Differences among substance abusers in Spain who recovered with treatment or on their own

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Differences among substance abusers in Spain who recovered withtreatment or on their own

José Luis Carballo a,⁎, José Ramon Fernández-Hermida a, Linda Carter Sobell b,Mariam Dum b, Roberto Secades-Villa a, Olaya García-Rodríguez a,

José Manuel Errasti-Pérez a, Susana AlHalabí-Diaz a

a Grupo de conductas adictivas, Departamento de Psicología, Universidad de Oviedo, Spainb Center for Psychological Studies, Nova Southeastern University, United States

Abstract

This exploratory study compared the differences among substance abusers in Spain who recovered withtreatment or on their own. Advertisements were used to recruit 58 individuals (29 self-changers and 29 treatment-changers) who had had problems with alcohol or drugs, and who had been recovered for at least one year. Thegroups differed significantly in severity of dependence, psychiatric treatment prior to recovery, and copingstrategies to maintain recovery. Consistent with previous studies, those who had recovered through treatment had amore serious substance use history than those who changed on their own. In addition, social support wasassociated with maintenance of change for both groups. These findings parallel those for English-speakingpopulations.© 2007 Elsevier Ltd. All rights reserved.

Keywords: Alcohol abuse; Drug abuse; Self-change; Treatment; Spain; Natural recovery

Natural recovery or self-change from substance abuse is not an isolated or rare phenomenon. Majorreviews of the literature (Carballo et al., 2007; Klingemann & Sobell, in press; Klingemann et al., 2001;Sobell, Ellingstad, & Sobell, 2000) and several large-scale population surveys (Cunningham, 1999;Dawson et al., 2005; Hasin & Grant, 1995; Sobell, Cunningham, & Sobell, 1996) have clearlydemonstrated that self-change is a major pathway to recovery for alcohol and drug abusers. Collectively,

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Addictive Behaviors 33 (2008) 94–105

⁎ Corresponding author. Facultad de Psicología, Universidad de Oviedo Plaza Feijoo, s/n. 33003 Oviedo-Asturias, Spain. Tel.:+34 985 10 41 89; fax: +34 985 10 41 44.

E-mail address: [email protected] (J.L. Carballo).

0306-4603/$ - see front matter © 2007 Elsevier Ltd. All rights reserved.doi:10.1016/j.addbeh.2007.07.013


studies of natural recovery challenge the traditional belief that recovery from an alcohol or drug problemcan only occur through treatment.

In all studies and surveys, treated individuals as compared to self-changers have been found to be moreseverely dependent, to have experienced more consequences, and to have longer problem histories thanself-changers (Bischof, Rumpf, Hapke, Meyer, & John, 2002; Chitwood & Morningstar, 1985;Cunningham, Lin, Ross, & Walsh, 2000; Sobell et al., 1996; Sobell et al., 2000; Weisner, Matzger, &Kaskutas, 2003). Consistent with these findings, self-changers have reported they did not believe theirproblems were serious enough to warrant treatment and that they believed that they could change on theirown (Klingemann et al., 2001; Sobell et al., 2001). Most natural recovery studies with alcohol abusershave also shown that both abstinent and moderate drinking outcomes occur. Similarly, in a major reviewof natural recovery studies (Sobell et al., 2000) low-risk drug use outcomes were reported in close to half(46.2%; 6/13) of all studies. In terms of maintenance factors, research shows that social and familysupport networks are important for maintaining change for both self-changers and treated substanceabusers (Bischof, Rumpf, Hapke, Meyer, & John, 2000; Bischof et al., 2002).

In early natural recovery studies, definitions of treatment and recovery varied considerably (Sobell,Sobell, & Toneatto, 1992) with some definitions of recovery allowing for unsuccessful treatments andshort lapses. Consequently, clear definitions of treatment, recovery types, and outcomes are important. Inthis regard, the last two major reviews of natural recovery studies have shown that most now providedetailed definitions of what constitutes treatment and self-help (Sobell et al., 2000; Chapter 5), includingthe most recent National Epidemiologic Survey on Alcohol and Related Conditions (National Institute onAlcohol Abuse and Alcoholism, 2006). It has been suggested that treatment be defined as resources ortherapeutic services directed at changing addictive behaviors, including regular attendance at self-helpgroups, psychological or psychiatric treatments, resources related to social services, inpatient treatment,and advice from doctors (Klingemann et al., 2001; Sobell et al., 2000). Finally, recognizing that a manyindividuals might attend a few self-help group meetings without seriously adopting a recovery programand because a few meetings are not viewed as sufficient by self-help groups (e.g., AA, NA) for recovery,some natural recovery studies do not consider attendance at three or less self-help meetings as treatment(Ellingstad, Sobell, Sobell, Eickleberry, & Golden, 2006; Sobell et al., 1992; Sobell, Sobell, Toneatto, &Leo, 1993; Toneatto, Sobell, Sobell, & Rubel, 1999).

A clear definition of recovery outcomes is similarly important. As noted earlier, natural recoverystudies from alcohol and drug problems include both of the recent major reviews of the self-changeliterature from alcohol and drug problems have reported that low-risk alcohol use as a frequent occurrenceand nearly half of the drug studies reported low-risk drug use (Carballo et al., 2007; Sobell et al., 2000).Consequently, both abstinent and non-abstinent outcomes need to be assessed and reported separately.

Because the majority of studies examining natural recoveries have been conducted in English-speakingcountries, studies exploring this phenomenon in other countries and cultures are needed. Consequently, itwas decided to conduct an exploratory study with Spanish speaking alcohol and drug abusers in Spainwith the objective of identifying factors antecedent and consequent to the recovery process for those whohad recovered with treatment or on their own. As noted in the literature, studies comparing self-changerswith treatment-changers have found that those who recover through treatment tend to have a more serioussubstance abuse history (Bischof et al., 2002; Chitwood & Morningstar, 1985; Cunningham et al., 2000;Sobell et al., 1996; Sobell et al., 2000; Sobell et al., 2001; Weisner et al., 2003). Therefore, the specificaim of this study was to examine the relationship of substance abuse severity with recovery type (self- ortreatment-changers).

95J.L. Carballo et al. / Addictive Behaviors 33 (2008) 94–105


1. Methods

1.1. Participants

Over 18 months, 68 substance abusers were recruited through advertisements of which 10 wereineligible. Reasons for ineligibility included not being recovered, were cigarette smokers, or recovered forless than one year. No background information was available for those who were ineligible as the onlyeligible participants could be administered study questionnaires.

Fifty-eight people, 29 self-changers (SC) and 29 treatment-changers (TC) met the eligibility criteriadescribed below. Prior to their recovery participants had to meet the DSM-IV-TR criteria (AmericanPsychiatric Association, 2000) for either an Alcohol Use Disorder (AUD, n=33: TC=17, SC=16) or aDrug Use Disorder (DUD, n=25: TC=12, SC=13). The DSM diagnosis refers to the number of criteriaendorsed for the primary substance from which participants recovered for either an AUD (abuse ordependence) or DUD (abuse or dependence). Participants with an AUD also had to meet the followingcriteria: (a) 18 years of age or older (legal drinking age in Spain); (b) at least one year prior to recovery,consumption of 21 or more standard drinks (SDs; 10 g) of alcohol per week for men and 14 or more SDsfor women (World Health Organization, 1998); (c) recovered for at least one year prior to the interviewdefined as either no alcohol use (abstinence), or low-risk drinking of no more than 3 SDs per day for menand 2 SDs for women (World Health Organization, 1998); and (d) if engaged in low-risk drinking no self-reported alcohol-related consequences (i.e., psychological, occupational, social, family, health and legal).

Those with a DUD had to meet the following criteria: (a) 18 years of age or older; (b) drug use for atleast one year prior to recovery; (c) recovered for at least one year prior to the interview defined as no druguse (abstinence) or low-risk drug use defined as one or two times per year for marijuana and one time peryear for all other illicit drugs with no adverse consequences. Definitions of low-risk, non-problematicdrug use have varied across studies, but what all have in common is very few days of use and no drug-related consequences (i.e., psychological, occupational, social, family, health and legal) when using(reviewed in Klingemann & Sobell, in press; Sobell et al., 2000; Zinberg & Jacobson, 1976).

Recoveries were of two types: self-changers (SC; n=29) and treatment-changers (TC; n=29).Participants in Group SC had not ever received formal help or treatment for an alcohol or drug problem,while those in the TC Group had been in some type of formal help or treatment before their recovery. Asdefined in past self-change studies (Sobell et al., 2000; Toneatto et al., 1999; Tucker, Vuchinich, &Gladsjo,1994) formal treatment included: (a) inpatient or outpatient medical, pharmacological, psychiatric, orpsychological services for an alcohol or drug problem; (b) three or more self-help meetings (e.g., AA, NA);or (c) any minimal intervention such as a brief discussion with a health care practitioner, reading self-helpbooks, or even one treatment session.

Voluntary participants were recruited using several different methods (e.g., newspapers and radioadvertisements; radio interviews; physicians specializing in substance abuse but not providing treatment;community centers; self-help organizations; posters at Oviedo University, social centers; bus stations;sports centers; and addictions specialists recruited only those who had recovered through treatment). Overtwo-thirds (69.00%) of all participants were recruited through media ads (SC: 75.86%; TC: 62.07%), withthe remaining participants recruited through the other methods described above. The two groups did notdiffer significantly (pN .05) in terms of being recruited through media advertisements.

The English translation of the ads used to recruit self-changers in Spain read as follows: “Did youchange your habits in relation to alcohol or other drugs without help? Did you give up or reduce your

96 J.L. Carballo et al. / Addictive Behaviors 33 (2008) 94–105


drinking or use of drugs by yourself? Did you change your way of drinking or taking other drugs withouttreatment? Researchers at the Psychology Faculty of Oviedo University are interested in interviewingpeople who have changed their habits in relation to alcohol or other drug use without treatment orprofessional help. If you are one of these people, we believe you can provide us with valuable informationthat can help us to improve existing treatments for problems of alcohol and other drug use. Totalconfidentiality promised.”

The English translation of the ads used to recruit treatment-changers in Spain read as follows: “Haveyou ever received treatment for problems of alcohol consumption or the use of other drugs? If you are oneof these people, we believe you can provide valuable information to the researchers at the PsychologyFaculty of Oviedo University for improving existing treatments for problems of alcohol and other druguse. Total confidentiality promised.”

1.2. Procedures

All interviews were conducted in Spanish. Interviews were conducted face-to-face in a single session atthe university, except for two participants who were interviewed by telephone because they could notcome in for the interview. Trained psychologists with expertise in the addictions field interviewed allparticipants. All data in this study were based solely on participants' self-reports. In person interviewsranged from 30 to 60 min. In Spain, the counterpart to an Institute Review Board is the Ministry ofScience and Technology of Spain (Ministerio de Ciencia y Tecnología, Spain). The current study wasreviewed and approved by this agency. All participants gave their consent to participate in the study andno participant was paid.

1.3. Measures

Questions about number of years a problem existed and number of years of recovery related towhether thepersonwas diagnosedwith a primaryAUD (abuse or dependence) or DUD (abuse or dependence) as definedby the DSM-IV-TR (APA, 2000) at 12months prior to their recovery using the alcohol and drug usemodulesof the Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS; Grant, 1997).Besides providing basic demographic information [i.e., education, gender, age at recovery, age wheninterviewed, stable relationship (married/partner) when interviewed and at the time of recovery, employmentstatus when interviewed and at the time of recovery] all participants completed the following questionnairesthat had been translated into Spanish. In cross-cultural research (e.g., Babor et al., 1994; Room, Janca,Bennett, Schmidt, & Sartorius, 1996; Sobell et al., 2001) one way to achieve good translations of Englishlanguage questionnaires (i.e., semantic equivalence) is to obtain two independent translations (expertpsychologist and professional translator) from English to Spanish; this occurred for the Drug Use HistoryQuestionnaire, Reasons for Change Scale, Life Events Checklist, and Maintenance Factors Checklist. Thefinal version of these instruments was a consensus of the two independent translations.

Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS). Alcohol abuseand dependence and drug abuse and dependence was diagnosed accordingly to the DSM-IV-TR(American Psychiatric Association, 2000) using the alcohol and drug use modules of the AUDADIS(Grant, 1997). The diagnosis for participants in the present study was determined based on questions thatasked about their alcohol or drug use over the past 12 months. Several studies have found good internaland test–retest reliability for these modules (Grant, 1997; Grant et al., 2003). Number of diagnostic



criteria met was also scored with a range from 1 to 7. The Spanish version of this instrument (Canino et al.,1999) was used in this study as in previous studies with Spanish-speaking substance abusers (Bedregal,Sobell, Sobell, & Simco, 2006).

Drug Use History Questionnaire (DUHQ) is a structured interview that captures lifetime information(e.g., years used, route of administration, year last used, frequency of use) about alcohol and illicit drugs(excluding prescription drug use), and has good psychometric properties with substance abusers (Sobell,Kwan, & Sobell, 1995).

Substance Abuse Recovery and Treatment History. The following information was obtained from allparticipants: (a) for alcohol abusers (TC=17; SC=16) the number of years they reported having had analcohol problem prior to their recovery, and for drug abusers (TC=12; SC=13) the number of years theyreported having had a drug problem prior to their recovery; (b) number of years recovered from theirprimary substance; (c) types of formal help or treatment used to deal with their primary substance problem(as noted earlier self-changers could not have reported any treatment); and (d) whether they were evertreated for psychiatric problems prior to their recovery.

Reason for Quitting Scale (RQS) is a psychometrically sound 12-item checklist that assesses extrinsicand intrinsic motivation for quitting or reducing different addictive behaviors including alcohol or druguse (Curry, Grothaus, & McBride, 1997; Curry, Wagner, & Grothaus, 1990, 1991). Participants wereasked to complete the scale in relation to “when you recovered from an alcohol or drug problem” bycircling one answer for each item using a 5-point Likert scale ranging from 0 to 4 in terms of whether eachreason was “not at all true” = 0, “moderately true” = 2, to “extremely true” to 4.

Social support and social pressure were probed using open-ended questions as with substance abusersin previous natural recovery studies (Ellingstad et al., 2006; Sobell et al., 1992, 2001; Toneatto et al.,1999). For social support participants were asked “Have you received support from your family, spouse orfriends for maintaining your change?” ForsSocial pressure participants were asked “Have you receivedany kind of pressure from your family, spouse or friends for changing your habits from alcohol or otherdrugs?”. Both questions were scored as “0” for those who answered that they did not receive any socialsupport or social pressure during the maintenance and recovery phases, respectively, and “1” for thosewho reported receiving social support or social support.

Life events checklist. A checklist of 14 events (e.g., legal problems, marital status, job changes, healthchanges) occurring in the year prior to recovery was used to assess what might have influencedparticipants' recovery. The selected events were those used in past major natural recovery studies ofsubstance abusers (e.g., Bischof, Rumpf, Hapke, Meyer, & John, 2001; Cunningham et al., 2000; Sobellet al., 1993). Participants were asked to rate each of the events as to how it influenced their changing theiralcohol or drug use by circling one answer for each item using a 5-point Likert scale ranging from 1 to 5 interms of whether it “did not influence changing” = 1 to 5 = “influenced changing a lot”. Scores couldrange from 14 to 70.

Coping Behaviors Inventory (CBI). The 22-item Spanish adaptation (García González & AlonsoSuárez, 2002) of the CBI (Litman, Stapleton, Oppenheim, & Peleg, 1983) was used to assess strategies forchanging and maintaining those changes. The CBI has good internal reliability and construct validity withsubstance abusers.

Maintenance of recovery checklist. Participants were asked to complete a 21-item checklist thatcontained events that helped them to maintain their recovery (e.g., changes in health, job, marital status).The 21 items have been used in several past natural recovery studies with substance abusers (Blomqvist,1999; Ellingstad et al., 2006; McCartney, 1996; Sobell et al., 1992; Sobell et al., 1993; Toneatto et al.,



1999; Tuchfeld, 1981). Participants were asked to rate each maintenance factor by circling one answer foreach item using a 5-point Likert scale ranging from 1 to 5 in terms of whether each event was “not at alltrue” = 0, “moderately true” = 3, to “extremely true” to 5. Scores could range from 21 to 105.

2. Results

2.1. Data Analysis Plan

Data were analyzed using SPSS-12 for Windows. To evaluate possible differences between the SC andTC groups, chi-squared tests were performed for non-continuous variables, and independent t-tests wereused for continuous variables. A Bonferroni adjustment for a .05 alpha criterion was made for tests ongroups of related variables. Recovery type [i.e., treatment-changers (TC) recovered through treatmentversus self-changers (SC) who recovered on their own] was the dependent variable. Unless specified (e.g.,years reported using primary substance), data (e.g., length of recovery,% abstinent recoveries) were pooledfor alcohol and drug abusers within their respective recovery group (SC or TC) and relate to the primarysubstance from which the participants recovered. As noted earlier, previous natural recovery studies foundsubstance use problem severity to be associated with recovery type. In this regard, a bivariate logisticregression analysis was used to examine the predictive value of four independent variables related to theseverity of participants' alcohol (n=33) or drug (n=25) use problem: (a) number of dependence DSM-IV-TR criteria (ranging from 1 to 7) fulfilled for an AUD or DUD; (b) number of different substances usedlifetime as reported on the DUHQ; (c) years of use (i.e., based on reported number of years used for thediagnosed AUD or DUD); and (d) ever received psychiatric treatment prior to their recovery. Only one ofthe four independent variables (i.e., psychiatric treatment prior to recovery) was a dichotomous variable.The other three were continuous variables. The block entry method was used for the logistic regressionanalysis because the aim was to examine the classificatory power of the set of variables.

Table 1Demographic variables reported by self-changers (SC) and treatment-changers (TC)

Variable SC TC t /χ2

(p value) aN=29 N=29

% Male 82.76% (24) 82.76% (24) 0.00 (.99)Mean (SD) age when interviewed 41.68 (12.58) 43.13 (9.68) −0.49 (.62)Mean (SD) age at time of recovery 35.41 (11.30) 38.34 (10.00) −1.04 (.30)% Unemployed when interviewed 10.34% (3) 24.14% (7) 1.08 (.29)% Unemployed at time of recovery 0.00 % (0) 34.48% (10) 9.78 (.002) ⁎

Educational level% Elementary/primary 24.14% (7) 37.93% (11)% Secondary/technical 41.38% (12) 41.38% (12) 5.04 (.41)% Higher 34.48 % (10) 20.69% (6)

% Stable relationship (married/partner) when interviewed 41.38% (12) 41.38% (12) 0.00 (.99)% Stable relationship (married/partner) at time of recovery 51.72% (15) 44.83% (13) 0.69 (.79)

a Chi-squares were calculated for non-continuous variables and for continuous variables t-tests for independent samples were used.⁎ Significant at α=.0062 (Bonferroni adjusted).



Demographic variables for both the SC and TC groups, before and after their recovery, are shown in Table 1.A Bonferroni adjustment was made for tests on the eight variables, setting the permissible type I error rate toα=0.0062 (0.05/8). For demographic variables, the two groups differed significantly (p=. 002) on only onevariable. As expected and consistent with a less serious substance abuse history none of the SC wereunemployed at the time when they recovered as compared to a third of TC. Most of the participants weremale and were stable in terms of the majority having a secondary education or higher. At the time of theirrecovery, on average they were in their mid 30's, most were employed, and almost half had a stablerelationship (married/partner).

For both TC and SC, over 50% reported alcohol as their primary problem (SC: n=17, 58.63%; TC:n=16, 55.17%). The two groups did not differ significantly (pN .05) with respect to the number ofparticipants who had an AUD or DUD. For SC 24.14% reported a primary problem with cocaine, 10.35%with cannabis, and 3.44% with both heroin and other drugs. For TC, 24.4% reported a primary problemwith heroin, 13.79% with cocaine, and 6.90% with other drugs.

In the both groups, 90% reported at some time in their life using a substance(s) other than the primarydrug from which they recovered. Alcohol was used by all participants, and 85% reported tobacco use.There were no statistically significant differences between the two groups for the types of drugs ever used.Although all participants had to meet criteria for a psychoactive substance use disorders (AmericanPsychiatric Association, 2000), 65.51% of SC and 89.65% of TC met the criteria for a dependencediagnosis, a difference that was not statistically significant (p=0.06).

Variables related to substance use history and recoveries are shown in Table 2. A Bonferroniadjustment was made for tests on the two types of recoveries (abstinence or low-risk use) and number ofyears recovered from an AUD or DUD, setting the permissible type I error rate to α=0.025 (0.05/2). Asexpected, the percentage of participants whose recoveries involved abstinence irrespective of whetherthey recovered from alcohol or drugs differed significantly (p=.012) between the two groups. Therecoveries of almost all TC (27/29; 93.10%) involved abstinence compared to only two-thirds (18/29;62.07%) of SC. The remaining recoveries in both groups were classified as either low-risk drinking orlow-risk drug use (see earlier definition), a finding consistent with many other natural recovery studies(Carballo et al., 2007; Klingemann & Sobell, in press; Sobell et al., 2000), Lastly, as in previous naturalrecovery studies (Carballo et al., 2007; Sobell et al., 2000) both groups reported long-term stablerecoveries with a mean (SD) of 6.27 (7.01) years for SC, and 4.79 (5.44) years for TC.

Table 2Substance use history and recovery variables reported by self-changers (SC) and treatment-changers (TC)


(p value)aN=29 N=29

Mean (SD) years recovery 6.27 (7.01) 4.79 (5.44) 0.89 (.370)% (n) abstinent recoveries 62.07% (18) 93.10% (27) 6.35 (.012)⁎

Mean (SD) number substances used prior to recovery 3.86 (2.08) 5.17 (2.77) −2.03 (.047)Mean (SD) years reported using primary substance 16.27 (13.21) 18.06 (11.47) −0.55 (.580)Mean (SD) DSM IV-TR dependence criteria reported prior to recovery 3.24 (1.61) 5.24 (2.14) −4.00 (.000)⁎⁎

% (n) reporting psychiatric problems prior to recovery 13.79% (4) 48.28% (14) 6.52 (.011)⁎⁎

aChi-squares were calculated for non-continuous variables and for continuous variables t-tests for independent samples were used.⁎Significant at α=.025 (Bonferroni adjusted for the two recovery variables).⁎⁎Significant at α=.0125 (Bonferroni adjusted for the four substance use history variables).



A Bonferroni adjustment was made for tests on the four substance use history variables, setting thepermissible type I error rate to α=0.0125 (0.05/4). Treatment-changers [Mean (SD)=5.24 (2.14)] metsignificantly (pb . 001) more DSM-IV-TR dependence criteria for either an AUD or DUD (AmericanPsychiatric Association, 2000) prior to recovery than the self-changers [Mean (SD)=3.24 (1.61)]. Inaddition, three times as many TC (48.28%) reported having received psychiatric treatment prior to theirrecovery compared to SC (13.79%), a statistically significant difference (p=.011).

Table 3 displays variables related to change and to the maintenance of recovery. A Bonferroniadjustment was made for tests on the six maintenance of recovery variables, setting the permissible type Ierror rate to α=0.007 (0.05/6). Statistically significant differences were found for only two variables,coping strategies and social support. As shown in Table 3, the TC had significantly (p=. 001) higher meanscores on the overall Coping Strategies scale as compared to the SC. In addition, significant differenceswere found (pb0.007) for all four of the CBI subscales suggesting that TC report using more strategiesthan SC. Lastly, twice as many of the TC (82.76%) reported receiving social support during themaintenance phase than the SC (41.38%), a difference that was statistically significant (p=.003).

Finally, a logistic regression analysis was performed to evaluate the predictive value of the number ofDSM-IV-TR dependence criteria fulfilled for an AUD or DUD, number of substances used lifetime, yearsof use (i.e., based on reported years used for the diagnosed AUD or DUD), and psychiatric treatment priorto recovery with respect to whether participants were SC or TC. The block entry method was used becausethe aim was to reveal the classificatory power of the set of four variables. The assumption of multi-collinearity was not violated since the correlations among the independent variable were found to be small(less than 0.3). The results of the logistic regression are presented in Table 4 and show that more TCreported receiving psychiatric treatment prior to their recovery (OR=5.05; p=.035), and met more DSM-IV-TR dependence criteria for an AUD or DUD (OR=1.59; p=.015) than SC. The other two variables(number of substances used lifetime: OR=1.53, p=.033; number of years used primary substance:

Table 3Reasons for change and maintenance of recovery variables reported by self-changers (SC) and treatment-changers (TC)


(p value) aN=29 N=29

Mean (SD) Reasons for Change scale score b 23.17 (10.64) 22.24 (10.53) 0.33 (.730)Mean (SD) Life events checklist (LEC) score c 9.13 (6.15) 13.48 (11.73) −1.76 (.083)% (n) reporting pressure to change prior to recovery 41.38% (12) 72.41% (21) 4.49 (.034)Mean (SD) Maintenance factors checklist d 50.75 (14.02) 58.20 (18.03) −1.75 (.085)Mean (SD) score on Coping Behaviors Inventory (CBI) and subscales e 23.10 (11.17) 38.34 (13.40) −4.70 (.000) ⁎

Positive thinking 8.37 (3.92) 11.34 (4.00) −2.85 (.006) ⁎

Negative thinking 3.31 (3.43) 7.44 (3.65) −4.44 (.000) ⁎

Distraction 4.96 (4.45) 11.37 (3.27) −4.49 (.000) ⁎

Avoidance 2.51 (2.47) 4.79 (2.85) −3.24 (.002) ⁎

% (n) reported receiving social support for their change after recovery 41.38% (12) 82.76% (24) 8.86 (.003) ⁎

a Chi-squares were calculated for non-continuous variables and for continuous variables t-tests for independent samples were used.b Reasons for Change scale scores could range from 0 to 52.c LEC scores could range from 14 to 70.d Maintenance factors checklist scores could range from 21 to 105.e CBI score could range from 0 to 70; subscale score ranges: Positive thinking from 0 to 15; Negative thinking from 0 to 12; Distraction from

0 to 27; Avoidance from 0 to 9.* Significant at α=.007 (Bonferroni adjusted for maintenance variables).



OR=1.05, p=.035) were not significant predictors in this model. This model correctly classified 69.00%of all cases, 65.52% (19/29) of SC, and 72.41% (21/29) of TC.

3. Discussion and conclusions

This is the first study to examine factors antecedent and consequent to the recovery process for Spanishspeaking substance abusers that had recovered with treatment or on their own. Although the minimumrecovery length for all participants was one year, the mean for both groups was five or more years, a figurethat parallels results from past natural recovery studies with English-speaking populations (reviewed inCarballo et al., 2007; Sobell et al., 2000). This figure reflects stable long-term recoveries. The two groupsdiffered significantly on only one demographic variable. All SC were employed at the time of theirrecovery compared to two-thirds of the TC. This was not surprising as the SC also had a less serioussubstance use history.

As expected, the TC met significantly more DSM IV-TR criteria for alcohol or drug dependence. In thisregard, the logistic regression analysis showed that dependence symptoms and being in psychiatrictreatment prior to recovery were good predictors for correctly classifying TC and SC, with higher scoresfor the TC. These findings are consistent with previous studies showing that those who recover throughtreatment have a more serious addiction history than self-changers (Carballo et al., 2007; Sobell et al.,2000).

Abstinence was the most common recovery for both groups of participants irrespective of whethertheir recovery was from alcohol or drugs. This, however, was not surprising as most traditionalsubstance abuse treatment programs require abstinence. While over a third of SC reported low-riskdrinking or low-risk drug use (as defined earlier) only 7% of TC engaged in such behaviors. Theseresults are also consistent with results from past natural recovery studies with alcohol and drug abusers(Carballo et al., 2007; Klingemann & Sobell, in press; Sobell et al., 2000). One possible reason that SCare successful at low-risk drinking or low-risk drug use is that they have not been exposed to thephilosophy of traditional treatment programs where the message is that moderation or low-risk use isimpossible (Cook, 1988; Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997). Another possibleexplanation may be that individuals whose problems less severe are better able to achieve a moderationrecovery (Sobell & Sobell, 1995).

Table 4Results of bivariate logistic regression analysis for predictive value of substance severity variables for recovery type (TC or SC)

Variable B S. E. Wald Significance OR I.C. 95.0% for OR

Lower Upper

Years of use a .049 .028 3.081 .079 1.050 .994 1.109Number of different substances usedlifetime from the DUHQ

.142 .146 .947 .330 1.153 .866 1.536

Ever received psychiatric treatmentprior to recovery

1.619 .767 4.457 .035 5.048 1.123 22.693

Number of DSM IV-TR dependencecriteria filled for AUD or DUD

.461 .190 5.916 .015 1.586 1.094 2.300

a Based on reported number of years used for the diagnosed AUD or DUD.



Another notable difference is that TC reported using significantlymore coping strategies than SC.Whileadoption of action plans to prevent relapses in substance abuse treatment programs (Marlatt & Donovan,2005; Sobell & Sobell, 1993) may explain this difference, it may also be that those in treatment had a moresevere addiction history and hadmore challenges that required coping. As expected, significantly more TCthan SC reported having ever been in psychiatric treatment prior to their recovery, again reflecting a moresevere addiction history. In summary, the overall picture of a more serious profile for TC compared to SC isconsistent with findings of past studies of the self-change process (Bischof et al., 2002; Chitwood &Morningstar, 1985; Cunningham et al., 2000; Weisner et al., 2003).

Social support has been found to be an influential element in the maintenance of change for alcohol anddrug abusers. High levels of social and family support have been reported for those who recover throughtreatment and for those who change on their own (Bischof et al., 2000, 2002; Rumpf, Bischof, Hapke,Meyer, & John, 2002; Tucker, Vuchinich, & Rippens, 2004). In the present study, while both groupsreported receiving substantial social support, significantly more TC than SC participants reported socialsupport as a maintenance factor. Finally, while it was not possible to pay participants, as was done in manypast alcohol and drug natural recovery studies (Carballo et al., 2007; Sobell et al., 2000), it can be arguedthat this improves the external validity of the findings.

The present study has three limitations often associated with alcohol and drug natural recovery studies.The first is the retrospective nature of the data collection. As with treated substance abusers (see Babor,Steinberg, Anton, & Del Boca, 2000), the primary confirmation of self-reports of self-changers has beenby interviewing collaterals and by comparisons with official records (reviewed in Carballo et al., 2007;Sobell et al., 2000). In this regard, studies have shown that naturally recovered substance abusersgenerally provide fairly accurate reports of their pre-and post-recovery substance use (Sobell, Agrawal, &Sobell, 1997; reviewed in Klingemann & Sobell, in press; Sobell, in press).

The sample size is the second limitation of this exploratory study. However, while the sample sizesomewhat limited he power of statistical analyses, the large effect size found in the multiple logisticcoefficient of determination (R2 =0.412; indicating a large strength of association) suggests that thislogistic regression model may be replicated in different samples.

The third limitation, the self-selected nature of this sample, has been recognized in all natural recoverystudies that used a convenience sample (see Klingemann & Sobell, in press).

The results from this exploratory study comparing Spanish speaking alcohol and drug abusers in Spainwhose stable recoveries occurred either with or without treatment are very similar to those reported withEnglish-speaking cohorts. The findings also parallel the findings from natural recovery studies withalcohol, heroin, and cocaine abusers in Canada and Switzerland (Sobell et al., 2001; Toneatto et al., 1999).One likely reason why the results might resemble studies in other countries is that the course of addictivebehaviors may be similar across cultures. That is, individuals with more severe substance use histories aremore likely to experience treatment encounters because of the severity of their consequences. Clearly,additional studies in non-English-speaking countries with larger samples are needed to address this topicfurther. In this regard, this study will be replicated with Hispanic/Latino participants in South Florida.

Acknowledgement

The research described in this article was conducted as part of Jose Luis Carballo's doctoraldissertation and was supported by the grant MCYT-03-BSO-00732 (Ministerio de Ciencia y Tecnología-Ministry of Science and Technology, Spain).



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Differences among substance abusers in Spain who recovered with treatment or on their own

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