‘Natural recovery’ is a term used to describe recovery from addiction without the help of professionals. It’s a term that rather implies there’s something unnatural about the professional or even AA route. However, other terms that have been used are also problematic, given that they all embody an explanation of the phenomenon that is open to question. For example, Tuchfield (1981) was one of the first to describe what he called “spontaneous recovery”, although the recovery his alcohol dependent respondents described were generally the product of a sense of shame that had grown over a long period of time, even if the ultimate decision was sudden. Winnick (1962) described a process of “maturing out” in a group of nearly 17,000 opiate addicts registered as such in the USA in 1954-55, two-thirds of whom failed to appear on the Register over a period of 5 to 6 years. “Self-change” is now frequently used to describe recovery without professional help, but surely all change is self-change, professionally assisted or not.
Whatever the term used to describe the process, recovery without recourse to professional help has repeatedly been shown to account for a greater degree of success than is achieved in clinical populations (Klingemann, 2001). This has encouraged those who question the efficacy of the recovery movement and the mutual help practices of AA; and the suggestion that promoting self-change in the community should take priority as a treatment strategy has put the treatment community somewhat on the defensive. However, the justification for a mutual stand-off is slender, because self-change on the one hand, and professional treatment on the other, are not strictly speaking, antagonistic methodologies. Rather, they are complementary. Those who come for treatment presumably view it as being of value in their personal quest for self-change, so no controlled comparison of self-change and professional treatment is feasible, even in principle.
It is, of course, likely that those who seek treatment, or are encouraged to undergo treatment, are at the serious end of the addiction dependence continuum. Whilst this has been generally acknowledged to be a plausible assumption, there are two questions arising that need to be addressed. The first concerns the ability of those with more serious conditions to recover by themselves. The second concerns the extent to which professional treatment actually improves the prospects of more seriously dependent persons.
The first question has recently been addressed in an important Dutch study (Boschloo 2012). The data reported come from the ‘Netherlands Study of Depression and Anxiety’ (NESDA), which aimed to follow up the long-term consequences of depressive and anxiety disorders in a total of 2981 people, about half of whom had experienced an anxiety and depressive disorder, or symptoms of anxiety and depression. 253 of the participants had a diagnosis of remitted Alcohol Dependence (AD) or current AD (assessed in terms of (DSM IV ) at baseline and were followed up over a period of two years.
What predicted Recurrence of AD in those who were in remission at base-line? By far the most important factor predicting recurrence was the Severity of base-line AD, with 43% of those in the highest Quintile of problems having a recurrence. The comparable figure for all those alcoholically dependent people in the lower four quintiles of problematic usage was an overall average of only 9%. In other words, the top 20% in terms of problem severity were about five times as likely as the bottom 80% to relapse. Figures for Persistence of AD in those who at base-line received that diagnosis again indicated that Severity of AD was by far the most important factor in predicting persistence of the disorder with 78% of the most severe cases persisting, as against 32% of the least severely dependent cases.
What about the presence or absence of other mental health problems? Anxiety and depression are frequent accompaniments of addiction, and it is important to know if they are aggravating factors in self-change. Unexpectedly, depressive and anxiety symptoms (but not diagnosed disorders) significantly predicted Recurrence, though not Persistence. There are other surprises in these data. No personality, or socio-demographic factors were generally associated with Recurrence, and nor were childhood trauma or family history of AD, or illicit drug use. However, men were somewhat more likely to relapse than were women.
The overarching importance of severity of addiction in determining whether those who attempt to change succeed or not, seems now to be well demonstrated in the Boschloo study. And a further point needs to be made about that finding. When you exclude the most severely addicted persons from the analysis, relative severity of addiction at the lower levels remains an important predictor of successful self-change. Severity of dependence is important across the full dependency range.
I’d like to make four points about the practical importance of these results, the first three relating to the critical importance of severity:
- We still need to investigate how and for whom professional treatment adds value to independent efforts to change. This means that at any given level of dependence severity, Recurrence should be demonstrably lower for those who undergo treatment than for those who do not.
- In order to achieve evidence on this point we have to ensure that severity of dependence is routinely assessed in a convincing and generally accepted way.
- We should consider varying our treatment strategy in relation to severity of dependence. For example, treating a client at a low level of dependence as someone with a chronically recurring condition may well be counterproductive.
- It is important to assess depressive and anxiety symptoms in relation to the risk of relapse.
Relating to the first point, a commentator on the Boschloo article writes that, “the case for the increased availability of treatment services would be strengthened if there was better evidence for specific treatment outcomes above the outcomes which are potentially attributable to natural recovery” (my italics, Najman 2012). That point is well taken, and necessitates greater attention being paid to the development and use of generally acceptable measures of addiction severity in all our research. I would also add that we need to look broadly at individual patterns of addiction when assessing severity of dependency. Clients rarely arrive with just one addiction problem, and measures of overall addiction severity are needed (e.g. Christo et.al, 2003) to ensure that recovery in one area of addiction (alcohol in the present case) can take account of compensatory increases of dependence in other areas of addictive behaviour.
Professor Geoffrey Stephenson