Psycho[ogical Reports, 1992, 71, 691-698.
@ Psychological Reports 1992
IMAGINAL, SENSORY, AND COGNITIVE EXPERIENCE IN SPONTANEOUS RECOVERY FROM ALCOHOLISM ' JEFFREY D. ZIMMERMAN AND BARBARA R. ZELLER Good Shepherd Rehabilitation Hospital, Allentown, PA Summary.-Although alcoholism is often regarded as an intractable disorder that requires intensive treatment, studies of the natural history of alcoholism indicate that unaided, spontaneous recovery may be the most common pathway to remission from alcoholism. Negative environmental consequences of alcoholic drinking have been invoked to explain spontaneous recovery, but a more compelling reason for sudden changes in drinking behavior concerns shifts in the personal meanings surrounding alcohol use. Extensive interviews in a multimodal format were conducted with two groups of alcoholics: one group comprised of 7 subjects who spontaneously recovered without treatment and the other group comprised of 9 people who believed formal treatment was necessary to abstain from drinking. Spontaneously recovered alcoholics reported experiencing vivid sensations and images at the time they decided to quit drinking, and they reported subsequent transformations of their persona1 identities. Active alcoholics reported no comparable experiences in imaginal, sensory, and cognitive modalities. Implications of the results for current alcoholism treatments are discussed.
Efforts to understand the causes and cures of alcoholism command the attention of a widening sphere of researchers and practitioners. Despite obvious gains in knowledge, fundamental questions remain concerning the essential features of alcoholism. For example, Miller and Hester (1989) identified 10 contemporaneous theoretical models, each of which posit a unitary etiology, in turn leading to varying degrees of incompatibility concerning treatment processes and goals. However, regardless of theoretical orientation, on one point most professionals are in accord: alcoholism is a highly intractable disorder that requires intensive treatment, a strong commitment to continuing care, and on-going personal vigilance to prevent relapse (Stall & Biernacki, 1986). Despite the seeming intractabhty of alcoholism and the apparent complexities of integrating different theoretical perspectives, a small but conspicuous body of evidence indicates that rates of "self-cure" are high among alcoholic individuals (Drew, 1968; Edwards, Orford, Egert, Hawker, Hensman, Mitcheson, Oppenheimer, & Taylor, 1977; Ludwig, 1972; Stall, 1983). Furthermore, when compared to the number of alcoholics who have been in formal treatment programs, alcoholics who achieve and then maintain abstinence outside formal treatment settings might represent the majority of re-
~
'Correspondence may be addressed to Jeffrey D. Zimmerman, who is now at Berks Youth Counseling Center, 525 Franklin Street, Readin PA 19602. A description of the interview format and a summary of subjects' self-reports willke provided upon request.
692
J. D.ZIMMERMAN & B. R. ZELLER
covered alcoholics (Tuchfeld, 1981). From the standpoint of the natural history of alcoholism, then, the course of this disorder is far from being inexorably progressive, but instead is susceptible to a wide range of environmental and developmental influences (Mulford, 1984; Zucker & Gomberg, 1986). To account for variations in the natural progression of alcoholism, Marlatt, Baer, Donovan, and Kivlahan (1988) argue that the mediating influence of environmental events leads directly to the decision to initiate and maintain abstinence from alcohol. Negative or punishing consequences of drinking and unsettling changes in employment, residence, or social relationships are given as examples of external contingencies that result in changes in drinking patterns outside the treatment setting. Emphasizing environmental contingencies associated with spontaneous recovery, however, does not clearly show the inner nature of the change event: in other words, the phenomenology of change. With this in mind, Ludwig (1985) attempted to identify and then analyze cognitive processes that covary with negative environmental events. His findings demonstrated that regardless of the situational context in which subjects spontaneously decided to discontinue alcohol use, the common cognitive denominator was an aversive "mental association" to alcohol that heightened subjects' awareness of the extent of suffering they endured as a result of alcoholism. Also, despite a history of having experienced strong, persistent urges to drink, 11 of the 29 subjects in his study reported a complete lack of desire to use alcohol, ostensibly as a result of negative mental associations to alcohol. Ludwig's (1985) data emphasized one particular point which is instructive for studying the spontaneous recovery process. Specifically, negative environmental events per se had little inherent meaning; more important were the personal meanings about those events that individuals construed. For example, subjects in his sample reported repeated struggles throughout their drinking histories, including legal, financial, social, and health problems, any one of which could have been sufficient to promote abstinence. However, shifts in the personal meaning of these events explained better the decision to quit drinking than did the presence of any singular source of environmental stress. The present study was designed to explore further the experience of spontaneous change outside treatment by extending previous qualitative methodology in the following three ways. First, sensory-perceptual domains were more fully assessed. Including these variables in the analysis was expected to facilitate a better understanding of the relationship between negative cognitive associations to alcohol and changes in drinking behavior. Microprocess variables that included kinesthetic, visual, auditory, gustatory, and tactile sensations were considered specific to the sensory-perceptual modality (Gendlin, 1986; Lazarus, 1981).
SPONTANEOUS RECOVERY FROM ALCOHOLISM
693
Second, interview questions were formulated that more directly elicited subjects' assessment of how their life meanings had changed subsequent to their experience of spontaneous recovery. Subjects were asked to reflect on how they felt different about themselves, for example, whether changes occurred in what they wanted their lives to represent, whether changes occurred in attitudes about certain people, activities, and events, whether changes occurred in personal or interpersonal values. Thud, we included a second group of people who were unable to quit drinking on their own and who had requested counseling to achieve this goal. These subjects were also asked to reflect upon sensory-perceptual and phenomenological experiences that accompanied their most recent yet unsuccessful effort to quit drinking. Their responses were then contrasted with ones made by the first group of subjects. Subjects were recruited From admissions to an outpatient agency that speciahzes in treatment for chemical dependency. Only those clients who voluntarily requested treatment services were considered for inclusion in the present study; they were not required to seek treatment by the legal system or by their employers as part of Employee Assistance Program (EAP) policies. Participation in rhe present study also was voluntary. Subjects were assigned to one of two groups. (1) The first group was comprised of people who had significantly altered their drinking behavior ourside of treatment and (2) the second group was comprised of people who believed that they could make similar changes in drinking behavior only within treatment. In contrast to the latter group of subjects who specifically requested alcoholism treatment, the former group sought to explore interpersonal concerns often associated with alcoholism, including such themes as co-dependency, marital conflict, and children of alcoholics. Clients asked to partlclpace as subjects were required to have had (or to currently have, as for the within-treatment group) a history of drinlung consistent with DSM-111-R (1987) criteria for Alcohol Dependence Their self-reports of alcohol use were assessed by two independent raters. Agreement between raters on the assessment OF Alcohol Dependence was required before the offer to participate in the study was extended. An additional criterion for participation in the outside-of-treatment group was their report of a spontaneous experience of change that was unintended, i.e., no conscious decision having been made to commit to abstinence. Further, clients selected for this group could not recall having been under any immediate external pressure to quit drinking, such as the threat of losing a job or a spouse. Consequently, these subjects, at the time of the spontaneous recovery, reported feeling surprised at the suddenness at which they made a decision to commit to abstinence. Seven people were selected who met the above criteria for participation in the oursideof-treatment group: three men and four women. At the time of their interviews, these subjects had been abstinent from seven months to two years, and all expressed a desire to continue to live alcohol free. Interestingly, none of the seven subjects were deeply concerned about the potential for relapse, an attitude they attributed to the intensity of their spontaneous experience o l change. Nine people were included in the withn-treatment group, three men and six women. These subjects continued to use alcohol, even though they wanted to establish abstinence as a way of life. Interviews were conducted using a multimodal assessment procedure consistent with Lazarus' (1981) BASIC ID. Two to four 60-min. interviews were conducted with each subiect, de-
694
J. D. ZIMMERMAN
&
B. R. ZELLER
pending on the complexity of the self-report. All interviews were conducted by the investigators.
RESULTS Experiences reported by the outside-of-treatment group were consistent with previous qualitative research (e.g., Ludwig, 1985). All had struggled with alcohol dependence for an extended period of time, having made occasional and unsuccessful efforts to quit permanently. Also, at the time each made the spontaneous decision to quit, negative cognitive associations to alcohol were present, and these associations were extremely aversive and unsettling. I n addition, interview data from the present study highlight several aspects of the spontaneous change experience not fully evident in previous reports. 1. Each subject experienced sensations and perceptions suggesting a mild to moderate dissociative experience. Their perceptions of the world, themselves, and alcohol changed in a way that momentarily produced a state of nonordinary reahty (cf. McPeake, Kennedy, & Gordon, 1991), a finding alluded to by Ludwig (1985), who described subjects in his study as having been "jolted emotionallyH before they could initiate change in drinking behavior. Subjectively, nonordinary reality was described as a perception of looking at oneself from the outside, having a sense of being suddenly in a different state of mind, or experiencing a slightly altered sense of time. This sudden and momentary sense of nonordinary reality, and the strong emotions it evoked, seemed to place subjects in a receptive state of mind that heightened the effects of subsequent images and cogktions. Also generally reported by these subjects were kinesthetic sensations that made alcohol feel distant or "far away." Whereas previously the thought of alcohol was kinesthetically sensed as being a large and dynamic presence that pervaded self-awareness, spontaneous change produced an internal kinesthetic sensation that alcohol had "moved further away," thereby becoming smaller and more ineffectual. 2. While in a slightly altered state of consciousness, spontaneous images were pervasive and intense. These involved seeing in the "mind's eye" images of themselves that were repulsive or frightening. O n e person saw himself lying in a coffin with the lid closing over him. Another person saw herself as if through other people's eyes, and this image showed her how foolish she might look to others and how seemingly unmanageable her life had become. 3 . Subsequent to having a sense of nonordinary reality and after experiencing a constellation of noxious sensations, images, and affects, certain cognitions emerged that were categorized into two related sets of beliefs. First, attitudes about the importance of alcohol began to change dramatical-
SPONTANEOUS RECOVERY FROM ALCOHOLISM
695
ly. Whereas prior to this experience alcohol was thought an essential component of their lives, the belief w h c h emerged was that alcohol was a nonessential ingredient for managing daily life, thereby rendering alcohol use a less attractive and compelling activity. Rather than inspire enthusiasm about its effects, alcohol became conceptualized as a relatively inert substance, void of positive personal meaning and incapable of providing benefits for satisfactory living. The second change in cognition concerned personal identity. This experience seemed to produce an awareness of how "incomplete" subjects found their lives to be. A deeper recognition of failed relationships and of missed opportunities seemed to inform them that, as one stated, an alcoholic lifestyle was "not me," and that they had failed to represent their lives in the ways they had ideahzed or in terms of values previously believed to be important. I n summary, subjects in the outside-of-treatment group recalled a spontaneous experience of change not mediated by any singular environmental event or by any conscious and deliberate decision. Instead, a mild to moderate nonordinary state of consciousness was reported to covary with subsequent sensory impressions, with negative mental images, with a distorted sense of time, and with changes in beliefs about alcohol's intoxicating effects. Perhaps most strilung were sudden changes in personal identity, such that the end-state of the spontaneous change event was a belief that future drinking would be inconsistent with how they suddenly perceived themselves to be. F i n d y , the profound effect of spontaneous change was evident in subjects' reports of having no overly distressing withdrawal symptoms, despite describing a history of heavy drinking, and little or no sense of loss that a previously valued "central activity" (Fingarette, 1988) in their lives was n o longer present. I n contrast, subjects in the within-treatment group, who were beginning formal treatment, felt overwhelmed when trying to shake the belief that they could construct a life pattern for themselves exclusive of heavy alcohol use. Apprehension about possible withdrawal was not given as a primary concern about the prospect of changing drinking behavior. Rather, feeling highly uncertain about how their personal and social identities would change and worry about how they would manage stress without alcohol were the primary reasons given by these subjects when explaining what it was that frustrated unaided efforts to quit drinking. Not surprisingly, then, subjects in the group expressed greater ambivalence and confusion regarding their life goals and personal values than did subjects in the other group. Associated with the above-mentioned concerns among subjects within treatment were ambivalent associations to alcohol and a kinesthetic sensation of alcohol as being large, present, or powerful, as opposed to a lunesthetic - -
696
J. D. ZIMMERMAN
&
B. R. ZELLER
sensation of alcohol as being distant, as was reported by outside-of-treatment subjects. The consensus among those within treatment was that, given this kinesthetic sense, they could not "get out of a drinlung state of mind," making difficult a more objective evaluation of the negative consequences of frequent intoxication. These qualitative data are based on two s m d samples matched on demographic and clinical variables. Because of methodological factors (e.g., qualitative design, descriptive data dependent upon memory recall, interviewers who were not blind to the purpose of the study, and small sample), further studies less exploratory in nature and designed with greater experimental control are recommended. Nonetheless, within the context of alcoholism treatment, present results are heuristic for two reasons. First, spontaneous change was described by subjects as a psychologically comprehensive experience that involved multiple modalities, including two modalities rarely addressed in traditional alcoholism treatments: the sensation (including sensations of consciousness) and imagery modalities. Specifically, nonordinary states of consciousness and vivid sensory and imaginal experiences spontaneously appeared, and sudden changes within these two modalities seemed to create an inner psychological context that promoted subsequent shifts in personal and interpersonal behavior, affect, and cognition. I n view of the central role attributed to sensory and imaginal processes by outside-of-treatment subjects and given the finding that subjects in the within-treatment group did not recall anything similar, this variable in the change process could potentially represent an important aspect of recovery which, at best, is marginally included in current alcoholism treatments. Although changes in the sensory and imaginal modalities in the outside-oftreatment group were spontaneous, a better understanding of the mechanisms involved could assist in the development of treatments that help people focus intentionally on these modalities for making therapeutic changes in their drinking behavior. Initial steps in this direction have been made by McPeake, et al. (1991) in their formulation of "Altered States of Consciousness Therapy," as well as by Andreas and Andreas (1990) in their adaptation of neurolinguistic programming in "planning" for spontaneous change. The second significant finding was that a strong shift in personal meaning occurred for outside-of-treatment-group subjects, both with respect to personal identity and to their relationship with alcohol. T h s finding paralleled Biernacki's (1986) sociological analysis of the ways opiate addicts were successful in recovering from addiction, unaided by professional help or by involvement in a specific program of therapy. I n general, Biernacki (1986) found that opiate addicts who recover without treatment were able "successfully [to] transform their identities and come to be treated as 'ordinary
SPONTANEOUS RECOVERY FROM ALCOHOLISM
697
people' " (p. 179). Furthermore, similar to our findings with alcoholics, Biernacki (1986) found that it was not necessary for addicts to be confronted to discontinue with a sudden onset of environmental stress to feel opiate use, although that sometimes happened. More significant for the group of opiate addicts sampled was the emergence of a new identity or the renewal of a former identity relatively unaffected by addictive behavior that was incompatible with future opiate use. I n that study as in ours, shifts in personal identity were reported as crucial for maintaining negative cognitive associations to the addictive substance and for maintaining behavioral avoidance of situational cues capable of precipitating relapse. Investigating the contextual influence of personal identity for alcoholics attempting to quit drinking is another aspect of the recovery process deserving more attention. Contemporary treatments typicaUy involve medical detoxification, 12-step programs, psychoeducational instruction about alcoholism, group counseling that encourages emotional catharsis (for example, children of alcoholic themes), and cognitive-behavioral strategies for relapse prevention. Designing treatments that incorporate methods for modifying processes specific to personal identity-identities that eventually evolve to be inconsistent with alcoholic drinking-might complement existing treatments that focus primarily on processes involving actual drinking behavior. Examples of extant theory from which such therapeutic programs could be designed include models of deep structure change (Arnkoff, 1980; Burrell, 1987), developmental constructivism (Mahoney, 1991), and hermeneutics (Bouchard & Guerette, 1991; Frank, 1987). Treatments which were engineered accordingly could result in changes within treatment that mimic the robust change exhibited by people who spontaneously alter addictive behavior outside of treatment. The prevalence of spontaneous change outside of treatment points to a serious gap in current research on the treatment of alcoholism. As data gradually accumulate about the pathways of unaided recovery and about the psychological mechanisms involved, it will become increasingly imperative to develop treatments that methodically incorporate so-called "spontaneous" processes into present treatment formats. I n discussing the etiology of alcoholism, Zucker and Gomberg (1986) stated that, "To truly understand etiology is to understand also how alcoholism does not develop and what produces insulations against it, as well as what contributes to it" (p. 791). A suitable paraphrase which reflects the purpose of spontaneous change research in alcoholism is that to understand successful treatment outcome is to understand also how people recover witbout participation in formal treatment and how those resources can be made available to those who require the support of formal intervention.
698
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& B. R.
ZELLER
REFERENCES AMERICANPSYCHIATRIC ASSOCIATION. (1987) Diagnostic and statistical manual of mental disorders. (3rd ed., Rev.) Washington, DC: Author. ANDREAS, C., & ANDREAS, S. (1990) Briefer than brief: a methodical approach to spontaneous change. Family Therapy Networker, (March/April), 37-41. ARNKOFF,D. B. (1980) Psychotherapy from the perspective of cognitive therapy. In M. . Mahoney (Ed.), Psychotherapy process: current issues and future directions. New Yor : Plenum. Pp. 339-361. BERHACKI,I? (1986) Pathways from heroin addiction: recovery without treatment. Philadelphia, PA: Temple Univer. Press. BOUCFIARD, M., & GUERETIZ, L. (1991) Psychotherapy as a hermeneutical experience. Psychotherapy, 28, 385-394. BURRELL, M. J . (1987) Cognitive psychology, epistemology, and psychotherapy: a motor-evolutionary perspective. Psychotherapy, 24, 225-232. DREW,L. (1968) Alcoholism as a self-limiting disease. Quarterly Journal of Studies on Alcohol, 29, 956-967. EDWARDS, G., ORFORD,J., EGERT,S., HAWKER,A,, HENSMAN, C., WTCHESON, M., OPPENHEIMER,E., & TAYLOR, C. (1977) Alcoholism: a controlled trial of "treatment" and "advice." Journal of Studies on Alcohol, 38, 1004-1031. F K N G A R EH. ~ ,(1988) Heavy drinking: the myth of alcoholism as a disease. Berkeley, CA: Univer. of California Press. FRANK,J. D. (1987) Ps chotherapy, rhetoric, and hermeneutics: implications for practice and research. ~ ~ c h ~24,t 293-302. ~ ~ m ~ ~ , GENDL~N, E. T. (1986) What comes after traditional psychotherapy research. American Psychologist, 41, 131-136. LAZARUS, A. A. (1981) The practice of multimodal therapy. New York: McGraw-Hill. LUDWIG, A. M. (1972) On and off the wagon: reasons for drinking and abstaining by alcoholics. Quarterly Journal of Studies on AIcohol, 33, 91-96. LUDWIG,A. M. (1985) Cognitive processes associated with "spontaneous" recovery from alcoholism. Journal of Strrdies on Alcohol, 46, 53-58. MAHONEY, M. J. (1991) Hziman change processes: the scientific foundations of psychotherapy. New York: Basic Books. ~ R U \ T , G . A., BAER, . S., DONOVAN, D. M., & KIVLAHAN, D. R. (1988) Addictive behaviors: etiology an treatment. In M. R. Rosenzweig & L. W. Porter (Eds.), Annual Review o/ Psychology, 39, 223-252. MCPEAKE,J. D., KENNEDY, B. l?, & GORDON,S. M. (1991) Altered states of consciousness therapy. Journal of Substance Abuse Treatment, 8, 75-82. b ~ W. R.,, & HESTER,R. K. (1989) Treating alcohol problems: toward an informed eclecticism. In R. K. Hesrer & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches. New York: Pergamon. Pp. 3-13. MULFORD, H. A. (1984) Rethinking the alcohol problem: a natural processes model. Journal of Drug Issues, 14, 31-43. STALL, R. (1983) Spontaneous remission from problem drinking in the bluegrass region of Kentucky: an inductive study. Journal of Drug Issues, 13, 191-206. STALL,R., & BIERNACKI, P. (1986) Spontaneous remission from the problematic use of substances: an inductive model derived from a comparison of the alcohol, opiate, tobacco, and food/obesity literatures. InternationalJournal of h e Addictions, 21, 1-23. TUCHFELD,B. S. (1981) Spontaneous remission in alcoholics: empirical observations and theoretical observations. Journal of Studies on Alcohol, 42, 626-641. ZUCKER, R. A., & GOMBERG, E. S. L. (1986) Etiology of alcoholism reconsidered: the case for a biopsychosocial process. American Psychologist, 41, 783-793.
r!
d
Accepfed July 27, 1992
@ Psychological Reports 1992
IMAGINAL, SENSORY, AND COGNITIVE EXPERIENCE IN SPONTANEOUS RECOVERY FROM ALCOHOLISM ' JEFFREY D. ZIMMERMAN AND BARBARA R. ZELLER Good Shepherd Rehabilitation Hospital, Allentown, PA Summary.-Although alcoholism is often regarded as an intractable disorder that requires intensive treatment, studies of the natural history of alcoholism indicate that unaided, spontaneous recovery may be the most common pathway to remission from alcoholism. Negative environmental consequences of alcoholic drinking have been invoked to explain spontaneous recovery, but a more compelling reason for sudden changes in drinking behavior concerns shifts in the personal meanings surrounding alcohol use. Extensive interviews in a multimodal format were conducted with two groups of alcoholics: one group comprised of 7 subjects who spontaneously recovered without treatment and the other group comprised of 9 people who believed formal treatment was necessary to abstain from drinking. Spontaneously recovered alcoholics reported experiencing vivid sensations and images at the time they decided to quit drinking, and they reported subsequent transformations of their persona1 identities. Active alcoholics reported no comparable experiences in imaginal, sensory, and cognitive modalities. Implications of the results for current alcoholism treatments are discussed.
Efforts to understand the causes and cures of alcoholism command the attention of a widening sphere of researchers and practitioners. Despite obvious gains in knowledge, fundamental questions remain concerning the essential features of alcoholism. For example, Miller and Hester (1989) identified 10 contemporaneous theoretical models, each of which posit a unitary etiology, in turn leading to varying degrees of incompatibility concerning treatment processes and goals. However, regardless of theoretical orientation, on one point most professionals are in accord: alcoholism is a highly intractable disorder that requires intensive treatment, a strong commitment to continuing care, and on-going personal vigilance to prevent relapse (Stall & Biernacki, 1986). Despite the seeming intractabhty of alcoholism and the apparent complexities of integrating different theoretical perspectives, a small but conspicuous body of evidence indicates that rates of "self-cure" are high among alcoholic individuals (Drew, 1968; Edwards, Orford, Egert, Hawker, Hensman, Mitcheson, Oppenheimer, & Taylor, 1977; Ludwig, 1972; Stall, 1983). Furthermore, when compared to the number of alcoholics who have been in formal treatment programs, alcoholics who achieve and then maintain abstinence outside formal treatment settings might represent the majority of re-
~
'Correspondence may be addressed to Jeffrey D. Zimmerman, who is now at Berks Youth Counseling Center, 525 Franklin Street, Readin PA 19602. A description of the interview format and a summary of subjects' self-reports willke provided upon request.
692
J. D.ZIMMERMAN & B. R. ZELLER
covered alcoholics (Tuchfeld, 1981). From the standpoint of the natural history of alcoholism, then, the course of this disorder is far from being inexorably progressive, but instead is susceptible to a wide range of environmental and developmental influences (Mulford, 1984; Zucker & Gomberg, 1986). To account for variations in the natural progression of alcoholism, Marlatt, Baer, Donovan, and Kivlahan (1988) argue that the mediating influence of environmental events leads directly to the decision to initiate and maintain abstinence from alcohol. Negative or punishing consequences of drinking and unsettling changes in employment, residence, or social relationships are given as examples of external contingencies that result in changes in drinking patterns outside the treatment setting. Emphasizing environmental contingencies associated with spontaneous recovery, however, does not clearly show the inner nature of the change event: in other words, the phenomenology of change. With this in mind, Ludwig (1985) attempted to identify and then analyze cognitive processes that covary with negative environmental events. His findings demonstrated that regardless of the situational context in which subjects spontaneously decided to discontinue alcohol use, the common cognitive denominator was an aversive "mental association" to alcohol that heightened subjects' awareness of the extent of suffering they endured as a result of alcoholism. Also, despite a history of having experienced strong, persistent urges to drink, 11 of the 29 subjects in his study reported a complete lack of desire to use alcohol, ostensibly as a result of negative mental associations to alcohol. Ludwig's (1985) data emphasized one particular point which is instructive for studying the spontaneous recovery process. Specifically, negative environmental events per se had little inherent meaning; more important were the personal meanings about those events that individuals construed. For example, subjects in his sample reported repeated struggles throughout their drinking histories, including legal, financial, social, and health problems, any one of which could have been sufficient to promote abstinence. However, shifts in the personal meaning of these events explained better the decision to quit drinking than did the presence of any singular source of environmental stress. The present study was designed to explore further the experience of spontaneous change outside treatment by extending previous qualitative methodology in the following three ways. First, sensory-perceptual domains were more fully assessed. Including these variables in the analysis was expected to facilitate a better understanding of the relationship between negative cognitive associations to alcohol and changes in drinking behavior. Microprocess variables that included kinesthetic, visual, auditory, gustatory, and tactile sensations were considered specific to the sensory-perceptual modality (Gendlin, 1986; Lazarus, 1981).
SPONTANEOUS RECOVERY FROM ALCOHOLISM
693
Second, interview questions were formulated that more directly elicited subjects' assessment of how their life meanings had changed subsequent to their experience of spontaneous recovery. Subjects were asked to reflect on how they felt different about themselves, for example, whether changes occurred in what they wanted their lives to represent, whether changes occurred in attitudes about certain people, activities, and events, whether changes occurred in personal or interpersonal values. Thud, we included a second group of people who were unable to quit drinking on their own and who had requested counseling to achieve this goal. These subjects were also asked to reflect upon sensory-perceptual and phenomenological experiences that accompanied their most recent yet unsuccessful effort to quit drinking. Their responses were then contrasted with ones made by the first group of subjects. Subjects were recruited From admissions to an outpatient agency that speciahzes in treatment for chemical dependency. Only those clients who voluntarily requested treatment services were considered for inclusion in the present study; they were not required to seek treatment by the legal system or by their employers as part of Employee Assistance Program (EAP) policies. Participation in rhe present study also was voluntary. Subjects were assigned to one of two groups. (1) The first group was comprised of people who had significantly altered their drinking behavior ourside of treatment and (2) the second group was comprised of people who believed that they could make similar changes in drinking behavior only within treatment. In contrast to the latter group of subjects who specifically requested alcoholism treatment, the former group sought to explore interpersonal concerns often associated with alcoholism, including such themes as co-dependency, marital conflict, and children of alcoholics. Clients asked to partlclpace as subjects were required to have had (or to currently have, as for the within-treatment group) a history of drinlung consistent with DSM-111-R (1987) criteria for Alcohol Dependence Their self-reports of alcohol use were assessed by two independent raters. Agreement between raters on the assessment OF Alcohol Dependence was required before the offer to participate in the study was extended. An additional criterion for participation in the outside-of-treatment group was their report of a spontaneous experience of change that was unintended, i.e., no conscious decision having been made to commit to abstinence. Further, clients selected for this group could not recall having been under any immediate external pressure to quit drinking, such as the threat of losing a job or a spouse. Consequently, these subjects, at the time of the spontaneous recovery, reported feeling surprised at the suddenness at which they made a decision to commit to abstinence. Seven people were selected who met the above criteria for participation in the oursideof-treatment group: three men and four women. At the time of their interviews, these subjects had been abstinent from seven months to two years, and all expressed a desire to continue to live alcohol free. Interestingly, none of the seven subjects were deeply concerned about the potential for relapse, an attitude they attributed to the intensity of their spontaneous experience o l change. Nine people were included in the withn-treatment group, three men and six women. These subjects continued to use alcohol, even though they wanted to establish abstinence as a way of life. Interviews were conducted using a multimodal assessment procedure consistent with Lazarus' (1981) BASIC ID. Two to four 60-min. interviews were conducted with each subiect, de-
694
J. D. ZIMMERMAN
&
B. R. ZELLER
pending on the complexity of the self-report. All interviews were conducted by the investigators.
RESULTS Experiences reported by the outside-of-treatment group were consistent with previous qualitative research (e.g., Ludwig, 1985). All had struggled with alcohol dependence for an extended period of time, having made occasional and unsuccessful efforts to quit permanently. Also, at the time each made the spontaneous decision to quit, negative cognitive associations to alcohol were present, and these associations were extremely aversive and unsettling. I n addition, interview data from the present study highlight several aspects of the spontaneous change experience not fully evident in previous reports. 1. Each subject experienced sensations and perceptions suggesting a mild to moderate dissociative experience. Their perceptions of the world, themselves, and alcohol changed in a way that momentarily produced a state of nonordinary reahty (cf. McPeake, Kennedy, & Gordon, 1991), a finding alluded to by Ludwig (1985), who described subjects in his study as having been "jolted emotionallyH before they could initiate change in drinking behavior. Subjectively, nonordinary reality was described as a perception of looking at oneself from the outside, having a sense of being suddenly in a different state of mind, or experiencing a slightly altered sense of time. This sudden and momentary sense of nonordinary reality, and the strong emotions it evoked, seemed to place subjects in a receptive state of mind that heightened the effects of subsequent images and cogktions. Also generally reported by these subjects were kinesthetic sensations that made alcohol feel distant or "far away." Whereas previously the thought of alcohol was kinesthetically sensed as being a large and dynamic presence that pervaded self-awareness, spontaneous change produced an internal kinesthetic sensation that alcohol had "moved further away," thereby becoming smaller and more ineffectual. 2. While in a slightly altered state of consciousness, spontaneous images were pervasive and intense. These involved seeing in the "mind's eye" images of themselves that were repulsive or frightening. O n e person saw himself lying in a coffin with the lid closing over him. Another person saw herself as if through other people's eyes, and this image showed her how foolish she might look to others and how seemingly unmanageable her life had become. 3 . Subsequent to having a sense of nonordinary reality and after experiencing a constellation of noxious sensations, images, and affects, certain cognitions emerged that were categorized into two related sets of beliefs. First, attitudes about the importance of alcohol began to change dramatical-
SPONTANEOUS RECOVERY FROM ALCOHOLISM
695
ly. Whereas prior to this experience alcohol was thought an essential component of their lives, the belief w h c h emerged was that alcohol was a nonessential ingredient for managing daily life, thereby rendering alcohol use a less attractive and compelling activity. Rather than inspire enthusiasm about its effects, alcohol became conceptualized as a relatively inert substance, void of positive personal meaning and incapable of providing benefits for satisfactory living. The second change in cognition concerned personal identity. This experience seemed to produce an awareness of how "incomplete" subjects found their lives to be. A deeper recognition of failed relationships and of missed opportunities seemed to inform them that, as one stated, an alcoholic lifestyle was "not me," and that they had failed to represent their lives in the ways they had ideahzed or in terms of values previously believed to be important. I n summary, subjects in the outside-of-treatment group recalled a spontaneous experience of change not mediated by any singular environmental event or by any conscious and deliberate decision. Instead, a mild to moderate nonordinary state of consciousness was reported to covary with subsequent sensory impressions, with negative mental images, with a distorted sense of time, and with changes in beliefs about alcohol's intoxicating effects. Perhaps most strilung were sudden changes in personal identity, such that the end-state of the spontaneous change event was a belief that future drinking would be inconsistent with how they suddenly perceived themselves to be. F i n d y , the profound effect of spontaneous change was evident in subjects' reports of having no overly distressing withdrawal symptoms, despite describing a history of heavy drinking, and little or no sense of loss that a previously valued "central activity" (Fingarette, 1988) in their lives was n o longer present. I n contrast, subjects in the within-treatment group, who were beginning formal treatment, felt overwhelmed when trying to shake the belief that they could construct a life pattern for themselves exclusive of heavy alcohol use. Apprehension about possible withdrawal was not given as a primary concern about the prospect of changing drinking behavior. Rather, feeling highly uncertain about how their personal and social identities would change and worry about how they would manage stress without alcohol were the primary reasons given by these subjects when explaining what it was that frustrated unaided efforts to quit drinking. Not surprisingly, then, subjects in the group expressed greater ambivalence and confusion regarding their life goals and personal values than did subjects in the other group. Associated with the above-mentioned concerns among subjects within treatment were ambivalent associations to alcohol and a kinesthetic sensation of alcohol as being large, present, or powerful, as opposed to a lunesthetic - -
696
J. D. ZIMMERMAN
&
B. R. ZELLER
sensation of alcohol as being distant, as was reported by outside-of-treatment subjects. The consensus among those within treatment was that, given this kinesthetic sense, they could not "get out of a drinlung state of mind," making difficult a more objective evaluation of the negative consequences of frequent intoxication. These qualitative data are based on two s m d samples matched on demographic and clinical variables. Because of methodological factors (e.g., qualitative design, descriptive data dependent upon memory recall, interviewers who were not blind to the purpose of the study, and small sample), further studies less exploratory in nature and designed with greater experimental control are recommended. Nonetheless, within the context of alcoholism treatment, present results are heuristic for two reasons. First, spontaneous change was described by subjects as a psychologically comprehensive experience that involved multiple modalities, including two modalities rarely addressed in traditional alcoholism treatments: the sensation (including sensations of consciousness) and imagery modalities. Specifically, nonordinary states of consciousness and vivid sensory and imaginal experiences spontaneously appeared, and sudden changes within these two modalities seemed to create an inner psychological context that promoted subsequent shifts in personal and interpersonal behavior, affect, and cognition. I n view of the central role attributed to sensory and imaginal processes by outside-of-treatment subjects and given the finding that subjects in the within-treatment group did not recall anything similar, this variable in the change process could potentially represent an important aspect of recovery which, at best, is marginally included in current alcoholism treatments. Although changes in the sensory and imaginal modalities in the outside-oftreatment group were spontaneous, a better understanding of the mechanisms involved could assist in the development of treatments that help people focus intentionally on these modalities for making therapeutic changes in their drinking behavior. Initial steps in this direction have been made by McPeake, et al. (1991) in their formulation of "Altered States of Consciousness Therapy," as well as by Andreas and Andreas (1990) in their adaptation of neurolinguistic programming in "planning" for spontaneous change. The second significant finding was that a strong shift in personal meaning occurred for outside-of-treatment-group subjects, both with respect to personal identity and to their relationship with alcohol. T h s finding paralleled Biernacki's (1986) sociological analysis of the ways opiate addicts were successful in recovering from addiction, unaided by professional help or by involvement in a specific program of therapy. I n general, Biernacki (1986) found that opiate addicts who recover without treatment were able "successfully [to] transform their identities and come to be treated as 'ordinary
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people' " (p. 179). Furthermore, similar to our findings with alcoholics, Biernacki (1986) found that it was not necessary for addicts to be confronted to discontinue with a sudden onset of environmental stress to feel opiate use, although that sometimes happened. More significant for the group of opiate addicts sampled was the emergence of a new identity or the renewal of a former identity relatively unaffected by addictive behavior that was incompatible with future opiate use. I n that study as in ours, shifts in personal identity were reported as crucial for maintaining negative cognitive associations to the addictive substance and for maintaining behavioral avoidance of situational cues capable of precipitating relapse. Investigating the contextual influence of personal identity for alcoholics attempting to quit drinking is another aspect of the recovery process deserving more attention. Contemporary treatments typicaUy involve medical detoxification, 12-step programs, psychoeducational instruction about alcoholism, group counseling that encourages emotional catharsis (for example, children of alcoholic themes), and cognitive-behavioral strategies for relapse prevention. Designing treatments that incorporate methods for modifying processes specific to personal identity-identities that eventually evolve to be inconsistent with alcoholic drinking-might complement existing treatments that focus primarily on processes involving actual drinking behavior. Examples of extant theory from which such therapeutic programs could be designed include models of deep structure change (Arnkoff, 1980; Burrell, 1987), developmental constructivism (Mahoney, 1991), and hermeneutics (Bouchard & Guerette, 1991; Frank, 1987). Treatments which were engineered accordingly could result in changes within treatment that mimic the robust change exhibited by people who spontaneously alter addictive behavior outside of treatment. The prevalence of spontaneous change outside of treatment points to a serious gap in current research on the treatment of alcoholism. As data gradually accumulate about the pathways of unaided recovery and about the psychological mechanisms involved, it will become increasingly imperative to develop treatments that methodically incorporate so-called "spontaneous" processes into present treatment formats. I n discussing the etiology of alcoholism, Zucker and Gomberg (1986) stated that, "To truly understand etiology is to understand also how alcoholism does not develop and what produces insulations against it, as well as what contributes to it" (p. 791). A suitable paraphrase which reflects the purpose of spontaneous change research in alcoholism is that to understand successful treatment outcome is to understand also how people recover witbout participation in formal treatment and how those resources can be made available to those who require the support of formal intervention.
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& B. R.
ZELLER
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Accepfed July 27, 1992
