Spontaneous remission from alcoholism--A community study

Revealing the complexity of quitting smoking: a qualitative grounded theory study of the natural history of quitting in Australian ex-smokers

Objective

To explore the quitting histories of Australian ex-smokers in order to develop an understanding of the varied contribution of smoking cessation assistance (either pharmacotherapy or professionally mediated behavioural support) to the process of quitting.

Design

Qualitative grounded theory study; in-depth interviews.

Participants

37 Australian adult ex-smokers (24–68 years; 15 men, 22 women) who quit in the past 6–24 months.

Results

Although participants’ individual quitting histories and their overall experiences of quitting were unique, when the 37 quitting histories were compared it was clear two experiences were common to almost all participants: almost no one quit at their first quit attempt and almost everyone started out quitting unassisted. Furthermore, distinct patterns existed in the timing and use of assistance, in particular the age at which assistance was first used, how some participants were resolutely uninterested in assistance, and how assistance might have contributed to the process of successful quitting even if not used on the final quit attempt. Importantly, three patterns in use of assistance were identified: (1) only ever tried to quit unassisted (n=13); (2) started unassisted, tried assistance but reverted back to unassisted (n=13); (3) started unassisted, tried assistance and quit with assistance (n=11). For most participants, insight into what quitting would require was only gained through prior quitting experiences with and without assistance. For a number of participants, interest in assistance was at its lowest when the participant was most ready to quit.

Conclusion

Quitting should be viewed as a process drawing on elements of assisted and unassisted quitting rather than a stand-alone event that can be labelled as strictly assisted or unassisted.

A qualitative study of self-managed change in substance dependence among women

Alcohol and drug abuse and dependence are common disorders in our society, and the vast majority of those who recover do so without formal treatment. Although this phenomenon appears to be more common among women than men, no study reported in the literature has provided information on the process of natural recovery among women. This qualitative study found that the model of natural recovery described by Biernacki appears to adequately characterize the broad categories of the process among women. There are, however, gender-specific aspects to a number of the processes and strategies described, and in the degree of salience of some of the factors in enhancing motivation to change addictive behaviors. The term “self-managed change” has been adopted to more adequately characterize this process.

An early evaluation of implementation of brief intervention for unhealthy alcohol use in the US Veterans Health Administration

AIMS

The US Veterans Health Administration [Veterans Affairs (VA)] used performance measures and electronic clinical reminders to implement brief intervention for unhealthy alcohol use. We evaluated whether documented brief intervention was associated with subsequent changes in drinking during early implementation.

DESIGN

Observational, retrospective cohort study using secondary clinical and administrative data.

SETTING

Thirty VA facilities.

PARTICIPANTS

Outpatients who screened positive for unhealthy alcohol use [Alcohol Use Disorders Identification Test Consumption (AUDIT-C ≥ 5)] in the 6 months after the brief intervention performance measure (n = 22 214) and had follow-up screening 9-15 months later (n = 6210; 28%).

MEASUREMENTS

Multi-level logistic regression estimated the adjusted prevalence of resolution of unhealthy alcohol use (follow-up AUDIT-C <5 with ≥2 point reduction) for patients with and without documented brief intervention (documented advice to reduce or abstain from drinking).

FINDINGS

Among 6210 patients with follow-up alcohol screening, 1751 (28%) had brief intervention and 2922 (47%) resolved unhealthy alcohol use at follow-up. Patients with documented brief intervention were older and more likely to have other substance use disorders, mental health conditions, poor health and more severe unhealthy alcohol use than those without (P-values < 0.05). Adjusted prevalences of resolution were 47% [95% confidence interval (CI) = 42-52%] and 48% (95% CI = 42-54%) for patients with and without documented brief intervention, respectively (P = 0.50).

CONCLUSIONS

During early implementation of brief intervention in the US Veterans Health Administration, documented brief intervention was not associated with subsequent changes in drinking among outpatients with unhealthy alcohol use and repeat alcohol screening.

Gambling: the psychology of a non-drug compulsion

In 1968 an editorial in the British Medical Journal rejected the view that compulsive or pathological gambling should be included under the rubric of illness. Exactly 20 years later an invited paper to the same journal noted that the problem was an addictive behaviour or dependency disorder and listed the American Psychiatric Association's diagnostic criteria. The following review critically evaluates some of the key conceptual and research developments during the intervening period.

Interrelations between patients' personal life events, psychosocial distress, and substance use

This study investigated interrelations between life events, psychosocial distress, self-efficacy, and substance use among patients manifesting substance use disorders. Gender differences in these interrelations were also explored. Patients (N = 352) were recruited during 2008 and 2009 from 16 Norwegian facilities. These patients completed a questionnaire with validated measurement instruments. Interrelations were investigated by SEM analysis. The results suggested that negative life events facilitated substance use and psychological distress. Positive life events were associated with self-efficacy, but weakly related to substance use. The results supported the notion that males are more prone to use substances when faced upon negative life events.

Remission from pathological gambling among Hispanics and Native Americans

This community survey studied remission from pathological gambling (PG) among American Indian (AI) and Hispanic American (HA) veterans. Remission was defined as having a lifetime diagnosis of PG, but no gambling symptoms in the last year. Sample consisted of 1624 AI and Hispanic veterans. Instruments included demographic data, the computer-based algorithmic Quick Diagnostic Interview Schedule Symptom, and three symptom checklists, one each for substance related problems (MAST/AD), anxiety and depressive symptoms (BSI-57), and combat-related post-trauma symptoms (PCL/M). Remission was associated with absence of a current Axis 1 diagnosis, especially absence of a current post-traumatic stress disorder.

The clients' perspective on change during treatment for an alcohol problem: qualitative analysis of follow-up interviews in the UK Alcohol Treatment Trial

AIM

To develop a model of change during and following professional treatment for drinking problems, grounded in clients' accounts.

PARTICIPANTS

Subsets of consecutively selected clients of the UK Alcohol Treatment Trial (UKATT), followed-up at 3 months (n = 211) and 12 months (n = 198) after randomization. Location Five statutory and non-statutory alcohol problems treatment agencies in three areas of England and Wales. Data Open-ended interviews conducted according to a brief interview guide, leading to 400-800-word post-interview reports used for analysis (tape-recordings used for auditing purposes).

ANALYSIS

Reports analysed by a team according to grounded theory principles, involving an iterative process with successive refinement of interviewing and analysis with each successive batch of data.

FINDINGS

A model of change from the clients' perspective was developed. Treatment was seen by clients as facilitating various changes in ways of thinking and/or increased support of various kinds from family and friends, along with new ways of acting in relation to drinking or more generally. For many those changes had led to an appreciation of the benefits accruing to them. Treatment was seen as part of a broader treatment system which included pretreatment assessment, forms of help additional to the trial treatment, plus an element of self-directed change during and following treatment. Taken with awareness of worsening alcohol-related harms, triggering events and external influence to seek treatment (the catalyst system), to which clients continued to refer following treatment, the change process is depicted as a complex, ongoing set of systems in which a trial treatment is embedded.

CONCLUSIONS

Models of change should be broadened so that treatment is seen as a complex system of parts, facilitating a nexus of cognitive, social and behavioural changes, embedded within a broader system of events and processes catalysing change. Such a model helps explain the relative absence of between-treatments outcome differences in UKATT and in the alcohol problems treatment and more general psychotherapy research literatures.

Social context and "natural recovery": the role of social capital in the resolution of drug-associated problems

This paper explores the social context of "natural recovery" from problems associated with the misuse of intoxicants. Using data collected from in-depth interviews with 46 former alcohol- and drug-dependent persons, this paper examines how the social capital that these respondents had accumulated prior to their addiction and maintained during it aided in their recovery without treatment. We specifically explore how the relations within their lives and the actual and virtual resources available to subjects through their social capital aided in our respondents' "natural recovery" from drug-use related problems. We conclude with a discussion of the implications an analysis of social capital has for the treatment of drug-associated problems as well as for drug policy.

Spontaneous remission from alcohol, tobacco, and other drug abuse: seeking quantitative answers to qualitative questions

A quantitative review of the substance abuse literature revealed a mean general prevalence of spontaneous remission from alcohol, tobacco, and other drugs abuse of 26.2% when a broad definition of remission was employed and 18.2% when a narrow definition was implemented. From the results of this review, it was concluded that few meaningful differences exist between spontaneous remitters and persons who either continue misusing substances or remit through treatment on pre-remission measures of prior drug involvement. Of the factors cited by self-remitters as important in facilitating their desistance from substances, the present review found that health concerns, pressure from friends and family, and extraordinary events were instrumental in initiating spontaneous remission, while social support, non-drug-using friendships, willpower, and identity transformation were pivotal in maintaining change. Evidence is presented to indicate that spontaneous remission from alcohol and illicit drugs and spontaneous remission from tobacco smoking may differ in several key respects.

Does enhanced social support improve outcomes for problem drinkers in guided self-change treatment?

Although social support has been repeatedly identified as a strong correlate of recovery from alcohol problems, enhancing social support has seldom been a focus of treatment research. Married problem drinkers who were willing to have their spouses involved in their treatment were randomly assigned among two brief outpatient treatment conditions: directed social support (DS, n = 28) and natural social support (NS, n = 28). In both conditions the treatment in which the problem drinkers participated was an identical program of guided self-change, a cognitive-behavioral motivational intervention involving an assessment and four individual treatment sessions. Problem drinkers' spouses each attended two individual counseling sessions where they were informed about the counseling procedures. The conditions differed in that spouses in the DS group were encouraged to play an active role in helping their partner by being supportive and particularly by reacting to relapse episodes in a manner consistent with a relapse prevention model. One year follow-up found that participants in both groups improved significantly from pretreatment to the end of treatment, and that the gains were maintained over follow-up. The two groups did not differ significantly from one another at any point in time. Possible explanations for the results include that (a) the baseline level of social support in this population may have created a ceiling effect, and (b) the prognosis for this population may be so positive that it is difficult to demonstrate significant enhancement of outcomes.

Treated and untreated recovery from alcohol misuse: environmental influences and perceived reasons for change

This Swedish study compared assisted and unassisted subjects with different long-term drinking outcomes with regard to drinking patterns, significant life events, and attributions as to what initiated and maintained recovery. It was found that both recovery, independent of help-seeking status, and help-seeking, independent of long-term outcome, were preceded by prolonged harmful drinking consequences and increasing negative stress. Initial attempts to solve the drinking problem were followed by a significant reduction in life stress, but stable recovery was uniquely associated with stability and/or major improvements in the life context. Unassisted recovery was more often gradual in character and/ or motivated by positive incentives than assisted recovery. Possible clinical and social-political implications are discussed.

Outcome of treatment for alcohol abuse and involvement in Alcoholics Anonymous among previously untreated problem drinkers

A sample of 515 initially untreated problem drinkers was followed for one year after contacting alcohol information and referral or detoxification services. At a one-year follow-up, participants had self-selected into one of four groups: no treatment (24%), Alcoholics Anonymous (AA) only (18%), outpatient treatment (25%), and residential or inpatient treatment (32%); some outpatients also attended AA, and some inpatients also attended AA and/or outpatient programs. These four groups were compared on changes in drinking-related variables, other aspects of functioning, and stressors and resources over the follow-up year. Also examined were associations between amount of treatment and outcomes at one year. All four groups improved on drinking and functioning outcomes but changed less on stressors and resources. Although individuals who received no help improved, persons in the two treatment and the AA-only groups improved more, particularly on drinking-related outcomes. Inpatients were more likely than outpatients or AA-only participants to be abstinent; otherwise, type of intervention had few differential effects. More AA attendance was associated with abstinence among AA-only, outpatient, and inpatient group members. Among outpatients and inpatients, more formal treatment was associated with abstinence and improvement on other drinking-related outcomes.

The challenge of sobriety: natural recovery without treatment and self-help groups

Natural recovery is a phenomenon that is not understood and largely challenged by self-help group members and professionals working in the field of substance abuse. So strong is the supposition of the process of recovering as a life-long condition that requires treatment and/or a self-help group for on-going support and rehabilitation that recovery on one's own is given little credence. Yet there is growing empirical evidence that natural recovery not only exists, but may be more prominent than is currently recognized. This article presents a study of natural recoverers from alcoholism and problem drinking, reporting their subjective motivating factors and strategies of recovery, while examining an issue of which there is still limited data--the perceived changes since abstaining, i.e., how their lives have been altered by pursuing abstinence on their own. It concentrates on rich narrative data to explore the meaning of the change experience that can be applied to various addictions, for the purpose of illuminating novel approaches that have the potential for expanding practice techniques and forums, thereby enhancing its effectiveness.

Self detoxication by amphetamine dependent patients: a pilot study

Fifty current or past amphetamine dependent clients attending a Community Drug and Alcohol Team service took part in structured interviews about their previous attempts to stop using amphetamine. Thirty three had made a total of 47 attempts at self detoxication; 15 had undergone enforced withdrawal and ten had previously sought medical treatment. A total of 86% of subjects described significant withdrawal symptoms on stopping use of amphetamines. Increased use of other drugs was commonly reported as a means of coping with withdrawal, psycho-social techniques being used less systematically. The implications for the provision of attractive, effective treatments are discussed.

Resolution of drinking problems without formal treatment

TOPIC

Self-resolution of alcohol abuse among individuals with mild to moderate drinking problems.

PURPOSE

To examine self-resolution of drinking problems and clinical/research implications.

SOURCE

Review of the literature.

CONCLUSION

Two pathways toward self-resolution of alcohol problems have been proposed. One appears to be relatively spontaneous, the other involves ongoing cognitive appraisals and a conscious effort to change. Nurses have the potential to play an important role in encouraging self-change by conducting screenings, implementing brief interventions, and promoting the use of self-help materials. Opportunities also exist for nurses to spearhead research efforts in this long-neglected area.

Paths to recovery from substance misuse: change of lifestyle and the role of treatment

Controlled outcome studies have, on the whole, failed to demonstrate more than rather weak and short-lived effects of substance misuser treatment. There is, at the same time, growing evidence that people often recover from substance misuse problems without the help of formal treatment. This state of affairs has, not least in times of economic recession, been taken as an argument for cutting fundings of treatment facilities and other forms of formal help. This article questions that present knowledge necessarily justifies such conclusions. We do know that even severe misusers are sometimes capable of changing their way of life. We do not, however, know very much about the circumstances and situations-planned or not and designated as "treatment" or something else-that contribute to such change processes. A closer integration of two research areas-outcome research and research on "spontaneous recovery"-is proposed as a way of learning more about the possible interplay between "real life" events, various formal interventions, and change of life style.

Pathways to self-help among women for sobriety

Women for Sobriety represents a self-help option oriented toward positive thinking and behavior modification. Formed in 1975, there are now approximately 125 active WFS groups holding weekly meetings in the United States and Canada. Using data collected from a 1991 membership survey (n = 600, response rate = 73%), this paper chronicles WFS members' pathways to recovery. We describe turning points in seeking help, things women tried at first to contain their drinking, exposure to other treatment approaches, and referrals to WFS from formal treatment programs. Only 15% of the respondents sought treatment because they had been confronted about their drinking, while physical symptoms or emotional problems represented the turning point for over half the women. Another fifth said their life had gotten out of control, and these were the ones to achieve sobriety most quickly. Almost all WFS members had sought professional help for their drinking, and three-fourths have undergone individual therapy-suggesting that WFS members are fairly open to a psychological approach such as WFS offers. WFS philosophy is based on the belief that behavior is predicated on thoughts, so the program teaches members that maintaining sobriety must involve the realization that negative emotions are destructive-and that members can control how much they allow problems to bother them. Goals of membership include abstinence, improved self-esteem, and spiritual and emotional growth. About a third of the respondents currently attend AA, and no differences in length of sobriety associated with current AA attendance were found within the WFS membership. However, women who sought professional help in response to the turning point experience but who also attended AA that year were most likely to have achieved sobriety within a year of the turning point.

Older adult controlled drinkers and abstainers

Little is known about the lifetime course of alcohol problems, especially during late adulthood. Many individuals with a history of alcohol problems achieve remission of their symptoms through abstinence or controlled drinking. This study examined 135 older adults with a prior history of alcohol diagnoses who were symptom free for at least the past year. Two groups were identified based on their alcohol consumption within the past year: abstinent individuals (n = 92) and controlled drinkers (n = 43). The groups did not differ in age, racial composition, education, income, or years since their last alcohol-related symptom, but they did differ in gender composition, indices of alcoholism severity, history of formal and informal treatment, as well as lifetime alcohol consumption patterns. Abstinent individuals had more severe alcohol problems, consumed higher amounts of alcohol on drinking days, had more years of heavy alcohol consumption, and were more likely to have attended alcohol treatment and Alcoholics Anonymous (AA). The controlled drinkers had a longer history of moderate social drinking, and their current consumption habits appeared to be similar to symptom-free older adult drinkers. The results suggest that gender, alcoholism severity, history of formal and informal treatment, and past consumption patterns are associated with whether older adults with histories of alcoholism attain successful outcomes through abstinence or controlled drinking.

Two pathways out of drinking problems without professional treatment

This 3-year longitudinal study examined two recovery pathways among 135 problem drinking individuals who never received professional treatment. Almost half (48.3%) of those individuals for whom outcome could be clearly determined became moderate drinkers or stably abstinent. At baseline, individuals who subsequently became abstinent (n = 28) were of low socioeconomic status, had severe drinking problems, and believed their drinking was a very serious problem. Once they began their recovery, they relied heavily on Alcoholics Anonymous as a maintenance factor. In contrast, individuals who became moderate drinkers (n = 29) had higher socioeconomic status and more social support at baseline than did individuals who became abstinent or continued to have drinking problems. A logistic regression on baseline data showed that it was possible to predict which natural recovery pathway an individual drinker would follow. The implications of these findings for alcoholism treatment and policy are discussed.

Resolution from alcohol problems with and without treatment: reasons for change

Volunteers at a local science center were asked their reasons for quitting or reducing their alcohol consumption. Of 248 respondents, 64 were classified as having had an alcohol problem from which they had successfully resolved for 1 or more years. Three quarters of all respondents resolved without treatment or self-help groups, and over half (57.8%, 37 of 64) of these respondents' resolutions involved nonabstinence (i.e., moderate drinking). The reason for resolution most often endorsed by respondents was that they had "weighed the pros and cons of drinking and not drinking." The implications of these findings for intervention programs are discussed.

Young heavy drinkers and their drinking experiences: predictors of later alcohol use

This study illustrated the impact of late adolescent and young adult alcohol experiences on current level of alcohol use. Additional factors investigated include reported age of problem onset, initial age of alcohol use, marital status, and life-span risk-taking behavior. A stepwise discriminant analysis was used to determine the importance of various subtypes of drinking experiences and combinations of these subtypes. Correct classification of current light and heavy alcohol drinkers by use of these experiences was 83.7% for late adolescent experiences and 77.5% for young adulthood experiences. The results suggest that early drinking experiences are useful predictors of future drinking patterns.

Adequacy of recall of drinking patterns and event occurrences associated with natural recovery from alcohol problems

The adequacy of recall of drinking and events surrounding natural recovery from alcohol problems was investigated with 21 abstinent and 18 active untreated problem drinkers. During structured interviews, drinking was assessed for 6 years, and events were assessed for 1 year; both assessment periods ended about 6 years before data collection, which corresponded with the beginning of sobriety for abstinent subjects. The accuracy of subject reports of both variable classes was evaluated through comparisons with collateral reports, and the reliability of drinking reports was evaluated by reinterviewing a subset of subjects about 2 months after the first assessment. Reliability was generally high for subjects' drinking reports. Subject-collateral agreements were significant for drinking and event variables that collaterals could readily observe, but not for variables that were less observable. Current drinking status and the length of recall did not influence reporting accuracy. With some qualifications, these findings support the use of structured recall procedures to investigate drinking patterns and environmental circumstances related to natural recovery and highlight limitations in the use of collaterals as a verification method.

Personality and religion among female drug misusers

Fifty female drug misusers completed the Eysenck Personality Questionnaire and the Francis scale of attitude towards Christianity on entry to a Christian residential rehabilitation programme. The data confirm the deviant personality profile of drug misusers, who score high on psychoticism and neuroticism and low on extroversion and the lie scale, and demonstrate that the general findings relating religious attitudes to the Eysenckian dimensions of personality among normal populations also hold good among this deviant group, thereby confirming the generalisability of the conclusion that it is psychoticism, rather than neuroticism or extroversion, which is fundamental to religiosity. The practical relevance of these findings is discussed for rehabilitation programmes which include spiritual or religious components.

The change process in alcoholics: client motivation and denial in the treatment of alcoholism within the context of contemporary nursing

Despite being constantly cited as a critical intervening variable in the recovery from alcohol problems, there is a paucity of literature on client motivation. This paper reviews the current literature which impacts on motivation and its importance in treatment and develops in a stepwise manner the revised expectancy/motivation hypothesis, tentatively explaining both motivation and denial as a natural process in behavioural change. Because of the revised expectancy/motivation hypothesis' distinctly defined stages which closely relate to the process of nursing and the qualitative and quantitative measurement it entails which the nursing process demands, it offers a particularly appropriate model for treatment within nurse practice.

Hearing the noise in the system. Exploration of textural analysis as a method for studying change in drinking behaviour

This paper explores how treatment research is to catch within its design those many unplanned influences which lie outside therapeutic control, but which may influence processes of change. These factors are excluded from the conventional controlled trial. The background literature is briefly reviewed. A study is then described which employed a computer assisted method of textual analysis and an entirely open-ended coding system. The material which was analysed derived from interviews with 49 subjects whose accounts were tape recorded 10 years after treatment contact. Episodes of successful or unsuccessful 'change attempt' (CA) were identified. The two types of CA were compared in relation to coded issues pertaining to the periods before, during and after the episode. A number of significant findings are reported. In the pre-attempt phase 'Success' CAs were significantly associated with traumatic events in the person's life, and with a variety of positive and negative events. During the 'attempt' phase, 'Success' was associated with choice of an abstinence goal. For 'post-attempt', 'Success' was associated with 'Substitution', 'Altruism', 'Fulfillment', and finding the process 'Difficult'. The very preliminary nature of these findings is stressed and the need for further rigorous methodological development.

Self-detoxification by opiate addicts. A preliminary investigation

A study of 50 opiate addicts attending a London service for treatment of drug dependence found that 47 subjects had previously made at least one attempt at self-detoxification. These subjects reported 212 previous attempts. Although 30 subjects reported having managed to complete at least one attempt, the success rate per episode was low (24%). One of the most commonly reported methods, used by 28 subjects, involved an abrupt cessation of opiates ('cold turkey'). Of the drugs used in their attempts at self-detoxification, benzodiazepines were reported by 24 subjects and opiates by 20. Practical strategies such as distraction and avoidance were also used. Self-help detoxification materials for opiate addicts might be useful.

The motivation for change from problem alcohol and heroin use

This paper provides an overview of the first study in Switzerland on spontaneous remission from substance abuse, conducted 1988. After a rigourous screening process, 60 practically treatment-free remitters could be identified. While 14 of the 30 alcohol cases reduced their consumption almost to abstinence, all but two heroin remitters stopped their consumption altogether. No selection bias could be detected when comparing the groups studied with clinic populations, survey data and police records. The qualitative analysis of the collected extensive life histories led to a typology of the autoremission process. The motivation to change, the implementation of the decision, the maintenance and the negotiation of a new identity or meaning in life represent the three major stages. This paper focuses on the first stage and the role of negative vs positive experiences in setting off subsequent changes in alcohol or heroin consumption. The variation in the motivational background is illustrated by a close look at the rich life history accounts as well as by quantitative data on life events and cognitive prerequisites of change. Methodological drawbacks of this first exploratory study, such as recall problems and a narrow definition of addiction excluding psychological problems, are discussed and the necessity of future prospective studies is underlined.

Assisted natural recovery from alcohol problems: effects of a self-help manual with and without supplementary telephone contact

One hundred and seven problem drinkers responding to a newspaper advertisement were randomly assigned to groups receiving: (1) a general advice and information booklet; (2) a behaviourally-based self-help manual; (3) in addition to the manual, an opportunity to make progress reports to a telephone answering service; and (4) in addition to the manual, an opportunity to make telephoned progress reports to an interviewer. Eighty-seven (81.3%) respondents were successfully followed-up and collateral information was available for 54 (61.1%) of these. Results showed a higher proportion drinking above recommended limits at six months follow-up in the control group (78%) than in the groups receiving the manual (53%). There were no significant differences due to presence or type of telephone contact and poor use was made of the opportunity for telephone contact. Findings justify the widespread promotion of self-help materials as a means of assisting the natural recovery process among problem drinkers.

Psychology and brief interventions

In this article, a discussion of the definition and description of brief interventions is followed by broad reviews of their effectiveness in the cigarette smoking and alcohol fields. It is then argued that brief interventions should not be justified only in terms of early intervention; that there is at present insufficient evidence to warrant the abandonment of conventional outpatient treatment for clinic attenders; and that the relative contribution of motivational and active behaviour-change components of brief interventions is an important area for research.

Ageing and recovery from alcoholism

Fifty-five dependent (DSM-III) male alcoholics, chosen for good social adjustment, were personally followed up about 20 years after their first admission to hospital. The conditions of all the alcoholics were evaluated with a multidimensional diagnostic schedule when first admitted. At the follow-up, 11 were abstainers, 11 reported a change to social drinking via abstinence, and 10 reported a change to social drinking by gradual stages. Improvement after the age of 45 was mainly due to gradual change to social drinking. This type of improvement was in half of the cases attributed to a decreased tolerance for alcohol. In the present sample, there were no indications of any relationship between premature ageing and gradual change to social drinking. It is hypothesised that physiological processes of normal ageing with concomitant changes in reactions to alcohol may be of importance for remission from alcoholism in middle-aged and older alcoholics. The relationships of personality, social factors and the degree of alcohol-dependence to patterns of successful long-term adjustment are discussed.