Coping and maintenance strategies of spontaneous remitters from problem use of alcohol and heroin in Switzerland.

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The International Journal of the Addictions. 27(12), 1359-1388, 1992

Coping and Maintenance Strategies of Spontaneous Remitters from Problem Use of Alcohol and Heroin in Switzerland Harald K.-H. Klingemann, Dr.rer.pol. Swiss Institute for the Prevention of Alcohol and Drug Problems (SPA), P.O. Box 870, CH-1001Lausanne, Switzerland

ABSTRACT A short review of the literature is followed by data from a Swiss study on spontaneous remission from problem use of alcohol and heroin conducted in 1988. The analysis of the collected life histories led to the identification of a motivation phase, a stage of decision implementation, and a struggle for maintenance as the major sequence of the autoremission process. The discussion focuses on the “tools” which remitters use to put their decision into practice. The coping mechanisms identified are “diversion,” “self-monitoring,’’ and “distancing.” In relation to the maintenance phase, the perception of possible relapse situations and intuitive predictions of the subjects and collaterals are analyzed.

Key words. Natural recovery; Heroin; Alcohol; Switzerland; Coping

1.

INTRODUCTION, AND DEFINITION OF THE PROBLEM

The idea that alcoholics or heroin users can stop their habit without treatment (so-called autoremission) contrasts sharply with the view that alcoholism I359 Copyright

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or drug addiction is a disease and the notion of the irreversibility of deviant careers. One of the hottest controversies in alcohol research is whether the problem drinker can become a controlled drinker. The idea contradicts the widely held belief that early detection of addiction behavior as well as more therapy for everything and everybody would be a desirable policy (Peele, 1989). Owing to both political resistance and methodological problems, reseach into licit as well as illicit drugs in this area has been modest (see the overviews by Smart, 1975/76; Fillmore et al., 1988). We are dealing here with the questions of whether so-called “natural recovery” is at all possible, how frequently it occurs, and what processes it involves (e.g. Kendell 1965; Kissin et al., 1968; Emrick, 1975; Zinberg and Jacobson, 1976; Knupfer, 1972; Maddux and Desmond, 1980; Tuchfeld, 1981; Stall, 1983; Vaillant, 1983; Biernacki, 1986; Brecht and Anglin, 1990). The Canadian longitudinal study being conducted at the Addiction Research Foundation of Ontario (ARF) (19841 1989) on 119 alcohol remitters is the most up-to-date in North America (Sobell et al., in press); particularly worth noting is that it includes a control group of nontreated problem users. In Europe the discussion has dealt exclusively with drug policy (Buelow, 1989; Weber and Schneider, 1990) or with the “maturing out” thesis (Schneider, 1988a; Lange, 1986; Gekeler, 1983). The few empirical data on hand have been provided by the studies carried out by the drug coordinator at the University of Amersterdam, C. Cohen, on cocaine use in nondeviant subcultures (Cohen, 1989) and a German study on heroin addicts (Happel, 1986, 1990; Schneider 1988b, 1988c; Integrative Drogenhilfe an der Fachhochschule FFM e.V. 1988). The relevance of such studies for drug policy has been recognized in Switzerland only recently (Fehr, 1989; Spreyermann, 1990). Previously autoremission had been only touched upon in research (Hornung et al., 1983). The results presented here have been drawn from the first autoremission study carried out in Switzerland. The first part of the project was conducted in the German-speaking part of the country in 1988 and 1989 by the Swiss Institute for the Prevention of Alcohol Problems. For the first time, autoremission was examined comparatively in an alcohol and a heroin group by the use of a life-history approach. The general research objective was to explore the dimensions and stages of autoremission from problem use of alcohol and heroin. The analysis is based on the subjects’ interpretation of the causes of their recovery which is embedded in their comprehensive life accounts and on objective lifecourse data. This paper addresses the question: What coping strategies do autoremitters use, and is the assumption that social support is crucial in all stages of autoremission justified? Also, it discusses some preliminary indicators of the stability of problem resolution, comparing alcohol and heroin remitters.

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However, the reader should keep in mind that this is, first and foremost, a descriptive study. It will be complemented in a second stage by a longitudinal analysis, including an untreated control group (‘problem unresolved’). Only such a design will permit us to identify the causal factors underlying recovery without professional treatment and formulate clear recommendations for a more rational drug policy.

2. WORKING DEFINITION For the purposes of this study, autoremission was defined as “a significant improvement in consumption behavior (alcohol or heroin as the primary addiction problem) which has been achieved without any or with minimal treatment or self-help groups and has lasted at least one year before the time of the interview.”

3.

METHODS

Recruitment of Subjects In 1988 and the spring of 1989, by means of newspaper and radio announcements, autoremitters were invited to take part in the study and to call a given telephone number. When recruiting volunteers for this study, we were appealing to altruistic motives: “You’ve got to tell a success story which might help other addicts who haven’t made it yet.” In fact, most respondents who participated in the life history interviews donated their small bonus of $30 US. to a good purpose. In response, 366 calls were registered on the specially installed automatic answering service. After evaluating the first spontaneous information recorded, 103 persons were eliminated from the telephone screening interview from the start, because they could not be reached when called back or the information recorded did not fit our objectives: 40 respondents reported on autoremission from other addictions, especially smoking ( n = 33). In the end a telephone screening interview (TSI) was conducted with 202 people ( n = 120 with alcohol problems and n = 82 heroin cases). The individual statements of about half of the respondents ( n = 97) were supplemented by collateral telephone interviews (TCI). As the result of rigorous screening, 60 remitters who were practically treatment-free were identified; 18 of the 30 alcohol cases had become abstinent, and all but two heroin remitters had stopped their consumption. The two remaining heroin subjects still use heroin at most once a month, and the subjects who continue to drink alcohol consume at most three drinking units per day.


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Only three cases in the alcohol group and four in the heroin group had inpatient treatment (at most 4 weeks ever, but not directly preceding the autoremission); one-third of the largely treatment-free 60 remitters had never had any contact with outpatient counseling or self-help groups, and 43% ( n = 26) reported having had contacts with only one outpatient facility. The remaining cases had contacted a maximum of one (alcohol group) or three (heroin group) outpatient programs during the two years before recovery.

Instruments Spontaneous autobiographical accounts were the focal point of the detailed personal interviews. The procedure was similar to the technique of the narrative interview (see Schutze, 1977; Denzin, 1989): After asking the subject to draw his or her own life curve with its ups and downs [“board drawing” (BD) according to Alasuuntari, 19861, the following question served as a stimulus: “Could you please explain to me now the course of your life curve, with its ups and downs?” The interviewer noted down in detail the narrative, told with the help of the drawing (DN). In addition, an introductory 10-minute summary of the life story (SLS) was recorded as well as a concluding 5-minute recall of the autoremission (SAR).

Validity Besides the basic question “Is it a true story?,” other, more banal sources of error had to be considered: the subject simply forgets or invents a story. More specifically, this could be manifested in exaggerating the reduction in consumption and playing down the influence of therapy. Finally, not everyone can tell a story well. To counter these effects, we used recall-aids, including information from collaterals, compared personal accounts on the same topic over time, and offered alternative ways of describing life experiences (board drawings, grid).

4.

RESULTS

The following qualitative analysis is based on people’s own accounts of how they overcame their addiction problems. The transcripts of the recorded summaries, as well as the transcriptions of the life-courses of 60 objective remitters, are analyzed according to the principles of “grounded theory .” The first content-analysis made it clear that the general stages of autoremission described by Biernacki, “resolving to stop,” “breaking away from addiction,” “staying abstinent,” and “becoming and being ordinary” (Biernacki, 1986; similar to Stall and Biernacki, 1986), also emerged as rough stages of develop-


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ment in the present life-stories, largely regardless of the specific addition problem. An analysis of the initial stage of autoremission showed that “hitting rock bottom” experiences and personal problems are not the dominant feature of natural recovery. Rather, a much broader range of positive motivational factors must be considered: Classic “hitting rock-bottom” patterns are less common than patterns of the “crossroads types” and “pressure-sensitive types” who in no way demonstrate unbearable suffering. Even more important, however, were patterns of positive motivation to change: The familiar “maturing out” type, sudden key experiences, or new reference groups (Klingemann, 1991). The following presentation focuses upon the everyday methods and tools that remitters use to put their decision to stop (or to cut down) into practice and the subsequent efforts of maintenance and normalization.

The “Toolbox” of Remitters and NormalizationA Qualitative Typology

4.1,

Action Stage

What everyday techniques do spontaneous remitters develop to break their habit? How important are social support, access to the drug, rituals of quitting, and substance related substitutes? Of course, some remitters do not knowingly use any coping strategies. They seem to have had either no conscious motivation to change (“maturing out”) or a sudden overpowering experience that made extra tricks and aids unnecessary. One such experience is religious conversion. The instrumentality of praying and participating in Bible groups is more or less evident; the motivating life-event thus already includes specific solutions for problems that may arise in the maintenance phase. Another mechanism is diversion from the addiction: Work, contacts with reference persons, or important life events may fulfil this function: “influenced by the birth and the child, I was so busy.. . I never thought of taking drugs again (#138:SAR28). This mechanism involves no deliberate self-change. However, most remitters are conscious strategists (see also Klingemann, 1991). They are motivated to change and rely on (a) everyday behavioral concepts, (b) ideas about effects of drugs and adequate substitutes for drugs, and (c) techniques of distancing. Behavioral strategies often include a gradual lengthening of drinking intervals and increasingly smaller amounts. At the same time the remitter calculates the costs, financial and other, of resuming the habit against the experienced benefits of reduced consumption: “After taking stock of my life I came up with the firm resolution to stop drinking for another four weeks. . . and it worked,


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and after four weeks I told myself that I managed four weeks, and then two months went by, and so on up to one year. . . and a great calm came over me. I could start things easier, slept much better and gained new fun in life” (#249:SAR58). After a self-imposed slow withdrawal from heroin, #329 describes “an increased sensual feeling, as if the rain comes after an extreme dry season and everything smells and feels more intensively” (DN72,73). #166 reports a more ordinary reward-the return of his driving licence. Because of previous failed attempts, this personal self-evaluation is often secret so as to avoid pressure for success: “Don’t you say anything, otherwise this will backfire-I would rather have bitten my tongue off than telling anybody I was going to stop” (#166,SAR14). Finally “the bottle trick” should be mentioned (see Appendix) as well as the reading of self-help guides (#112: “I really felt how the book was mad with me” SAR36). Personal ideas about drug substitutes in the extreme case may simply mean switching to other harmful substances (#77 heroin case: “Alcohol helped a lot; when I felt the craving I went to the bar to get loaded” DN12,SAR4; #138 transition from heroin to pills and alcohol). Other remitters take medication during the action phase to relieve the withdrawal symptoms, or enormous quantities of water (#l: “I had to drink water all day long” SAR4), coffee (#87) or sweets (#72 heroin caselfemale: “stuffed myself with sugar and chocolate” SAR3). Others assume a model of a natural physiological equilibrium: “Well I analyzed the alcohol problem and thought I had put something into my body, and I can’t simply take something out but have to come up with a compensation. . . against the beast which I swallowed. . . taking vitamins and nutrients, following autogenic training . . .” (#146 alcohol case/male SARDc,d). The subjects refer to everyday concepts about the effects and the true nature of alcohol, which are sometimes directly borrowed from the 12- step movements (also: books, sporadic group participation, literature, radio programs; #209). The belief that one is allergic or specially vulnerable to alcohol is a good example: #356 does not want to join A.A. but “I accepted their scheme for my situation: Not a single drop anymore, otherwise I’d be done again” (SAR30). Independently of A.A. models, #166 offers a similar reasoning: “After one month of abstinence I thought by myself the first time how it would be to gulp a Pastis. And then I said, wait a minute. . .how will I react to that Pastis. . . maybe after one or two I’d be drunk already and would put up a fuzz, or what? And this thought inhibited me and I did not find the courage anymore to do it” (SARIS). These more or less individualized coping patterns are complemented by attempts to create a drug-free environment and to strengthen the personal commitment to change by symbolic acts.



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The former may be expressed in a temporary or lasting voluntary manipulation of the individual access to the drug: This can mean a voluntary retreat (to a secluded farm, a ship, an island, or the parent’s house) for a withdrawal, a self-imposed drying out period, removing alcohol stocks from the home (#236,SLS54: “decided to have no beer at home to begin with” or #209,SAR41: “we threw the whole bar out”), changing the way home to avoid bars, moving to a different part of town or emigration to escape from the old pals (#124,SLS9: “To get out of this clique and we’ll see what happens . . . four days before I started my new job in South Africa I stopped fixing. . .got to know completely new people”). Distancing oneself from the old life is in some cases done by performing a ritual of quitting: “When I was in Basel I threw the last three junks, one morphine, one heroin and one cocaine junk, all three together, and then I took the train and that was i t . . .” (SAR32); “ , . .I had a last fix at home . . . after long reflection I flushed it down the toilet.. .” (#296,DN84) or, a young woman, when asked about anything she kept from her former drug life: “I threw a lot away from the past and find it important that you also . . . get rid of the clothes and the whole stuff.. .it’s so dirty, it just carries so much filth with it (#139,SAR31,32). Maintenance Stage

Most accounts do not include elaborate descriptions of the maintenance phase. Sometimes the interviewers provide supplementary information. As discussed before, the transition from one autoremission phase to the other may be blurred. This holds true, for example, for the “maturing out” type, or generally for all those remitters whose plans to put their decision into practice happen to influence the success of the autoremission: Actions such as moving away, or ideas about the effects of drugs or alcohol, which were meant to be only temporary aids for handling the problem, may have unexpected long-term effects. Such exceptions and limitations apart, three stages of maintenance of the attempt to reach a lasting solution of the drug problem without professional help may be identified. The first stage can be characterized by an increased self-confidence in the ability of self-control which is acquired by consciously staging self-tests and gradual exposure (“hardening”) to risk situations, testing coping strategies. Fear of relapse and other deterrent effects provide additional back-up. #355 puts bottles of alcoholic beverages unopened in his cupboards to prove himself: “I am strong enough to resist, even if alcohol is in the house” (DN40) and #47 uses a long flight as a test of his regained control: “I was so happy that I almost banged my head in the plane when I managed to drink just


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a glass of wine with my meal and some champagne when we crossed the equator and did not feel any desire to drink more” (SAR9). Experiences of coping with crisis without the help of drugs strengthen self-confidence: “In spite of the terrible grief when my son died, I did not go back to the bottle” (#209,DN73). Changing his threshhold of tolerance helped #151: “In the old times, to be quite honest with you, I fixed myself a whisky when I had troubles, today I just simply say ‘kiss my ass’ and that is it” (DN53). Deterrent negative models support the decision as well. Death and illness of relatives (#217’s brother died on drugs and #72’s husband keeps on fixing and has caught AIDS) or former buddies from the drug scene, combined with the fear of AIDS, play an important role: “A former buddy of mine with whom I actually started to take drugs will die of AIDS next year or maybe the year after. . . realizing that, I find it quite tragic” (#124,SLS9). Similarly #167: “Just a week ago a friend of mine died.. . he had AIDS, he died of an overdose. . . was the last fixer of my time, now they are all dead” (DN48). These forms of consolidating the conviction of having made the right choice are complemented by a “hardening” in difficult social situations: After #303 had successfully rebuffed an old drinking-mate friend for the first time, he almost made a sport of it:“. . . you might say I almost acted perverse in a way; I went to the bar to find out how long I can play this game” (SAR59). Subjects also report on their ability to offer alcoholic drinks to others without having to drink themselves, experiencing this as a feeling of success and further evidence of their new strength (#161,SAR45). While the first period of the maintenance phase still absorbs most energy to fight off the drug, the remitter focuses in the second phase more and more on the perceived rewards from the new way of life and on protecting the gains. The pay-off is mainly a growing sense of personal well-being: “We finally made it. Also financially there is an upward trend. . . we can pay our debts and live in a nice apartment. . . the job is satisfying. . , . It makes a big difference if you get into your car without having to worry that you have too much alcohol in your blood.. . . It is also quite reassuring if you don’t have to call the carpenter all the time because you broke something again” (#224,DN69). The remitter wants to catch up with all the wasted years and enjoy life again: “With 50 I realized, this is half a century, I still want to enjoy my life, but not with alcohol” (#87,DNll) and “I want to make up for what I missed” (#124,SASR38). This new joie de vivre is also expressed in the resumption of hobbies. The social environment reacts in part by increased support. The remitters who had been motivated by social pressure will be rewarded by a more stable drug-free relationship; the convert can count on group help, sometimes even for the family (e.g., #283). The support of the sympathetic boss or the reactions of the barmaid of the former favorite pub are reported as forms of appro-



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Val: “I made the experience that you can also have a good talk with the barmaid without having a glass and she will take you serious, even if you live without alcohol” (#303,DN85). The last step to normality is the internalization of new social roles. It may also be called the successful completion of a search for meaning in one’s life, a leitmotiv that emerges from many life histories. Being confronted with “the hole which the drug filled” (#65) or the “inner emptiness” (#148), remitters become “helpers” and “postmaterialists” or begin to reconcile themselves with society. They do not need drugs anymore to reach a better world and to recover from their narcissism (Battegay, 1988, pp. 53 and 54), The first group applies implicitly the idea of “helping oneself by helping others.” Since helping is much better regarded in our society than being helped, members of this group improve their status and strengthen their ego: Working with handicapped adults (#209), or on the staff of a psychiatric ward (#66) or a treatment facility for drug addicts (#214), or in the social field in general (#282, also #217: “ideal job in a social service agency”) is typical of professional helper roles undertaken by the remitters (see Brown, 1991). Privately also, the new helpers begin to support other family members-which in the extreme may even lead to a helper syndrome-(#355 “a life for the son”), or as informal experts/counsellors: “Other colleagues’ wives came to me and asked: Could you please do something about my husband, he has become impossible, . . I am so embarrassed and you can’t imagine how much I suffer from this” (#166,SLS13). The postmaterialists feel at home in new spiritual worlds. Some are religious (e.g., #138,DN101: “my faith gives me the strength not to go back to the drug; #146,DNf “ . . .the Bible taught me that alcohol is only part of a materialistic superficiality”; similarly #62). Others are forms of “alternative spirituality” (#296 esotericism, #65 ghost healer, #209 the world of Steiner). Politics (#366 ecology, #217: “contacts which opened up new perspectives of my identity as a woman”) and the art world (#87 starts writing novels and #I becomes a painter) are also reported as new orientations of the postmaterialists. The last group consists of remitters who reconciled themselves with society’s role expectations: Normal husbands and fathers who realized that “living without the poison does not necessarily mean that you have to be a petit bourgeois” (#2 14,SAR38), but also persons who become independent in their ideal line of work (#29), look forward to becoming an apprentice and have fun with the computer (#303), or accept new challenges (giving up smoking, emigrating, getting married). The comment that “the negotiation of a new identity” need not coincide at once with change in behavior is made impressively by a male former heroin addict who finally grew up: . . . the problem was to find a new meaning in life or to redefine the role. . .to become able to push the ideal“

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istic role of the junkie.. .and the whole self-pity business on the side. . .because you can stay a junkie for years without shooting, somehow deep inside, because fixing is only what is crystallized deep down.. . .” (#148,SLS16). This concludes the discussion of the dimensional, qualitative analysis of the different stages of the autoremission process. An overview of this typology can be found in Table 1. 4.2. Coping and Social Support-A

Group Comparison

The above analysis of the rich qualitative material supplied by a group of autoremitters provides a holistic understanding of the autoremission process. The typology developed shows-for both heroin and alcohol recovery-an impressive variety of coping behavior, possibilities of identity change, and adoption of new roles. We have not yet considered quantitative indicators of the objective situation of the remitters. In particular, an understanding of the effects of the social network requires an analysis of other, more standardized data (standardized parts of DN, TSI, and TCI). Table 1. The Stages of Autoremission Motivation stage: Negative motivation: “Hitting rock bottom” (sudden or cumulative) “Deterrence” (cross-roads and pressure sensitive cases) Positive motivation: Maturing out Positive life-turning-points (key events and reference groups) Action stage: Diversion Problem-related strategies: Everday behavioral concepts Drug-related ideas about adequate substitutes and potential consequences Distancing (manipulation of personal access and rites of quitting Maintenance stage: Tricks and a renewed self-confidence Protecting the achievement A new life: Becoming a helper New Age and other postmaterialists Peace of mind and reconciliation with others


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Change and Transition After reflection and with sufficient motivation to action, the self-changer enters the implementation stage. What resources does the self-changer tap to put his decision into action? Self-changers do not, or rarely, seek professional help. Tuchfeld speculates that . . . resistance to formal treatment could be counterbalanced by receptivity to informal types of social control . . .the timely intervention of family or friends. . . could prove more beneficial in producing changes” (Tuchfeld, 1981, p. 632). Such specific forms of informal social support are said to play a significant role in autoremission (see Klingemann, 1988; Stall and Biernacki, 1986). Do changes in social support networks precede or follow autoremission? And could it be that existing possibilities of help are simply not perceived? Table 2 shows clearly that about three-quarters of the remitters, when describing their period of dependency, referred to feelings of having been left alone and not being able to count on anybody for help. They also reported hardly any experienced support when exposed to stressful situations during the last year before recovery. Interesting differences can be noted when comparing the discrepancy between perceived and experienced social support by type of addiction. The much higher level of stress of the heroin remitters seems to lead to a distorted perception of the available support (Klingemann, 1988, p. 128), which is much less the case in the group of alcohol remitters. The proportion reporting a general feeling of loneliness (73%)exceeded that of those who in fact did not receive help when under stress (63%).This tendency is even more marked in collaterals’ accounts: These witnesses of the subjects’ former drug careers indicate much more frequently having played an important role in the recovery process. Three-quarters of the collaterals (heroin group) also believe that help was at least offered by other people at some point. Although this cannot be verified, the rare answers about resource persons in the past show that family and partner have at least some chances to overcome this perceptional bias. In these cases the former addict at last has something to offer and can reciprocate in helping relationships (Gouldner, 1960). Despite their goodwill, the helplessness of people when confronted with the addict’s problems and the lack of help models may also contribute to the rejection or unawareness of help being offered (Jung, 1986). In the light of these results it is not surprising that the subjects tend to adopt individualistic strategies for coping when confronted with craving, which even at this stage is still common (70% heroin cases, 48% alcohol cases). Only five cases (characteristically, heroin remitters) mention social relationships as significant for their solution ( 1 . “warmth”; 3. “child”; 6. “family”; 16. “colleagues”; 20. “telephone talk”); whereas “distraction,” “anticipation of nega“

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Table 2. Perceived and Experienced Social SupporVlsoIation Before and After the Autoremission by Study Groupsa


Treatment-free alcohol remitters

Treatment-free heroin remitters

Social Support Prior to Natural Recovery I. Perceived support ( PLISAb): % “felt rather alone” 71 0.3 average number of resource persons 2. Experienced support (PLISA): % “nobody helped” 70 0.4 average number of helpers 2a. Experienced support (TCI‘): % “people did not help himlher” 86 2b. Experienced support (TCI): % no special helping function of collateral 27

n (alcohol/heroin)

73 0.4

(30l30)

63 0.6

(30l30)

22

(14/ 18)

17

(W15)

Social Support afrer Autoremission 3 . Perceived today (PLISA): 3 (-70%) % “cannot count on anybody” 10 (-67%) average number of resource persons 2.4 2.7 3a. Number offriends today (PLISA): % 1-3 friends 43 50 % 4 and more friends 53 50 4. Experienced support (PLISA): % “nobody helped in stress situations last year” 59 (-11%) 45 (-18%) 0.7 0.8 average number of helpers 4a. No help for maintenance (PLISA): 73 57 %

(29l30)

(30/30) (30/30) (29129)

(30130)

aFigures based upon the following items: 1. PLISA #1.1: “Let’s talk about the time before your current recovery. During that period when you were still fully dependent-Did you feel rather left alone or did you think you could count on other people’s support? (“rather alone,” “could count o n . . .”); 2. PLISA #I .4: Did somebody actually help you in these situations?” (if “yes” interviewer probes: “Who did help you and by what means?” Note the specific kind of support); 2a. TCI #5.2: “Did other people help himlher in some way, or tried to do it?” (yeslnoldon’t know); 2b. TCI K2.8: “Did yourself play an important role during the recovery?” (yeslnoldon’t know); 3. PLISA #1.5: “And how is the situation today-on which people can you possibly count in case you really need some help?” (“can’r count on anybody”/“can count on the following persons. . .”); 3a. PLISA #1.8.3: “How many persons would you consider as close friends today? Please give me their first names and indicate since when you know them”; 4. PLISA #1.7: “Has anybody actually helped you in these situations?” (Interviewer: if yes-“What kind of people did help you?”); 4a. PLISA #3.2: “Did anybody help you to stick to your decision?” (no, yes: . . .). Data source: PLISA = personal life history interview-structured appendix. Data source: TCI = telephone collateral interview.



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tive consequences of consumption,” and various modes of “mental coping” are typically stressed (Table 3). Analysis of the reported occasions that revive craving shows unprecise answers in many cases; specific situations and triggers are very often not identified. Answers such as “periods which come and go,” “by chance,” or “no situation in particular, it just comes over me” illustrate how difficult it is to anticipate these situations. The absence of any early warning signs consequently favors short-term individualistic solutions and rules out the more complicated resort to external help at this stage. During the transition to the action stage, the resolution to change is most unstable (Appel, 1986, pp. 77 and 78). The deliberate isolation from social networks and the belief that good intentions should not be made public during this vulnerable stage therefore appear to be a plausible subjective strategy. Conclusion: The primarily positive and social motivation for change, as revealed by the analysis of the first stage of the autoremission process (see Klingemann, 199 I), leads to a strong individualistic, inner-directed implementation phase. The relative importance of individual bias in the perception of help and the deliberate retreat from social relationships in this vulnerable phase, as an explanation of the surprisingly weak influence of social support on natural recovery, need more detailed studies. Maintenance and Social Reaction

Within the “life stress model,” health-related well-being is conceptualized as a result of the interplay of social, psychological, and physiological resources and a variety of stressors (Lin and Ensel, 1989, p. 387). If this approach is applied to the issues discussed in this context, changes in the support networks and the stress level as consequences (or correlates) of modified consumption lead to an improved sense of well-being, which in turn can be perceived as one important aspect of maintaining the autoremission. Subjective general well-being, measured by the “thermometer question”, has considerably improved for both the alcohol and the heroin remitters after autoremission: Whereas the “fever” initially averaged 41 “C, the temperature had dropped to 37.8”C during the last year before the interview. The problem-specific stress level generally decreases, notably the reduction of mental stress. Fewer feelings of helplessness and less tension in the family occur within the alcohol group particularly; the fear of the police and feelings of insecurity and powerlessness become less within the heroin group (Table 4). Stress as a result of loss events also decreases for both study groups, as indicated by work problems: Such problems during the previous year were mentioned by only 3 % of the alcohol cases (40% before autoremission) and by 17 % of the former heroin addicts (67 % during the last year before recovery).

~~

~ o ~ u t i ostrategyb n

chocolate, beer/if heroin is the subject; I feel good with pot

13. In the case of booze: if a limit is exceeded, thirst for morelif after a lot of booze enjoy without pot 14. Rja-vu, with the same music, similar situation. Smells. 15. Especially with family squabble/if something special happens which I don’t want 16. In situations of crisis o r dispute

12. Had tummy ache, pain would go away

Shrank into my shell again and againkhanks to pals

It came and went Either I buy some or I don’t, mostly nothing

Imagined how,. . . imagined my condition afterwards, removal of the pain would not solve the problem Sleep, sober again in the morningho contact with junkies, no stuff available

Sat in a comer and waited until the urge wenudrank some beer, but not much No problem

11. Do not need it anymore to solve my conflicts, more a craving for

Get drunk, just last week

9. No specific situations, simply comes over me

10. Can’t explain, phases that come and go for no reason

1. With people at home who were all hooked on it/took shit three times and

Autoremission from Heroin Found it weird, lying and cheating, lots of warmth elsewhere I realized it’s horrible, I don’t want this pseudo-warmth any more 2. If I meet junkies, that is true or in the morning after dreams with heroin Simply wait and know that I’m not doing it 3. E.g., death of the dogkometirnes in the nightlthoughts. sometimes taste Recently through prayer, at one time through support, through the child in the mouth 4. If I’m desperatehf I see films in which drugs are involved Through my faith 5 . When I was feeling so good/if an old acquaintance called on me Stopped frequenting the relevant places, saw that junkies stopped calling on me 6 . In euphoric mood Conscious of my responsibility to the family 7. When I’m aloneho specific situations, simply comes over me Just by simply being busy 8. When one’s sitting as on needles, is still a habit after years Only smoke pot no/don’t bring myself face to face with it

Triggers, reasona

Triggers of the Craving for Drugs and Solution Strategies in the Action Phase According to Problem Groups (all remitters free of treatment who report withdrawal situations)

Table 3.


z

c

x

I said “no” By working on myself, I open up (telephone, relate)/am too comfortable, off to Zurich at night and rush about after shit

Good

Single seats in the next streetcadthink things over

Inward: can no longer refuse the second glass/outward: mineral water and fruit juice by the liter Don’t know

11. After a working day, alcohol no longer function of self-reward

14. Depends on the moon phase, on the weather

a

PLISA question #3.1.1: “In which situations did this express itself!” PLISA question #3.1.2: “How did you get over it?” (follow-on questions after affirmative answer to PLISA question No. 3.1: “Since you got a grip on your alcohol/heroin problem, were there moments in which you again had a strong craving for alcohol/heroin?”; i.e., n = 14 alcohol self-healers, n = 20 heroin self-healers).

Shut idwent for a walk/light sleeping tablet/sleep Can let it stand, leave no room for it

13. At the beginning

prescription drugdin phases of depression, financial problems, etc.

12. If I don’t feel good, I have thought about it again: alcohol and

When I thought about the risk, the craving goes I don’t take anything I go for a run, exercise or into the garden

There were days not allowed to go to pub for coffee/ can offer wine to guests, we drink mineral water

8. At first only made one miserable, then I began to tremble 9. Chance 10. Emotionally disturbing relationship situations

6. After withdrawal, after two weeks, rather depressed/ after withdrawl, after three months, at a patty 7. Itching and twinging, can suddenly crop up

Only went into cafes, even today Sit in the car or on the moped and drive around/anywhere with friends, seek out people who don’t drink Inner cruel struggle

Drank water Don’t run the risk of pouring myself a drink

2. If I’m too shy at a party, I drink so as to feel in top form. .

3. Sometimes think it would be wonderful to drink a glass with friends 4. When I went into town, past restaurant 5 . Triggered by anything, especially foolish situations

Occurred to me how things used to be, definitely stopped now/TV and knitting

1. When I met an old friend at a patty

Autoremission from Alcohol

17. Difficulties in apprenticeship with orientals there/ drug-addicted woman got into the same streetcar perhaps also locked away as an old memory 18. If one talked about it/or when I saw it, e.g., on the Limmatquai in Zurichlthrough nervousness, cringing, sweating 19. Periodically at first, now hardly any more 20. If it’s foggy, greylif trouble at worklit can be anything


3:

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73

rn

z

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rn

;a

v)

L

77 67

15 Feelings of helplessness and insecurity 19 Family tensions 27 Fear of trouble with the police

or the authorities

30 Diagnosed HIV-positive

23 Changed to less responsible job

57

13 8 7 5 0

13‘ Death of a loved one 7 Failed training program or exam

25‘ Accident to a loved one

35 25 23 23 18 10

-8

-30

30

2. Mental Distress - 50 83 - 39 73

-54

- 56

0

+5

- 27

-50

0 0

7 3

-7

- 10

+ 10

- 27 - 15 - 13

-27

-

-20 - 37

-5 -3

+

20 10

30 27 18

10

-20 - 18 0 I5

-I8

40

-43

53

73 47

-25 -33

70 58

1. “Loss” Events

%Before Difference % after

% Before Difference % after

alcohollheroin I 1 Separation/divorce 5 Moved to worse apartment 22 Loss of job, unemployment 24 Accident to self

26b Problems obtaining enough

3 Financial problems 20 Job difficulties

1 Health problems

Stressful life events

Treatment-free alcohol remitters ( n = 30)

All treatment-free remitters ( n = 60)

83

70 60

0

7 7

17 7

17

20 30

60 20

67

67 70

- 80

-43 -27

+ 10

-4 -7

-7

+ 20

0

- 27

- 10 - 13

-20 -47 - 50

%Before Difference % after

Treatment-free heroin remitters ( n = 30)

Stressful Life Events and Feelings Preceding and Following the Natural Recovery by Type of Addiction (treatment free remitters)a

Table 4.


> z z

1

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22 1 82

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z J 0 X

8

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01 -

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01 -

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01

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I376

KLINGEMANN

Regardless of these commonalities, the group of nontreated heroin remitters shows a number of specific characteristics. Although the former heroin addicts managed to reduce their initial stress level even more successfully than the alcohol group in absolute terms, they could not compensate for their unfavorable starting position; the balance of stress decreases sharply but they are still subjected to relatively higher psychological stress (especially familyrelated) and confronted more frequently with loss outside their sphere of control (e.g., the death of close ones), as well as the late consequences of their addiction (see Table 4). At the same time, heroin remitters continuously report higher proportions of “gains” (family, job training, etc.) in life than do the alcohol cases. They nevertheless contribute to the general stress level. The reduction in the mental stress situation is paralleled by a number of structural indicators. Both groups experience upward occupational mobility, consolidate their socioeconomic status, and strengthen their social ties. Changes in consumption, stress level, and structural variables are followed by an impressive development of social networks. Both groups, but especially the heroin remitters, perceive the potential of available help to be very high today and indicate having received support when under stress much more frequently than before recovery. The heroin subjects believe that they can count on at least three (alcohol group: two) support persons, mainly in the family, when they are in urgent need. About half of the respondents specify four or more friends, and 55 % of the heroin group and 3 1 % of the alcohol group received some kind of help when under stress during the previous year (Table 2). After this rather positive balance of coping resources, a more specific estimate of the stability of the problem resolution is necessary. Expressed differently: What factors might endanger the maintenance of the autoremission? According to decision models in cognitive psychology, the reinforcement of positive behavior patterns and counterconditioning play important roles during the maintenance phase in particular (Prochaska and DiClemente, 1986, p. 9). Beyond a cross-sectional view of life events, an interactionist prespective suggests a closer look at possible labeling effects. How much people know about the former drug careers of the subjects reflects the readiness of the remitter to disclose this experience and the difficulty of keeping such a habit secret. Indeed, almost all friends and relatives knew of the remitters’ addiction, while only about a third of their colleagues at work had learned about their “first” or “double life” (Fig. 1A). Employers and neighbors are the least informed, having the strongest formal and informal sanctions at their disposal. However, to what extent an informed social environment strengthens or undermines natural recovery depends very much on the evaluation of the deviant act. Fifty percent of the reactions with which

Rlendc who know

Employer who knows

RrlallVUWhO knOW

NclghbDrS Who know


93

Alcohol (n = 30)

Hcroin (n = 30)

Fig. IA. Actual visibility of the remitters’ former drug life in primary and secondary groups by addiction problem. Note: Based upon PLSI question #I .9. I : “Which of the people you know well are aware of your former life as an addict?” (Interviewer presents list; multiple answers.)

AlwhOl(nl = 5 8 , n 2 = 2 4 h = 7 . 3 )

Huoln (nl = 52 n2 = 29b = 5.3)

Fig. 1B. Reactions of the social environment to the spontaneous recovery by problem and strength of rating. Note: Based upon PLSI question #1.9.2: “How do the people who know about your life as an addict react to you now?” “Positive,” e.g., “they are proud that I made it” or simply “positivehery positive.” “Neutral,” e.g., “they don’t carehndifferent” or “just treat me as a normal person.” “Ambivalenr,” e.g., “others observe me” or “I make people feel insecure.” “Negative,” e.g., “old friends try to pull me in the drug scene again” or “some pass mocking remarks about me.” nl = total responses (1st-4th reaction); n2 = total of respondents; X = rating average (positive = 4, negative = I).


1.778

KLINGEMANN

successful heroin remitters are confronted are still rather neutral or ambivalent. Approval (such as “fantastic, you made it”) is much more frequently accorded to alcohol remitters (Fig. 1B). All in all, heroin remitters not only keep on struggling with a still relatively high stress level, but also feel the stronger societal discrimination against illicit drug use than against alcoholism, even after successful recovery. Finally, analysis of the future life perspectives of the autoremitters serves as a preliminary (pending a planned follow-up) indicator of the achieved stability of the recovery and the chances of a lasting long-term normalization. How do the self-changers judge possible risk factors in their future lives? Does the relapse risk assessment of the collaterals differ from the remitters’ estimate? More than half of the remitters cannot (or do not want to) imagine any critical risks of relapse. Two-thirds of the heroin cases have reached this subjective consolidation, whereas the alcohol remitters still refer to social stressors, especially loss events (Fig. 2A). Likewise, when asked about “the worst that could happen to you in the future,” the new occurrence of drug problems is hardly mentioned by the heroin interviewees (3% of the responses), and most alcohol remitters also consider this risk to be irrelevant or manageable (83% of the responses; Fig. 2B). However, loss events, such as death and accidents of close relatives, are rated as the most severe anticipated problems in the life course. Do collaterals share these views? Their assessment is even more positive and quite congruent with the problem-related self-evaluation of the remitters (Fig. 2C). The chances of long-term recovery of alcohol remitters are perceived more sceptically than those of heroin subjects. This may be partially explained by the higher proportion of nonabstinent and older subjects in the former goup. However, what nurtures the optimistic view of the collaterals about the heroin remitters in view of their higher exposure to stress and social discrimination, factors that should lead to a poorer prognosis? Certain clues can be obtained from an analysis of the substitutes for the drug which are given. When asked “Is there anything which has taken the place of the drug in your life?,” heroin addicts refer more often than do former alcoholics to substitutes that no longer include any kind of substance (Table 5). This can be interpreted as a sign of a profound identity change. Idealistic values and a happy family life typically “fill up the hole which the drug has left” inside heroin respondents, whereas former alcoholics feel still some attraction to less harmful forms of addiction. Data obtained from tests of the possibility of “substitute addictions” in a narrower sense show that the resolution of the primary drug problem (alcohol/ heroin) is associated with less use of other drugs. Most heroin addicts stopped their consumption of other drugs after autoremission. One notable exception: 51 % ( n = 31) of the objective and subjective remitters continued their use of

I379



96 of raapoaDes

“1

61

Alcohol (n 1 = 40, n2 = 30)

Haoin (nl = 33, n2 = 30)

Fig. 2A. Perception of relapse risk factors by nontreated remitters according to addiction problem. Note: Based upon Question PLISA: “Which situations might tempt you again to resume drinkinglheroin use?” nl = total of responses (multiple answers); n2 = total of respondents.

cannabis. In the alcohol group, only generic drugs were used-and only by some-before the natural recovery. Again, a multiple resolution was achieved by almost all former consumers (90%, n = 23). Other studies report similar findings, such as dual alcoholltobacco (a substance not included in the present design) recoveries (Sobell et al., in press). These findings tentatively support the assumption that common factors promote the resolution of a variety of addictive behavior types which have traditionally been treated separately. Collaterals observe these attitudinal and behavioral changes of the remitters’ future. This may explain the more hopeful outlook of collaterals about the heroin group. It is only in a wider context that the specific aspects of drug substitutes and relapse assessment can be understood fully (Orford, 1986, p. 105). Of course, our quantitative data cannot demonstrate a change of values as a correlate of the individual maturation. However, the remitters’ comments on their world views and future orientation support in general the leitmotiv of “the search for a new meaning in life as the motor of natural recovery” which emerged from the qualitative text analysis of the life stories. Asked about their philosophy of life, about 45%-a proportion similar to that of their normal peers (Muller,

KLINGEMANN


I380

*** 44

30

**

A kobo1 (n1 = 36,112= 30)

Heroin (nl = 34. d = 30)

Fig. 2B. Gravest life problem assumed by alcohol and heroin remitters. Note: Based upon PLISA question #5.2: “What is the worst thing that could happen to you in the future?’’ nl = number of responses; n2 = number of respondents. **The following dramatic events were considered to be possible threats: “if something happened to the children,” “for a mother it is the loss of a child,” “if the children turned out to be failures,“ “some kind of an accident, causing paralysis or paraplegic condition,” “loss of the parents,” “if a family member or relative died,” “if I died before my son had finished his education,” “if I kicked the bucket-you cannot say “die” under these circumstances,” “if something happened to my husband,” “death of relatives or illness,” “hitting bottom.’’ ***“something with the family,” “e.g., disease or death,” “if something happened to the family/the child or wifelthe sodthe daughtedthe childlthe son,” “to lose a partner or a child,” “to lose the family,” “if the husband died and the children were taken away,” “death of son/wife,” “Luke’s death or an accident.” “to die,” “that something happens to the family,” “if the son died.”

1983)-see happiness as “more autonomy and new experiences” and “problems with health, job and money” as the major obstacles to happiness. At the same time, however, a group comparison with representative survey data shows a remarkably higher degree of “inner-directedness” of the remitters, already suggested when discussing the individualistic strategies during the action stage of autoremission. Whereas only about a third in all age groups in the general population claim that “everybody is the architect of his own fortune,” 57% of the heroin remitters and 50% of the alcohol cases agree with this statement; in accordance with this finding, the proportion of the general public who feel manipulated by external forces is twice as high as in the study groups. The inner-directed remitters strive toward more autonomy and new


1381

% of respondents


)-[ 6o

n=82 Qdh’t

T

53

40

20

0

‘Trealmentfree alcohol remiWs”

Treolment free heroin remlllers”

Fig. 2C. Collateral’s perception of the risk of relapse by study groups. Note: Based upon TCI item #4.8: “How high do you estimate the danger of relapse?” “Pusirive,” nondifferentiated: e.g., “zero,” “excluded,” “no risk anymore,” “not at all,” or “not the drug type.” “Condirional,” according to the reasoning: “no relapse i f . . . (the marriage is O.K., . . . the business goes well,. . .no depressions occur,”etc.). “Doubts, negarive,” e.g., “you never can tell,” or “the greatest believer can wander from the path,” or an overall rating like “great danger.”

experiences but within the framework of generally accepted societal norms. Almost a third of the heroin remitters want to improve their private lives and are planning short- and long-term steps to change their occupation. As to the (on the average, older) former alcoholics, it is worth mentioning-and in line with the general characteristics of this group-that about a quarter have no plans at all for the next year, and that travel or emigration are prominent in their long-range planning. Conclusion: All autoremitters show a normalization of life perspectives and a high degree of subjective control of their lives, both conditions that favor a lasting consolidation of the natural recovery.

5.

DISCUSSION

Qualitative analysis of the life histories showed that autoremission has three main phases: Decision, action, and maintenance. During the action phase,

KLINGEMANN

I382

Table 5. Casewise Listing of Perceived Drug Substitute by Study Groupa Nontreated heroin remitters


Nontreated alcohol remitters (a) Substance-related substitutes: Coffee by the liter Chocolate/sweets, coffee, alcohol-free beer More smoking Coffee Chocolate, binge eating, smoking Sleeping-pills, but not as a narcotic Coffee Tea Coffee Uncontrolled drinking of mineral water Conscious diet Mineral water, to feel content

(a) Substance-related substitutes: Sugar Cannabis Cannabis Chocolate (and wife)

(b) Substitutes, not substance related: Apartment, painting My goals in life prevent me Self-confidence Jesus Faith Deep faith Self-confidence Work To accompany the son Positive books, sublimation cassette Intensive hobbies, greater feeling of happiness Inner security, self-confidence

(b) Substitutes, not substance related: Keep myself busy Relationship, joy of living Some time ago:fucking to get rid of my aggressions Sports, to accelerate the training Daughter Full life; I get going more easily Family; more pleasure to live thanks to a relationship Joie de vivre Family Family, a job I can identify with Daughter Self-confidence Personality Faith, child Faith Jesus

God New life perspective Outlook on life

Nothing has taken the place of the drug ( n = 6 ) a

Nothing has taken the place of the drug ( n = 9 )

Based upon PLISA #4.4: “Has anything taken the place of alcohol/heroin?” (no/yes, the following. . .).



I383

the focus of this paper, remitters resort to “diversion,” “everyday behavioral concepts,” “naive theories about drug effects or adequate substitutes,” and “structural/ritual techniques of distancing” to put into effect their decision to stop their habit. In the maintenance phase they negotiate new identities or roles (“peace maker,” “helper,” “postmaterialist”) as a reaction to “the hole which the drug leaves inside.” Quantitative analysis shows, contrary to the initial hypothesis, that social support, at least during the vulnerable action phase, plays a small part; the remitters prefer to withdraw and to reject any kind of informal or professional support as being of no use to them. During the maintenance phase, however, they (and their reference persons) find it easier to reduce their social isolation, to resume work, and to take part in social activities because of their achievement in lowering consumption; they have less mental stress and generally feel much better. Their belief that their problems are not solved is reflected in a strong inner-directedness as well as in their very conventional attitudes toward their future prospects and goals and in the positive assessment of their collaterals . For both alcohol and heroin remitters, the autoremission process follows a similar pattern. It differs in several ways, however. In heroin remitters it is more difficult, but also more stable. It is more difficult because of their higher initial stress level and their continuing craving for heroin. However, they do better than the alcohol remitters during the maintenance phase: both self-evaluation and collaterals’ assessment of their future progress are above average. This is all the more surprising since they continue to be exposed to a fairly critical degree of stress after the natural recovery, and their faster reestablishment of social networks is partly outweighed by the strains resulting from negative social reactions toward their past behavior. Two considerations may explain this apparent paradox: First, the combination of continuing social pressure and the support offered by primary groups may challenge the inner-directed remitter to pursue new goals in life. Heroin remitters are also much farther removed from their former “drug world” than are the alcohol subjects, clearly preferring nonmaterial/nonsubstance substitutes for the drug, if they feel a need for substitutes at all. Second, these changes are obvious in their social environment; their collaterals consequently assess them positively. Given the lack of research in this field, the exploratory nature of this study represents only a first step to a better understanding of some aspects of autoremission. Prospective studies are needed to test the predictive power and the validity of the typology offered in this paper. Therefore, the present phase of this project includes follow-up interviews with the remitters 4 years after the first interview and the setting up of a control group of treatment-free subjects with nonresolved problems.


I384

KLINCEMANN

The study of autoremission not only raises interesting theoretical and methodological questions, but is also of great political interest. To conclude, a closer look at the practical implications is proposed, starting out with three basic questions: What factors favor a social climate conducive to natural recovery? Which variables can be influenced, and who can influence them? Is there no more need of social workers and therapists? First, autoremission is likely to occur more often if the treatment system is less developed or if there is limited access to treatment. Besides, less intervention and a recognition that autoremission is possible probably accord with a general social policy of decentralization of social services and a shift of responsibilities to the informal sector. Political liberalism, after all, also trusts the “self-healing market forces.” More specifically, two intervening variables come into play. One is society’s view of the severity of the behavioral disorder which the remitter is trying to change. The other is the stigma that may be attached to it. Eating disorders are probably much more favorably placed than heroin addiction. The public believes that heroin addiction can rarely be cured. They see very few recovered addicts. From the media they hear or read only of death rates and horror stories (e.g., Wong and Alexander, 1991). In these circumstances, remitters-whose succeess is defined by “normalization” and “reintegration”-prefer to forget or to hide their stories. Rates of autoremission might be higher if the wider public and the agencies of social control were more tolerant of temporary deviant behavior during life stages which favor personal maturation, and if the stigma attached to deviant behavior could be made less disproportionate to the objective size of the problem (Happel et al., 1989). Without condoning the idea of harmless first use, the public might be taught that addiction is not a disease that can only get worse without treatment. The empirical findings on social support during the maintenance phase suggest that rates of autoremission may increase if conditions that favor social support are provided. This would include the elimination of mental blockages on the part of those who receive help, as well as of those who provide it. People in a crisis often do not realize that help is available. The support deterioration model offers an explanation for this-that stress can bias and impair the perception of the availability and adequacy of social support. However, the person in distress is not the only one to be blamed for not making good use of available help. Those who want to help must know or be told who needs what kind of help (Taylor, 1983). Is there no more need of therapists? Autoremission is not inconsistent with a minimal amount of treatment (Heather et al., 1990) or other complementary assistance. Remitters can be taught to deal more easily with withdrawal symptoms, and support to efforts to strengthen social ties, necessary to reestablish


I385


the earlier nondeviant identity, can complement personal means of achieving natural recovery (Cartwright, 1985; Happel, 1990, Stover, 1990). Also, measures to reduce anxiety and insecurity in the surroundings of the remitters will indirectly help them. In this way it is seen that professional treatment is not in conflict with reliance on a person’s own power to solve her or his problem.

APPENDIX Yvonne: “The bottle trick” (#87, 54 years old, cutter); excerpts from the tape recorded summary of the autoremission (SAR).

“O.K.” I said about three or four years ago, I can’t go on like this. I made up my mind I wanted to be a writer, a journalist, and you just can’t do that on alcohol. I couldn’t write like that. And then I got out a bottle of whisky and I said to myself “There must be a way” and I looked at the bottle for a long time and I got the idea that you could dilute it. And than I started, on the first day I had a little drink, a small glass, just like I always had these little drinks, I poured it from the full bottle and then water, I poured a little glass of water in. And so on, every day I had a glass, two, three glasses till nothing was left in the bottle except water, but the taste of whisky, that was still in the bottle and every day I poured myself a drink or two, until there was only water left and as “Ersatz,” how do you say that in English, as a “substitute’’ I drank that, thinking that it was “whisky”- and so it was for me. And with beer, what I did with that was, at first I still drank a couple beers, but then I gave it up too, because it wasn’t good for me all of a sudden, and so, then I just stopped drinking beer and at the end, there was just water and about a year ago, yeah, about a year ago I stopped altogether. I didn’t use the bottle any more or the glasses. And then I started drinking coffee-by the liter! (laughs)

ACKNOWLEDGMENT This research was financially supported by a grant from the Swiss National Foundation for Scientific Research 32-8626.85.

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THE AUTHOR Harald K.-H. Klingemann, Dr.rer.pol., studied at Cologne University (Germany) where he received the doctoral degree in economics and social science. He has taught at the University of Bonn where he was a senior researcher in criminology and at the Fachhochschule of Cologne. Currently research director at the Swiss Institute for the Prevention of Alcohol and Drug Problems (Lausanne), his main research interests include the crosscultural analysis of treatment systems and self-help groups and the study of everyday definitions of deviant behavior with regard to alcohol, drugs, crime, and youth problems. He is senior editor of a book Cure, Cure and Control: Alcoholism Treatment in Sixteen Countries (1992, State University Press of New York). Recent articles include “From controlling a wayward life to controlled therapeutic measures? Changes in Swiss commitment laws” (Contemporary Drug Problems, 1987); “The social context of spontaneous remission from problematic alcohol use” (Medizin Memch Gesellschuf, 1988); and “Supply and demand-oriented measures of alcohol policy in SwitzerlandCurrent trends and drawbacks” (Health Promotion, 1989).

Protective behavioral strategies mediate problem-focused coping and alcohol use in college students.

Heroin maintenance and heroin control.

Explicit and implicit heroin-related cognitions and heroin use among patients receiving methadone maintenance treatment.

Controlled use of heroin in patients on methadone maintenance treatment.

Pain beliefs and the use of cognitive-behavioral coping strategies.

The relationship between problem-focused coping strategies and quality of life in schizophrenic patients.

Coping with causal uncertainty through alcohol use.

Stress and alcohol use: moderating effects of gender, coping, and alcohol expectancies.

Drinking and flying--the problem of alcohol use by pilots.

Alcohol use in methadone maintenance clinics.

Social anxiety, disengagement coping, and alcohol-use behaviors among adolescents.

Alcohol use in the opiate use cycle of the heroin addict.

Spontaneous hydrolysis of heroin in buffered solution.

An exploration of alcohol use severity and route of drug administration among persons that use heroin and cocaine.

Coping strategies and individual meanings of illness.

Effectiveness of Problem-Focused Coping Strategies on the Burden on Caregivers of Hemodialysis Patients.

Alcohol expectancies and alcohol outcomes: effects of the use of protective behavioral strategies.

How much heroin maintenance (containment) in Britain?

Coping with inner feelings and stress: heavy alcohol use in the context of alexithymia.

veterans: Normative perceptions and coping strategies.

Sodium oxybate: a review of its use in alcohol withdrawal syndrome and in the maintenance of abstinence in alcohol dependence.

Association between Coping Strategies and Infertility Stress among a Group of Women with Fertility Problem in Shiraz, Iran.

Quantitative and temporal relationships of alcohol use in narcotic addicts and methadone maintenance patients undergoing alcohol detoxification.

Alcohol-Specific Coping Styles of Adult Children of Individuals with Alcohol Use Disorders and Associations with Psychosocial Functioning.