograph No. 30), pp. 207– 224 (Rockville, MD, National Institute on Alcohol Abuse and Alcoholism).*

STALL, R. (1983) An examination of spontaneous remission from problem drinking in the bluegrass region of Kentucky, Journal of Drug Issues, 13, 191– 206. STASIEWICZ, P. R., BRADIZZA, C. M. & MAISTO, S. A. (1997) Alcohol problem resolution in the severely mentally ill: a preliminary investigation, Journal of Substance Abuse, 9, 209– 222. TONEATTO, T., SOBELL , L. C., RUBEL, E., LEO, G. I., SOBELL , M. B. & AGRAWAL, S. (1994 November) Comparing untreated recovery in cocaine and alcohol abusers, Poster presented at the 28th Annual Meeting of the Association for Advancement of Behavior Therapy, San Diego, CA.* TONEATTO, T., SOBELL , L. C. & SOBELL , M. B. (in press) Natural recovery from cocaine dependence, Psychology of Addictive Behaviors. TUCHFELD, B. S. (1976) Changes in patterns of alcohol use without the aid of formal treatment: An exploratory study of former problem drinkers (Research Triangle Park, North Carolina, Research Triangle Institute).* TUCHFELD, B. S. (1981) Spontaneous remission in alcoholics: empirical observations and theoretical implications, Journal of Studies on Alcohol, 42, 626– 641. TUCKER, J. A. (1995) Predictors of help-seeking and the temporal relationship of help to recovery among treated and untreated recovered problem drinkers, Addiction, 90, 805– 809.* TUCKER, J. A., VUCHINICH, R. E. & GLADSJO, J. A. (1994) Environmental events surrounding natural recovery from alcohol-related problems, Journal of Studies on Alcohol, 55, 401– 411. TUCKER, J. A., VUCHINICH, R. B. & PUKISH, M. M. (1995) Molar environmental contexts surrounding recovery by treated and untreated problem drinkers, Experimental and Clinical Psychopharmacology, 3, 195– 204.* VANCE, B. K., CARROLL, S. L., STEINSIEK, P. & HELM , B. (1985) Alcoholism, abstinence, and self-control: a psychological exploration of alcohol problems, Paper presented at the Annual meeting of the Oklahoma Psychological Association, Tulsa, Oklahoma.b W ALDORF, D. (1983) Natural recovery from opiate addiction: Some social-psychological processes of untreated recovery, Journal of Drug Issues, 13, 237– 280. W ALDORF, D. & BIERNACKI, P. (1981) The natural recovery from opiate addiction: Some preliminary Ž ndings, Journal of Drug Issues, 11, 61– 74.* ZIMMERMAN, J. D. & ZELLER, B. R. (1992) Imaginal, sensory, and cognitive experience in spontaneous recovery from alcoholism, Psychological Reports, 71, 691– 698. * Studies with an asterisk after them are not source articles, but related to the source article and from which additional information was taken to evaluate the source article. a Contains two respondent samples (NADS survey; OADS survey) b Contains two respondent samples (Survey 3; Survey 4).