Self-Help Approaches for Addictions

Is Self-Help Good for Everyone?

Addictive behaviors can be and often are identified, modified, and resolved through self-initiated processes. As reviewed later in this chapter, individuals who were once dependent on addictive substances have demonstrated the ability to change those maladaptive behaviors, often through means of self-help alone. Notwithstanding this, isolative and self-administered recovery, particularly in advanced cases of substance use disorders, may be ill-advised. With the exception of natural recovery (see subsequent text of this chapter), individuals fully entrenched in profound and active addiction are unlikely to manage successful and enduring recovery by relying exclusively on their own resources. In those cases, self-help interventions may best be understood as an initial stage in a multifaceted intervention approach, helping to facilitate a greater appreciation of the nature, symptoms, consequences, and resources available to combat substance use disorders.

Self-Help as Empowering

Although there are risks associated with self-administered treatment, there are also benefits in addition to alterations in substance use, which occur on an idiosyncratic level. Lacking professional intervention or guidance, individuals pursuing self-help interventions run the risk of potentially acquiring inadequate or ineffective information. However, self-help has the advantage of enabling individuals to achieve the internal resources necessary to feel a greater sense of autonomy and mastery over their behavior and their environment. This cultivated sense of power can have positive effects on self-esteem, self-efficacy, and personal responsibility. These personal tools can breed the confidence and internal fortitude necessary to sustain recovery and prevent or recover from relapse. Such changes in coping and identity may be instrumental and necessary for individuals to seek professional help in the process of recovery.

Natural Recovery

Natural recovery refers to the process by which many individuals who experience considerable difficulties related to their substance use successfully implement change without any formal assistance. Some individuals appear to simply “mature out,” whereas others change in response to a specific event or set of circumstances. Sobell et al. seminal examination of natural recovery from problematic alcohol and/or drug use (excluding tobacco) considered 40 samples of participants in 38 studies published between 1960 and 1997. Carballo and colleagues subsequently examined 22 studies published between 1999 and 2005 but used a more liberal time period in designation of substance use problem resolution. Although the majority of studies of natural recovery have focused on alcohol, earlier studies also included heroin. In recent years, there has been a substantial surge in studies examining natural recovery from problematic cannabis use. These studies of natural recovery have largely relied on retrospective reports of participants’ reasons for changing. These narrative accounts raise questions regarding potential memory distortions, self-serving biases, and/or inaccurate attributions of the effectiveness of specific factors leading to change. Nevertheless, they provide potentially important insights into successful self-help strategies. Combining the 40 studies from 1960 to 1997 reviewed by Sobell and colleagues with the 22 studies from 1999 to 2005 examined by Carballo and colleagues, we found that the most frequently reported reasons for reducing or eliminating substance use by successful self-changers were health-related (45%), financial (37%), negative personal reasons (e.g., shame and guilt, 35%), family-related (34%), significant other (32%), and religious reasons (31%). Factors most strongly associated with successful maintenance of change were social support (40%), family/significant other (34%), avoidance of substance use situations (24%), religion (23%), and developing non–substance-related interests (23%).

Maturation Effects

Related to the idea of natural recovery is the process of maturing out. Epidemiological literature and studies of natural history indicate that the highest rates of alcohol and other substance use occur during late adolescence and early adulthood. Increasingly referred to as “emerging adulthood,” the period corresponding from about high school graduation through the early 20s is associated with increased risk behaviors and experimentation across a range of high-risk behaviors, including substances of abuse. The majority of young adults who use substances during this developmental stage, even at problematic levels, reduce or eliminate use as they assume career and family responsibilities. Individuals who experience substance use later in life and who reduce use without formal help tend to be in their mid-40s and report their heaviest use to be in their mid-to-late 20s, further suggesting that, for many, natural recovery may be a maturational process.

With respect to research related to natural recovery, the majority of the literature has focused on alcohol. Other specific substances have also been examined in the context of natural recovery, including nicotine, marijuana, cocaine, and heroin, with relatively similar findings across substances. Natural recovery from nicotine, alcohol, and marijuana is reviewed below.

Processes of Change

Directly related to natural recovery, processes of change have been described as part of the Transtheoretical Model of Change (or Stages of Change Model). The Transtheoretical Model of Change, which has been applied extensively to the field of substance use disorders and beyond, began with interviews of former smokers regarding their experiences with change. The model describes a sequence of stages in which individuals who are not initially aware of a need to change and are not in any way considering modification (precontemplation) over time begin to consider the possibility of making alterations (contemplation) and subsequently prepare for (preparation) and implement change (action). In the absence of relapse or regression to previous stages, individuals are ideally able to maintain change successfully (maintenance) over time. In the context of developing their model, Prochaska and DiClemente defined a number of processes that individuals identified as being important in their efforts to change. The processes of change include substitution, seeking information, cognitive evaluation, seeking support from others, self-rewards for change, affirmation of commitment, and restructuring one’s environment. The Transtheoretical Model of Change and associated processes has provided a useful framework for considering how people identify, approach, and resolve problematic behavior. But it is also clear that original formulations of the model were overly simplistic.

Replacement and Caffeine

Caffeine is a plant alkaloid found in numerous species, which acts as a central nervous system and metabolic stimulant. Estimates have indicated that upwards of 90% of American adults consume caffeine on a daily basis ; it is also believed to be one of the most widely used psychoactive substances in the world. Caffeine is typically consumed to overcome lethargy, to promote vigilance and alertness, and to elevate mood. The major source of caffeine is coffee beans, but it is also commonly found in chocolate, tea, and soft drinks, as well as energy drinks and over-the-counter medications for headaches, pain relief, and appetite control. Although caffeine remains unscheduled and recognized by the US Food and Drug Administration (FDA) as a “safe food substance,” it is an addictive substance that can lead to withdrawal symptoms after cessation of consistent use. Caffeine may be commonly overlooked as a drug of abuse, in part due to its nearly universal legal status, prevalence as a normative food staple, and absence of commonly associated negative consequences. Furthermore, people may be unaware of or may underestimate their daily caffeine consumption, as the drug is associated mainly in connection with coffee. As a result, consumers may not be aware of the amount of regular consumption, impact on their daily functioning, or degree of physiologic and psychologic dependence.

The fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) identifies Caffeine-Related Disorders to include Caffeine Intoxication and Caffeine Withdrawal. Currently, caffeine use cannot be diagnosed as a formal substance use disorder; however, Caffeine Use Disorder was identified as a condition for further study. The symptoms of acute caffeine intoxication may include restlessness, nervousness, hyperexcitability, insomnia, gastrointestinal disturbance, muscle twitching, rambling, tachycardia, and agitation. Very rarely, high doses of caffeine (>10 g) may produce respiratory failure or seizures. Regular users commonly develop tolerance to caffeine and may experience intense cravings after discontinuation. Withdrawal symptoms include headaches, flu-like symptoms, feelings of lethargy and reduced motivation, and dysphoric or irritable mood.

Individuals seeking to reduce or abstain from caffeine may find that the cravings can be managed by substance replacement. Because caffeine is less addictive than are other socially acceptable substances (e.g., alcohol, nicotine), replacement in social settings may be more easily achieved, providing a particularly effective way to reduce caffeine and mitigate adverse health consequences. The most popular replacement for caffeine is decaffeinated coffee, which contains between 2–15 mg of caffeine per 8-ounce cup compared to between 80–100 mg of caffeine in an 8-ounce cup of caffeinated drip coffee. International standards require that decaffeinated coffee beans are 97% free of caffeine, while the European Union standard requires that coffee beans are 99% caffeine-free by mass. This small amount of the active substance may help attenuate withdrawal symptoms including headaches, nausea, vomiting, muscle pain, and stiffness. Decaffeinated and herbal teas offer another option for caffeine replacement. Those individuals who are interested in reducing their caffeine intake from soft drinks have a variety of brand options offering caffeine-free drinks. There remains scant literature concerning the effectiveness of decaffeinated substitution for caffeine use; however, replacement in this manner can be a helpful harm reduction approach to significantly reduce one’s intake of the drug (in the case of decaffeinated coffee) or to eliminate intake altogether.

Replacement and Nicotine

Both anecdotal evidence and scientific data speak to the highly addictive nature of nicotine, and more specifically, of nicotine found in tobacco products. Researchers regard nicotine as one of the most addictive recreational substances in use. Similarly, the American Heart Association considers nicotine to be one of the hardest addictions to break. Nicotine, a central nervous system stimulant, is a plant alkaloid found most abundantly in tobacco leaves and is thought to be the main factor responsible for the dependence-forming properties of tobacco smoke. Although inhalation of tobacco smoke is the most common route of nicotine administration, tobacco may also be insufflated or chewed. Tobacco smoke contains carbon monoxide, as well as a mixture of particulate substances generated by the combustion process that make up tobacco tar. Inhalation of carbon monoxide and tar is primarily responsible for the various diseases resulting from long-term use. Physiological and psychological dependence on nicotine generally develops quite rapidly, reflecting nicotine’s pharmacokinetic properties, which are characterized by rapid distribution of nicotine to the brain that reaches peak levels within 10 seconds of administration. However, the acute effects of nicotine dissipate rapidly, as do the associated feelings of reward, promoting re-administration in order to maintain the drug’s pleasurable effects and prevent withdrawal. This characteristic pattern of administration/reward and withdrawal/punishment is instrumental in maintaining nicotine use despite its negative consequences.

Rapid decreases in cigarette use can result in a variety of uncomfortable withdrawal effects including restlessness, increases in appetite, difficulty concentrating, irritability, constipation, and sleep disruption. Given the myriad of injurious and life-threatening implications of regular, heavy tobacco use, there have been massive public health initiatives to address this problem. Consistent and strong positive associations exist between cessation of use and maintaining a tobacco-free lifestyle. The US Department of Health and Human Services underscores that early tobacco use relapse is associated with difficulty coping with withdrawal symptoms. In order to increase cessation success rates, nicotine replacement strategies were introduced to mitigate the early intense withdrawal symptoms linked with relapse, and thereby improve successful cessation maintenance.