C H A P T E R

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Natural RecoveryTony Toneatto

University of Toronto, Toronto, ON, Canada

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O U T L I N E

Introduction

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Value of Natural Recovery Research

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Rates of Natural Recovery

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Review of the Natural Recovery Literature

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Process of Natural Recovery

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13rinciples of Addiction, Volume 1

ttp://dx.doi.org/10.1016/B978-0-12-398336-7.00014-0

Maintenance of Natural Recovery

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Methodological Issues

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Natural Recovery from Problem Gambling

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Conclusions and Future Directions

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INTRODUCTION

Traditional conceptual models of addictive behaviorhave stressed their chronic, progressive, and unremit-ting nature. Among many expressions of this perspec-tive, the disease model of addiction, whether reflectedin the self-help emphasis on the spiritual aspects ofaddictive disease, or the more recent, neuroscientificview of addiction as a “brain disease,” the assumptionis that addiction is mediated by basic deficiencies inbrain, mind, or spirit. In the absence of treatment,and left to its own natural course, death, disability,and deterioration are the inevitable outcomes. Withoutthe active intervention of professionals, within thecontext of formal treatment, the assumption is thata durable recovery would be highly unlikely. Such viewsof addiction and its resolution have also generally beenheld by the general public. This model of addictivebehavior and recovery, based on the study of individualswith severe dependence or who have been in formaltreatment programs, and an emphasis on lifelong absti-nence, leaves little space for alternative approaches andoutcomes. As a result, a bias arguing against the possi-bility of natural recovery from addiction has resulted.This chapter will review the recent empirical literature

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describing what is known about individuals whorecover from addiction without formal psychologicaltreatment. Although the majority of the research hasfocused on the abuse or dependence on alcohol, studiesof natural recovery among other psychoactive depen-dencies and pathological gambling will also be cited.

The assumptions of the disease model have been seri-ously challenged in the past several decades with anaccumulating body of empirical research demonstratingthat recovery from addiction may commonly occur inthe absence of formal treatment and that such recoveriesdo not always lead to abstinence. Viewing addictionproblems on a continuum of severity ranging betweenmild and severe dependence opens the possibility thatthere may be multiple approaches to resolution of addic-tion and goals other than total abstinence.

Natural recovery (or spontaneous remission, naturalremission, untreated remission, spontaneous recovery,maturing out, self-change, auto-remission), the notionthat the resolution of a serious addictive problem couldoccur in the absence of professional treatment and anadherence to abstinence, is one of the “taboo” topics inaddiction treatment. Indeed, the presence of an addictioncould only be verified if the individuals could not stopon through their own efforts. If one could cease an

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addictive behavior, then it is unlikely that they wereaddicted in the first place. Such tautological reasoningserved as “blinders” to the empirical literature bydemonstrating the successful recovery by individualswho would be considered to be dependent on psychoac-tive substances by any diagnostic criteria. Althoughreports of recovery that did not conform to the receivedopinion had been available in the research literature,these did not significantly alter the basic view that addic-tion was a chronic, progressive disease that wouldultimately lead to destruction and death unless remedi-ated through professionally mediated interventions.The conviction with which this attitude has been heldby generations of clinicians and researchers is perplexingwhen it is considered that the vast majority (over 80%) ofindividuals with nicotine addiction, for example, haverecovered without formal treatment and that the ratesof lifetime addiction are not matched by similar ratesof lifetime treatment seeking.

The natural recovery research has also challenged theconventional notion that the control of the addictiveprocess lies largely outside the volitional control ofthe individual. Overcoming addiction, within the tradi-tional perspective, requires that the individualssurrender personal control over the addictive processto the influence and variables beyond them (e.g. a medi-cation, Higher Power, God, therapist, physician, groupprocess) and that the individuals’ control lies primarilyin the insight that such surrender is necessary. Withoutthe intervention and assistance of a transcendentalinfluence, the individuals cannot make therapeuticprogress and durable recovery is thus unlikely. Thisassumption has been strongly challenged by the exten-sive natural remission and problem-solving therapy(i.e. cognitive-behavioral therapy) literature which hasunequivocally and empirically demonstrated that indi-viduals with substance dependencies do remain able tochoose among a range of alternative resolution strate-gies (e.g. 12 Step programs, medication, residentialtreatment, outpatient therapy) including recoverywithout treatment even in the midst of an addictiveprocess. While the severity of the addiction may makeit less likely for an individual to choose naturalrecovery, such a choice remains a possibility and is oftenthe first choice. It has been argued that formal addictiontreatment is only sought if efforts to stop on one’s ownare unsuccessful.

In summary, although early studies of untreatedrecovery were controversial for their conflict with thetraditional concept of addictive processes, the consensustoday suggests that not only may natural recovery be themost common pathway to the resolution of an addiction,but that this process occurs across all addictive behav-iors, substance-based or behavioral (e.g. pathologicalgambling). Self-recovery has been demonstrated for

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several psychoactive substances, including alcohol, ciga-rettes, cannabis abuse and dependence, cocaine, andother drugs. Individuals with behavioral addictions,such as problem gambling, have also been shown torecover without formal treatment. The Institute of Medi-cine (1990) has identified and supported naturalrecovery as an empirically supported route to recovery.

VALUE OF NATURAL RECOVERYRESEARCH

Apart from the scientific interest in studyinguntreated remission as a valid pathway to addictionrecovery there are several clinically relevant reasonsfor studying this phenomenon. Firstly, what constitutestruly effective treatment is yet to be defined. Formal,professional treatment continues to evolve and no treat-ment is reliably and durably effective. The results ofProject MATCH have demonstrated how difficult it isto successfully match treatments to individuals. In theabsence of a therapeutic “cure” for addiction it behoovesthe clinical addiction research community to continue todeepen our understanding of the variables that lead tothe resolution of an addiction problem. Furthermore,treatment seeking occurs for only a small proportion ofall those who develop a clinically significant addiction.Indeed, the vast majority of addicted individuals neverseek treatment. Recent comprehensive reviews ofnatural recovery have shown that addicted individualsmay avoid treatment because they fear the associatedstigma (a variable that may help account for the reluc-tance of some minority groups and women to seek treat-ment), believe their problem is not sufficiently severe tomerit professional treatment, or have a preference toresolve their addiction problem on their own, relyingon their personal resources. Thus, knowledge of theprocesses that mediate this increasingly commonpathway to addiction recovery may improve interven-tions for individuals who wish to resolve withoutprofessional treatment.

In addition to the necessity of continuing to under-stand recovery, regardless of how it occurs, and ofderiving a coherent scientific theory of untreatedrecovery, the elucidation of the variables that facilitateandmaintain such behavior changemay have importantimplications for the delivery of professional treatment,prevention strategies, and public policy. Clinicians canintegrate the insights derived from the natural recoveryliterature into their formal interventions; prevention andawareness strategies can be developed based on thechange processes that have been shown to triggernatural recovery; public policy can make this informa-tion available to a wider population of addicted individ-uals through a variety of means (e.g. web-based).

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RATES OF NATURAL RECOVERY

Several studies in recent decades have repeatedlydemonstrated that significant numbers of individualswith substance dependencies recover without everreceiving formal treatment. That such recoveries occuris no longer surprising or controversial. Epidemiologicalsurveys of American adults found that almost three-quarters of those with alcohol dependence who hadremitted in the previous year had done so withoutreceiving professional help. These rates were similar tothe rates among older adults (aged 51–65). Otherresearch has found that as many as one out of fivecollege students with a history of adolescent bingesignificantly reduced their alcohol consumption ofdrinking while still in college and without treatment.

The duration of the recoveries reported in thesestudies were neither transient nor unstable. An averageof about 6 years has been reported across differentpsychoactive substances indicating that these recoveriesare durable and sustained. Since a period of about 5years is considered a stable recovery, with or withouttreatment, the length of recovery reported in sponta-neous recovery studies suggest that these recoveriesare not a mere respite from an ongoing addictiveprocess. However, it should be noted that some studieshave shown that the recovery from the primarysubstance does always mean that the individual is absti-nent from all psychoactive substances and may thus beassociated with the continued use or abuse of anothersubstance (e.g. of alcohol in a sample of naturally recov-ered cocaine and heroin users).

REVIEW OF THE NATURAL RECOVERYLITERATURE

In their seminal review of 38 natural recovery studies(comprising 40 samples) dating back several decades,from 1960s to 1998, Sobell, Ellingstad, and Sobell(2000) found that the methodological quality of theresearch was generally poor. In general, early studiesfailed to describe their samples adequately, did notdescribe pre-recovery substance histories and severityin sufficient detail, failed to assess factors associatedwith the maintenance of recovery, ignored the compli-cating factor of concurrent psychiatric psychopathology,did not corroborate subject self-report, or assess familyhistory of addiction. The vast majority (75%) of earlierstudies addressed the spontaneous recovery fromalcohol (not unusual since this substance is the mostabused in western culture), followed from heroin(22.5%) and cocaine (7.5%). Advertisements (38.5%)were the most common way these subjects were

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recruited, followed by snowballing techniques (28%)and surveys (23%). The samples surveyed were gener-ally male (69%), unmarried (64%), and unemployed(45%) with a mean age of 34.4 years at the time of theirrecovery.

Recently, Carballo et al. (2007) updated the Sobellet al. (2000) review. Twenty-two natural recoverystudies were published in the 7 years following Sobellet al. (2000). Similar to the earlier review, the Carballoet al. study (2007) found that the majority of the 22studies addressed natural remission from alcohol(82%) followed by cannabis (32%), heroin (23%), andcocaine (23%). Surveys (45%) and media solicitation(41%) remained the most common ways to recruitsubjects. The demographic profile across both reviewswas quite similar. Men continued to be the majorityof individuals recruited into natural recovery studies,with a mean age in the early 40s, likely reflecting thehigher prevalence of addiction among men. The Car-ballo et al. (2007) review found that the length of theaddiction prior to natural recovery was approximately13 years (compared to 11 years in the Sobell, et al.(2000) review). The mean length of the naturalrecovery was 8 years in the Carballo et al. (2007)review compared to 6.3 years in the earlier review.Abstinent outcomes continued to be reported by overhalf the sample in both reviews (57% versus 60%,respectively). Family-related reasons (54.5% of studies)with health (50%) followed by financial concerns (50%)were the most common explanations for the decision torecover from the addiction in the Carballo et al. (2007)review while health-related reasons were cited as themost important factor in the older review. The mostcommon factors maintaining natural recovery reportedin the Carballo et al. (2007) were social (54.5% ofrespondents) and family support (45.5% of respon-dents), similar to the 2000 review. About a third ofthe respondents reported avoidance of the addictivesubstance, self-control, and spirituality as importantmaintenance factors.

In their assessment of the quality of the naturalrecovery research since 2000, Carballo et al. (2007)noted that socio-demographic variables at the time ofthe recovery continued to be underreported (comparedto these variables at the time of the interview, whichgenerally tended to be well-reported). In other words,a clear understanding of the sample at the time of therecovery was generally lacking. Insufficient researchexamining the relationship between natural recoveryfrom multiple substances has been conducted andremains a neglected area of research. Naturally recov-ered individuals tended to have had a less severeaddiction with less severe consequences than didtreated populations, a finding that has been repeatedlysubstantiated empirically.

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The study of natural recovery from nonalcoholsubstances remain in the minority. The associationbetween natural recovery and psychiatric comorbidityremains unclear although in a recent study alcoholnatural recovery was equally prevalent among nonpsy-chiatrically comorbid or comorbid individuals suggest-ing that the presence of Axis I disorders was nota negative prognosis for untreated recovery fromalcohol dependence. However, this should not be inter-preted to mean that all natural recovery samples aresimilar. For example, three subgroups of naturallyrecovered populations have been delineated: lowdependence/few alcohol problems/low social support;high dependence/several alcohol problems/moderatesocial support; low dependence/high social support/few alcohol problems. Such complexity precludes anysimple description of naturally recovered populations.

PROCESS OF NATURAL RECOVERY

Having established the frequent occurrence of naturalrecovery, an issue of great interest is the trigger or reasonfor such transformations and the variables that maymaintain such recovery. There appears to be a growingconsensus that a cognitive process mediates naturalrecovery. In response to the debilitating effects of addic-tive behavior on their physical and mental health, rela-tionship with significant others, and financial status,individuals undergo a process of rational re-evaluationof their substance use, weighing the advantages anddisadvantages of continued use. Over time, the out-weighing of the positives of substance use through theaccumulation of negative consequences leads to a recon-sideration of the benefits, value, and advantages ofcontinued substance use. When the decisional balancetips irrevocably toward aversive effects, the individualis more likely to decide to make efforts to cease use.There are several models of cognitive change that areapplicable to this decision-making process such as theTrans-theoretical Model of Change and Conflict Theory.However, little is known about what contributes to thedefining decisional moment that leads to stable behav-ioral change.

This cognitive process mediating natural recovery isto be distinguished from recoveries triggered by theoccurrence of discrete, highly salient, negative conse-quences, such as a stressful life event (e.g. severe illness,loss of relationship, major injury), that leads to a rapiddecision to cease use. While these types of eventscertainly play a role, cognitive reappraisals appear tobe the more common process and have been observedin the recovery from cocaine, heroin, and alcohol addic-tion as well as behavioral addictions such as problemgambling. In a qualitative analysis of recovery

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narratives among alcohol, cocaine, and heroin subjects,the following 11 major categories of reasons for recoverywere identified: cognitive evaluations/assessments,behavior monitoring/action statements, problem-related reasoning, dramatic events, references toothers/statements of support, health, religious attribu-tions, time-frame, affect-related statements, alcohol-related statements, references to illicit/licit drugs. Themost common reasons allude to an ongoing examinationof the effects of the addictive behavior on the individ-uals’ functioning. Evidence for a role of cognitivere-evaluation (versus discrete events) has implicationsfor community-level interventions in which evaluationof the pros and cons of substance use is facilitated asa means of shifting the individual’s attitude towardthe substance in the direction of the cessation orreduction.

MAINTENANCE OF NATURALRECOVERY

The maintenance of natural recoveries has receivedless empirical study. The few studies that have investi-gated this aspect of recovery have identified the criticalrole of social support from significant others. Thisfinding replicates what is already known about themaintenance of recovery among treated samples. Inthe case of natural recovery from drug abuse, there isalso a “geographic” change in which the individualavoids social and physical environments associatedwith drug use. The role of social capital, defined asthe resources, available to an individual as a result ofthe availability of a network of mutual relationships,in the maintenance of untreated recovery can providesources of social control, family support, and extra-familial benefits. Taking into consideration the individ-ual’s social capital necessarily directs our attention tothe broader social context of recovery and the role thatstructured social relations play in overcoming drug-use related problems without treatment. How nonad-dicts respond to the individual recovery and whethersuch responses can facilitate the recovery requires addi-tional study. In a study of naturally recovered opiateaddicts, the importance of social and familial relation-ships, gratifying leisure activities (e.g. hobbies), andemployment in the maintenance of behavioral changewere identified as critical to the maintenance ofrecovery. A conventional lifestyle that brings structureto one’s life was considered crucial in establishinga successful recovery. It has been suggested that naturalremission from drug dependence, in contrast to alcoholdependence, often requires a radical modification oftheir social network and way of life. Naturally

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recovered alcohol abusers are more likely to return toa previously existing conventional lifestyle.

METHODOLOGICAL ISSUES

Natural recovery studies have been divided into twomajor types: those that investigate the variables associ-ated with the onset and maintenance of natural remis-sion (and which may include control groups) andthose that estimate the prevalence of natural remission.The two classes of studies are complementary as thelatter research provides the estimate of how widespreadnatural recovery is while the former elucidates thepsychosocial variables that contribute to naturalrecovery. In recent years, general population studieshave reduced their reliance on solicitation techniquesbased on snowballing or media thereby reducing thebiases of self-selection. Studies that have relied onmediarecruitment may recruit individuals who are differentthan those who do not respond to media solicitations(e.g. less dependent). The variability of what is consid-ered an alcohol problem (e.g. dependence, abuse, self-report) (not described in 40% of the studies reviewedby Sobell et al. (2000)) remains a serious weakness ofthe earlier literature. This variable is an importantdescriptive variable since, for example, natural remis-sion may be correlated with the severity of the alcoholproblem. This was demonstrated in a study where thosewith only one alcohol-related problem had elevatedrates of natural remission (87.5%) compared to thosewho reported six alcohol-related problems (53.7%).

The definition of what constitutes treatment hasvaried across studies. This issue has been furthercomplicated by the fact that the benefits of formal treat-ment may not always be correlated with the number ofsessions attended. There is strong evidence that evenvery brief professional contacts, as may often occur inthe offices of physicians, can have a significant impacton patients’ behavior. In some studies of naturalrecovery, some subjects have even reported receivingformal treatment but have adamantly maintained thatthese treatments did not affect their recovery. In othercases, especially when natural recovery over the lifespan has been examined, formal treatment may haveoccurred years prior to recovery. Thus, studies thatallow very minimal treatment contact, including self-help groups (i.e. two meetings), may describe a differentsample of natural recovery than do studies that rigidlyexclude any treatment contact whatsoever, includingattendance at self-help groups. Many studies unfortu-nately combine individuals with a treatment historywith those without such a history. In recent years,a stricter, more conservative definition of treatment hasbeen employed and data separated for those with

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a positive history from those with no history. Naturallyrecovered samples with a history of formal treatmentare not equivalent to those with no, or very minimal,histories of professional treatment. Typically, thosewith a history of treatment have more severe addictionproblems than those without any treatment history.

NATURAL RECOVERY FROM PROBLEMGAMBLING

Although identified as an impulse disorder in DSM-IV the key symptoms defining this disorder and the rec-ommended treatment approaches bear a very strongresemblance to substance use disorders. Not uncom-monly, gambling is considered an addictive disorderamong the professional community and the generalpublic. Since the prevalence data suggest that the popu-lation of individuals who have a mild to moderategambling problem may be much larger than thosewith a more severe problem, natural recovery asa common and preferred pathway to recovery requiresadditional study.

There have been a number of studies that have inves-tigated the natural recovery from pathological orproblem gambling. Not surprisingly, natural recoveryfrom problem gambling appears to be highly compa-rable to that observed for substance use disorders.Several sources of evidence suggest that recovery froma gambling problem may not always be mediatedthrough contact with the formal treatment system butrather reflect natural recovery processes parallelingthose found with untreated recovery from substancedependencies. As has also been the case with substanceuse disorders, epidemiological studies of gamblingprevalence frequently identify significant numbers of“former gamblers.” For example, over a third of lifetimegamblers surveyed reported no problems in theprevious year but did not report having received treat-ment. Similar results have been reported in Americanand Australian population surveys. In addition to theepidemiological evidence, the number of treatment-seeking gamblers is often considerably below whatwould be expected based on the point prevalence data.The National Gambling Impact Study Commission(1999) has estimated that less than 3% of pathologicalgambling had participated in formal treatment. Clearly,a substantial number of problem gamblers do notresolve this impulse disorder through formal treatment.

Similar to untreated recovery from addictions,natural recovery from problem gambling appears toinvolve a cognitive evaluation process focused on thedetrimental impact of gambling on the individuals’core values as well as an accumulation of gambling-related negative consequences. Negative emotional

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states, financial crisis, interpersonal distress, and conflicthave been identified as frequently mentioned reasonsfor resolving the gambling problem in several studies.Change strategies reported by naturally recoveredproblem gamblers included staying from social situa-tions and environments where powerful gambling trig-gers may be present, avoiding gambling locations,instituting desirable lifestyle change, and remainingaware of gambling-related negative consequences. Stim-ulus control, development of gambling-incompatiblelifestyle, reduced access to money, and awareness ofgambling-related negative consequences have beenidentified in many studies as the most common changemaintenance strategies following recovery. The majorityof naturally recovered gamblers, unlike what has beenreported in the substance use literature, choose absti-nence. Untreated, naturally recovered gamblers appearto have a less severe gambling problem than do treatedgamblers. Gambling severity was found to predict treat-ment entry with less severe problem gamblers morelikely to prefer natural recovery. Treated gamblerswere found to have had a longer problem gamblingduration, greater gambling severity, more numeroussymptoms of gambling (e.g. feelings of despair, panic,suicide), and more gambling-related negative conse-quences (e.g. family, health) compared to the untreatedbut recovered gamblers.

In summary, the severity of problem gambling maybe the main variable distinguishing those who chooseto recover from gambling without treatment. Moststudies of gambling natural recovery, like those ofsubstance dependence, identify a crisis in self-image orvalues as accompanied by multiple gambling-relatednegative consequences as precipitating a re-evaluationprocess of the role of gambling in their lives.

CONCLUSIONS AND FUTUREDIRECTIONS

Untreated recovery from addictive behavior has beendemonstrated to be a common pathway across all addic-tions. The results of a diverse set of methodologicalapproaches have shown this recovery process to berobust. Several approaches to identifying naturallyrecovered individuals (e.g. population surveys, mediasolicitation, surveys, snowballing techniques) haveshown substantial rates of recovery from alcohol andother drug problems without ever receiving formaltreatment or attending self-help groups. Such recoverieshave been shown to generally be triggered by cognitiveappraisals of the cost and benefits of substance use. Thatis, addicted individuals reach a point in their addictioncareer in which they can no longer continue or justifyaddictive behavior. While specific events may be

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associated with the final decision to quit or reducesignificantly, it is clear that a parallel cognitive processhas been active for which the triggering event has beenthe definitive one. Such cognitive processes are likelypresent in all individuals caught in the addictive cycleand can ultimately lead to recovery as the benefits oradvantages of substance use outweigh the decideddisadvantages and risks.

Most evidence suggests that naturally recovered indi-viduals are less severely dependent than those whorecover with formal assistance. A review of the naturalrecovery research literature came to the followingconclusions regarding the study of natural recovery(and applicable to the study of natural recovery fromproblem gambling as well). It was suggested that futureresearch should focus on the following: ethnicsubgroups (e.g. Asian), high-risk groups (e.g. aborigi-nals) and other minorities, individual differences char-acterizing those who recover without treatment, andgender differences. Major reviews of the naturalrecovery literature have also called for the study ofsubgroups within naturally recovered samples acknowl-edging that this population is not heterogeneous. Thus,future research should continue to explore individualdifferences in natural recovery in order to determinewhich subpopulations of substance dependence arelikely to adopt natural recovery. Such information willbe critical in developing targeted prevention and publichealth programs to reduce the incidence of substanceabuse and dependence.

SEE ALSO

Alcohol Use Disorders, Gambling, Epidemiology ofAddiction, Maturing Out

Further Reading

Biernacki, P., 1986. Pathways from Heroin Addiction RecoveryWithout Treatment. Temple University Press, New York.

Bischof, G., Rumpf, H.J., Hapke, U., Meyer, C., John, U., 2005. Naturalrecovery from alcohol dependence: how restrictive should ourdefinition of treatment be? Journal of Studies on Alcohol 63,229–236.

Carballo, J.L., Fernandez-Hermida, J.R., Secades-Villa, R., Sobell, L.C.,Dum, M., Garcıa-Rodrıguez, O., 2007. Natural recovery fromalcohol and drug problems: a methodological review of the liter-ature from 1999 through 2005. In: Klingemann, H., Sobell, L.C.(Eds.), Promoting Self-change from Addictive Behaviors: PracticalImplications for Policy, Prevention, and Treatment. Springer,New York, pp. 87–101.

Institute of Medicine, 1990. Broadening the Basis of Treatment forAlcohol Problems. National Academy Press, Washington, DC.

Klingemann, H., Sobell, L.C. (Eds.), 2007. Promoting Self-change fromAddictive Behaviors: Practical Implications for Policy, Prevention,and Treatment. Springer, New York.

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Klingemann, H., Sobell, M.B., Sobell, L.C., 2009. Continuities andchanges in self-change research. Addiction 105, 1510–1518.

National Gambling Impact Study Commission, 1999. Final Report.U.S. Government Printing Office, Washington, DC.

Rumpf, H.J., Bischof, G., Hapke, U., Meyer, C., John, U., 2009.Remission from alcohol dependence without formal help: currentstatus of the research. Sucht 55, 75–85.

Slutske, W.S., 2006. Natural recovery and treatment-seeking in path-ological gambling: results of two U.S. National Surveys. AmericanJournal of Psychiatry 163, 297–302.

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Sobell, L.C., Ellingstad, T.P., Sobell, M.B., 2000. Natural recoveryfrom alcohol and drug problems: methodological review of theresearch with suggestions for future directions. Addiction 95,749–764.

Toneatto, T., Millar, G., 2004. The assessment and treatment ofproblem gambling: empirical status and promising trends. Cana-dian Journal of Psychiatry 49, 173–181.

Toneatto, T., Sobell, L.C., Sobell, M.B., Rubel, E., 1999. Naturalrecovery from cocaine dependence. Psychology of AddictiveBehavior 13, 259–268.

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