Week 10 Discussion 2

RESEARCH ARTICLE

Exploring the processes involved in long-term recovery from chronic

alcohol addiction within an abstinence-based model: Implications

for practice

PETER MADSEN GUBI 1 * & HOWARD MARSDEN-HUGHES

2

1 School of Health, University of Central Lancashire, Preston, UK, and

2 Priory Hospital, Preston, UK

Abstract

Background: There is little consensus at policy or treatment level as to what defines ‘recovery’ in the alcohol addiction field.

Aim: From interviewing a cohort of eight severely alcohol-dependent people who fulfilled all categories of DSM-IV and ICD

10 diagnostic criteria and had achieved long-term recovery (LTR) of between 8 and 48 years, and who are long-term AA

members, a definition of recovery that is inclusive, and achievable, was sought from their lived experiences. Methodology:

Interpretative Phenomenological Analysis was used. Findings: This research uncovers the processes involved in long-term

recovery, and identifies them as: sober; maintaining sobriety; and recovery. It suggests a move away from the acute model of

cure by brief, time-limited therapy, towards a model of sustained, on-going and life-long recovery management, combined

with pro-social aid resources. Individuals need to observe, and hear, the success narratives of others, and the therapeutic

conditions of empathy, unconditional positive regard and congruence need to be strongly experienced by the individual.

Keywords: sobriety; recovery; abstinence; shame; chronic addiction; counselling; alcohol

Introduction

‘Alcoholism’ is now regarded as reaching ‘epidemic’

proportions in the UK (Plant & Plant, 2006).

Within the addiction field (AF), there has been a

move away from the traditional, pragmatic, harm

reduction approach, towards a recovery-based para-

digm (Laudet, 2010; Laudet & White, 2004); yet,

there is no consensual definition of what ‘recovery’

means. This failure undermines clinical research,

compromises clinical practice, and muddles the

AF’s communications to service constituents, allied

service professionals, the public, and policymakers

(White, 2007). The goals of treatment often vary.

There is a debate as to which form of treatment is

best. This consists of: (1) each therapeutic modality

has sought to prove the effectiveness of its own

particular procedures (Timulak, 2005); (2) the

aetiology of the condition (Polcin, 1997), where

the best way to understand, and ultimately change

addictions, is to understand why and how they

began (DiClemente, 2006); (3) whether alcoholism

should be treated as a disease, an obsessive-

compulsive syndrome, or a lifestyle-choice model,

thereby determining the selection of specific psy-

chotherapeutic modalities (Castonguay & Beutler,

2006). The idea that recovery from alcohol depen-

dence should involve permanent abstinence from

alcohol is considered unnecessary and debateable.

Yet, there is growing evidence, from drug- and

alcohol-dependent individuals themselves, that ab-

stinence, as the measure of recovery, is being

actively sought (McKeganey et al., 2004).

One absent cohort of stakeholders, about whom

there is minimal research, is those who have achieved

decades of long-term recovery from severe alcohol

dependence, and who fulfil all the diagnostic criteria

of DSM-IV and ICD-10. This research identifies

*Corresponding author. Email: [email protected]

Counselling and Psychotherapy Research, 2013

Vol. 13, No. 3, 201�209, http://dx.doi.org/10.1080/14733145.2012.733716

# 2013 British Association for Counselling and Psychotherapy

them as a resource of valuable information as to how

they have achieved this, how they maintain their

recovery, and how they understand and define

recovery. The aim of this study was to examine the

lived-experiences of individuals who have achieved

long-term recovery (LTR), in excess of five years, in

order to understand how their recovery had been

achieved, how recovery is viewed, and determine the

process that enabled them to transition from active

alcoholic dependence to LTR. The research ques-

tion asked was, ‘How do chronic alcohol-dependent

persons in long-term recovery experience the transi-

tion from alcohol dependence into recovery, and

how do they understand and maintain recovery?’.

Method

A thematic analysis was conducted of eight partici-

pants’ descriptions of their life-experiences in terms

of their transition from drinking, to addiction,

moving into recovery and maintaining LTR, which

was delineated as being longer than five years. The

researchers attended local Alcoholics Anonymous

(AA) meetings in Lancashire. Participants did not

have to meet any medically-recognised diagnostic

criteria, but were self-identified, severely dependent

alcohol users over prolonged periods (in excess of

12 years). The selection process was conducted on a

first come, first served, basis.

Participants

For each participant, alcohol was their primary drug

of choice, and none was actively drinking. All

participants were over 18 years old. Table I shows

the participant group.

Whilst disparate in their socio-economic back-

grounds, they were all involved within AA and the

12 Step Programme. With exceptions of drink

driving convictions (P3), none had been involved in

serious or violent crime, or experienced custodial

sentencing. All had come from white, Anglo-Saxon,

non-disadvantaged, middle class homes, with stable

family units. One participant (P8) reported evidence

of alcohol dependence in her father, otherwise there

was no evidence of siblings, parents, or other genetic

family members being reported for alcohol depen-

dence, or indicating any known genetic pre-disposi-

tion. No participant had been treated by any

therapeutic intervention as an in-patient for alcohol

addiction, and only one patient (P2) had been

admitted to hospital for alcohol-related problems.

Data collection

Interviews were semi-structured using the following

questions:

(1) How did alcohol become important in your

life?

(2) How did you experience the journey from

using alcohol to becoming addicted?

(3) How did you experience the recovery process?

(4) What do you understand recovery to mean?

(5) How do you maintain your recovery?

Additional questions were only asked for the pur-

poses of clarification. The data were analysed using

Interpretative Phenomenological Analysis (Smith,

1996; Smith et al., 1999). As Person-Centred

therapists, the researchers were keen to hear the

participants’ existential phenomenology as they re-

flected on their process in the context of the research

questions. Therefore, the thick data are included in

order for the participants’ own voices to be heard.

Ethics

Concern was taken to conduct the research accord-

ing to the ethical principles stipulated in the BACP

ethical guidelines for researching counselling and

psychotherapy (Bond, 2004). Ethical approval was

sought from, and granted by, the University Ethics

Committee. Following receipt of a participant’s

information letter, and the completion of a consent

form, interviews were digitally recorded and tran-

scribed. In case the interviews triggered painful

memories, therapeutic counselling was offered,

free-of-charge, to all participants, but this was not

required. The data were coded by letter and number

(e.g. P3) to protect anonymity. Participants received

a copy of the transcript of their interview to validate

accuracy and make any changes that they wished to.

Table I. Participant group.

Code Gender Age Length of sobriety (years)

P1 Male 67 31

P2 Female 63 25

P3 Male 75 43

P4 Female 51 17

P5 Female 54 22

P6 Male 62 18

P7 Male 72 33

P8 Female 84 48

202 P. M. Gubi & H. Marsden-Hughes

All information collected during the research was

kept strictly confidential, made anonymous and

stored on an encrypted computer, which was locked

securely.

Reflexive statement

Motivating this research, for us as researchers and

therapists, has been an intrigue as to why some

people seem to achieve recovery and others don’t.

There is a debate within the alcohol treatment field as

to which therapeutic modality works most effectively;

yet most research studies focus on outcome, and not

process. When patients have arrived at our doors and

have said that, for them, controlled drinking will not

work and that they need something different, it has

begged the question ‘what is that difference’? So we

felt, why not talk to people in long-term recovery and

ask them how they did it.

Findings

The recovering participants looked back on their

past from the vantage point of recovery and it is from

this remove that they were trying to make sense of

the past (Table II).

How alcohol become important in their lives

Dissatisfaction with self. From late childhood/early

adolescence, many individuals had an awareness of a

dissatisfaction with the self, where an egodystonic

voice (i.e. a voice that is at odds with one’s idealised

self) reinforced negative feelings of not being able to

cope with life (P3; P5; P7); a pervading sense of fear

(P5); shyness (P8); self-hatred (P3); insecurity (P5);

self-contempt (P3); isolation (P5); loneliness (P8);

feeling ill-equipped for life (P5); boredom (P6);

being emotionally immature (P3; P5); not being in

control (P5); being a failure (P3); disappointment

with self (P6) and having low self-esteem (P5). This

sense of difference, or not fitting into the milieu of

their social environment, was metaphorically de-

scribed as being, ‘a bit of a square peg in a round

hole’ (P8). They also shared a belief, gained in

recovery and with which they could identify, that

alcoholics displayed certain ‘personality traits’ or

‘defects of character’ which were identified as

grandiosity, dishonesty, self-deception, emotional

immaturity and lack of emotional development

(which was frozen when alcohol is first ingested)

and ruthless self-centredness (P3). Additionally,

there was an understanding that they suffered from

some kind of incurable illness (P1; P2; P4; P5).

Conforming. Despite differences in their social

backgrounds, they found the need to conform to

their social environment difficult. In the majority of

cases, alcohol was at some point ingested in adoles-

cence, where alcohol was seen as a normative and

pleasurable experience. It was described as being

‘normal’ (P5) or ‘typical’ (P1) of teenagers and their

behaviour was no different from others of their age

group. In one instance (P2) where alcohol was first

ingested in her early 20s, the legality of her actions

again reinforced this normality; there was no im-

mediate cause for concern. What they felt distin-

guished them from other people, was that their use

of alcohol, from the outset, was seldom for purely

social purposes.

. . . the start of my drinking, was drinking at home,

it was never out socially and that was for me the

first drink that I remember drinking on feelings,

rather than drinking socially . . . (P2)

Effect. What was noted was the ‘effect’ (P7; P8),

‘buzz’ (P2; P7), or ‘instant glow’ (P6) where alcohol

produced a range of countervailing feelings which

offset the negative egodystonic sense of self; ‘con-

fidence’ (P1; P5); self-efficacy (‘more capable’ [P5]);

a release of ‘social energy’ (P5). Alcohol not only

became a ‘support’ or ‘prop’ as a means of coping

with life, but was also configured in human terms as

a ‘friend’ (P5). In each case, a drinking pattern (P3;

Table II. Themes and subthemes.

Major themes

How alcohol became

important in life

Experiencing the transition

from using alcohol to

becoming addicted

Experiencing the

recovery process Understanding recovery

Subthemes Dissatisfaction with self Shame & guilt Cessation Being sober

Conforming Becoming two people External agency Maintaining sobriety

Effect Denial Supportive belonging Recovery

Self-contempt Maintaining recovery

Long-term recovery from chronic alcohol addiction 203

P8) was quickly established, yet the belief that they

drank in common with others reduced any feelings of

difference. The emollient effect of alcohol was,

therefore, perceived to be both pleasurable and

beneficial as it helped, ‘to manage my feelings’

(P2), or be ‘one of the boys’ (P1), or as a medicine

(P2) to numb emotional pain (P8), but only served

as a temporary demulcent (or soothing) on the

negative sense of self [DSM-IV:1(a)]. At this stage,

the use of alcohol, as a means of changing that

perception of self, was not possible to escape from.

One major effect of alcohol was that it quietened the

egodystonic voice, self-critic, or ‘flummery’ of the

mind (P3), allowing them, when intoxicated, to

rework and enhance the sense of self.

Experiencing the transition from using alcohol to

becoming addicted

Shame & guilt. Over time, the use of alcohol

increased in duration, frequency and volume, but

whilst their drinking was still perceived as being

purposive and beneficial to their self-image, the

emollient effect correspondingly decreased, thereby

requiring more alcohol [DSM-IV:1(b)]. Not only

did alcohol begin a process, phenomenologically

described as the ‘edging out’ of other normal social,

recreational, familial and developmental activities

(P3; P5; P7), to a point where one’s phenomenolo-

gical world had ‘shrunk to the confines and extreme

restrictions that drink inflicted’ (P5) [DSM-IV:6],

but secondary emotions of guilt (P2; P8), shame and

embarrassment associated with intoxication were

increasingly felt. Often these might be occasioned

in ‘blackout’ (P1; P4; P5; P7) where the individual

had no recall of prior events which, subsequently,

magnified personal shame and social embarrassment

[DSM-IV:7].

Becoming two people. Alcohol usage was viewed as

being progressive (P4; P5; P8), developing out of

awareness, where at some point the individual

crossed an ‘invisible line’ (P7) which projected

them from heavy drinking to alcohol dependence

[DSM-IV:1(a)]. Even the passage of time had not

provided an explanation as to how, when and why

they became severely dependent. Its problematic

impact on their environment was being brought

into their awareness by external interventions that

did not trigger cessation (P1; P3; P7). There was a

paradoxical belief that not only could the individual

exercise some physical control over ingestion and

behaviour, but, conversely, that they were ‘in trouble’

(P2) which necessitated a need to maintain secrecy

by hiding alcohol (P5; P8); ‘getting away with it’

(P2); ‘holding things together’ (P5), or ‘keeping the

lid on’ their drinking (P8), which, by now, was

expressed by the phenomenon of ‘alcoholic drink-

ing’. This was attended by feelings of dread (P5);

feeling a fraud (P6); of losing oneself (P5) and dying

inside (P8) [DSM-IV:3]. Fear typified the drinking

pattern of the severely dependent alcoholic. Two

powerful metaphors were used to describe the

cognitive and behavioural phenomena of this process.

The cognitive changes were explained by the meta-

phor of ‘the switch’ (P1; P8), which restricted

emotional growth and helped explain the apparent

lack of volition on the part of the individual to stop

drinking, reinforcing, ultimately, the need for total

abstinence. The second metaphor, that of ‘Mr Hyde’

(P1; P4), explained the loss of social control of the

individual’s behaviour whilst intoxicated. Both me-

taphors also helped reduce the individual’s culpabil-

ity, where alcoholic behaviour could be attributed,

either to Hyde, as a personified configuration of

alcohol dependence, or to a ‘side effect’ (P1), or

allergic ‘reaction’ to alcohol (P4).

Denial. In order to harden themselves against

increasing social problems, e.g. loss of employ-

ment/finances (P1; P3); domestic arguments (P1;

P6); domestic relationships (P2; P5), they continued

to drink, ignoring, distorting, or excluding from

perception attendant problems � which was de- scribed as the phenomenon of ‘denial’, the obscurant

nature of ‘Hyde’.

. . . the denial process, of this illness, is about always

telling you that you’re okay isn’t it and it’s every-

thing else that’s wrong in your world. (P2)

This phenomenon of denial is also aided by an

external configuration of ‘the alcoholic’ (P4), which

served as a comparator between their own behaviour

and the expected behaviour of a typical alcoholic;

provided that they were not falling down (P1); a

park-bench drinker (P6); drinking in the morning, or

during the day (P4); able to maintain physical

control (P6) � then their drinking was acceptable to themselves. Yet, there were feelings of loss of self-

efficacy, of having no choice (P5); having no self-

control, or self-will as soon as alcohol was ingested

(P4), despite repeated attempts to stop (P4) [DSM-

IV:4] and a daily ritual of behaviour surrounding the

204 P. M. Gubi & H. Marsden-Hughes

purchase, hiding and drinking alcohol [DSM-IV:5].

Slowly, there was a perception that they could not,

physically, control their alcohol usage. As their

control over the time, quantity and duration of

ingestion lessened, alcohol was concomitantly per-

ceived as no longer satisfying the internal need,

becoming less beneficial, yet through habituation, a

pattern of alcoholic behaviour had sedimented. This

pattern was phenomenologically experienced as an,

‘eternal circle’, ‘spiral’ (P4); going in circles (P8);

hamster going round (P7), where, ‘I knew that I

couldn’t get through a day without a drink’ (P5).

Alcohol ingestion, however, continued to grow,

where the individual was sneaking drinks (P6) and

‘topping up’ (P1; P2; P6), a phenomenon which

described a process of always being drunk, but not

appearing to be drunk and which silenced the

delirium tremens (P2; P6) [DSM-IV:2(a)(b)].

Self-contempt. Increasingly, a sense of incongru-

ence between their sense of self and their sense of

selves-in-alcohol, developed into a contempt of self.

The self-critic helped reinforce the feelings of low

social worth and lack of self-efficacy for which

alcohol, increasingly, became the only option. Self-

blame could often be redirected towards others (P5;

P8), or alcohol itself (P4).

Experiencing the recovery process

Cessation. At some point and, as a result of the

above, an irrefutable, causal link between alcohol

and their current situation is established in their

awareness. Cessation was, for some, no more than

dealing with an immediate problem, usually an

external intervention by a family member, friend,

general practitioner, or acquaintance (P2; P4; P5;

P6; P7; P8); an epiphanic experience of ‘spiritual

awakening’ (P1); or experiential catharsis. This

phenomenon was described as hitting a personal

‘rock bottom’ (P2; P3; P5); a lack of volition, self-

will and self-control (P4); loss of identity and self

loathing (P5) and being unable to stop drinking

(P5), described by the metaphor of, ‘I can’t stop

drinking’ (P4; P5), or ‘sick of being sick’ (P7).

Perceived long-term benefits to alcohol cessation

were not immediately present (P2; P6), or felt

achievable (P4), and complete and unassisted cessa-

tion was not always possible, or desired. For some

time the individual remained in a state of ambiva-

lence (P1).

External agency. AA was not an immediate choice

of therapeutic intervention. Little was known about

it, or what was expected of the individual and there

was a slow process of transition as they began to

engage with a group process, which they did not

understand and continued to be puzzled by (P8), but

which did not involve the use of alcohol. This was

seen as the phenomenon of being physically ‘sober’.

Individuals began to experience, within the group

process, conditions of empathy, unconditional posi-

tive regard and congruence.

Supportive belonging. Their initial involvement with

AA brought feelings of; belonging (P5); genuine

concern (P5); love (P2); ‘rapport’ (P3); reduction of

worry (P4); hope (P1; P6); whilst still being angry at

being denied their sole means of coping with the

stressors experienced in life. First, through observa-

tion (P8) and secondly, through hearing the stories

of other dependent alcoholics, recognising the simi-

larities in their drinking patterns (P4; P8), a didactic

process combined with the slogans, literature and

language of AA, helped them assimilate within the

group experience; this is the phenomenon of ‘identi-

fication’ where individuals (P2, P6) were not able, or

chose not to identify with the group, alcohol

dependence continued. In developing interpersonal

relationships, they experienced lambent feelings; of

hope; that something could change (P5); compa-

nionship (P8); encouragement and insight (P2); self-

efficacy; being in the same boat (P7); sharing a secret

(P8); having an illness (P5); not feeling insane (P8);

feeling comfortable (P5); being worthy of recovery

(P5) and a sense of belonging (P8). At this stage,

individuals faced financial uncertainty, a need for

reconciliation with family and employers, health

issues, as well as having an alcoholic reputation to

contend with, all of which started to improve (P1;

P3; P5; P8).

Understanding recovery

Recovery was viewed as a tripartite, interconnected

group of phenomena which were part of a daily

on-going process, which must not be hurried, and

which grew organically. The phenomena consisted

of (1) Being sober; (2) Maintaining sobriety; and

(3) Recovery.

Being sober. Over time, they became aware of

changes � firstly, with behaviour, and secondly, with cognition, through a perceived benefit with

Long-term recovery from chronic alcohol addiction 205

their attachment to the group. Their configuration

of self was now one of, ‘I without alcohol’ or,

‘I physically sober’. Both intra and interpersonal

relationships improved as the self-critical self became

normalised and integrated. Being sober, physically

not drinking, meant that they could now self-identify

with the group accepting the label ‘alcoholic’ which

was an ontological shift in the self; they began to see

that their alcohol dependence remained a problem to

themselves and to others. Membership of the group

also meant that the individual saw both the new-

comers (P3; P7) acting as potent reminders of where

they had been, but also those members who disen-

gaged from the group and began drinking again; it is

this latter cohort, who, from experience, faced death

(P2; P4; P8), again reinforcing the collective mes-

sage of recovery, especially the need for abstinence as

part of the complex phenomenon of motivation.

This ontological shift facilitated an epistemological

response; the need for abstinence (all participants);

an avoidance of triggers and cues, which may lead to

recidivism or reduce temptation (P5) and putting

oneself first (P5). This change in lifestyle became

effectively a new ‘way of being’ as a recovering

alcoholic, which was, continually being reinforced by

the group experience and feelings of loyalty and

gratitude towards it.

For those who have achieved LTR, this state of

remaining physically sober could last for up to ten

years (P7). Remaining in a state of being sober

without social support, or guidance and by will

power alone (P2) was described as ‘white knuckle

sobriety’ (P1) � and for those who wished to achieve LTR, it had to be avoided. The transition from being

sober, gradating towards sobriety, was not a coin-

cidentally correlated pathway. LTR recovery re-

quired more than mere abstinence. It required the

ability to feel comfortable with the self without

alcohol; of not drinking in the mind (P8), even

allowing for the fact that, during recovery, thoughts

of drinking were commonplace (P2; P4; P7).

Maintaining sobriety. LTR is typified by a search

for the phenomenon of a ‘quality of sobriety’ (P1).

This phenomenon is a multi-dimensional and un-

iquely personal construct. It involves feelings of

contentedness with the self without the need to

blur reality (P5). Increasing mastery over intra and

interpersonal functioning and developing compe-

tence, through practice in their environment, led to

a process of differentiation, where the individual

refined his/her understanding of sobriety and moved

from being sober to living in sobriety (P8). Having

observed and identified with the other group mem-

bers, shared personal experiences and currently

feeling the benefits of being physically sober, the

individual began the process of identifying a personal

pathway, which would contain those components

which they felt personally satisfying. Certain identi-

fications could be discarded whilst others were

retained through action (using those Steps which

were felt particularly relevant, Steps 1, 4, 5, 6, 10)

they learned that they did not have to be conformist.

Sobriety is:

. . . whatever you want it to be, I suppose, it’s how

you see yourself not drinking, how you want to

see yourself, how you want to be and live your

life; . . . . . . sobriety is how you feel about yourself,

it’s an . . . . inner calmness, a peace of mind which

we hoped would come from alcohol and now

comes from something else - music . . ., poetry . . .,

a sunset even, a beautiful painting, err, anything

that feeds the inner you, that’s sobriety. (P8)

Sobriety, as a ‘state of mind’ (P4) encompassed a

spiritual dimension as well as practical steps found

in the domain of a holistic lifestyle. This may be

achieved through the use of a sponsor, but can be

achieved alone.

Recovery. Recovery is the third phenomenon

essential for LTR. Again it is multi-dimensional

and personal and, as a form of personal development

(P3), it is the means by which remaining sober and

maintaining sobriety is achieved. Here the individual

further differentiates him/herself from the group in

the use of the 12 Step Programme. The steps served

as an ethical, moral and philosophical underpinning

of sobriety and were used idiosyncratically, rarely

sequentially and in some cases sporadically. What

the Steps did, appeared less important than what the

steps meant for those in LTR. They were seen as a

backdrop (P5), baseline (P2) or moral, ethical and

philosophical underpinning of sobriety (P6).

Maintaining recovery. For those in LTR, who

believe that they have an incurable illness (P5), for

which fellowship gained through AA is their only

hope of respite, it is achieved through abstinence;

through ‘sharing experiences with others’; forming

deep, personal, nurturing and lasting friendships

(P5) and attending AA meetings which help recharge

the batteries (P7). It is maintained on an on-going,

206 P. M. Gubi & H. Marsden-Hughes

daily process and requires patience not exigency (P5;

P8). In time, it engenders feelings of trust (P3);

gratitude (P5); comfort (P5); relaxation (P7); self-

acceptance (P1); choice (P1); does not require any

understanding of the aetiology of the dependent

condition (P5); necessitates action (P5) and is an

holistic approach to the individual’s lifestyle requir-

ing balance (P5; P8). A key ingredient is daily self-

reflection, prayer and meditation (P1; P2; P3; P4;

P6), where the aspects of the illness, or the config-

uration of ‘Hyde’, can be restrained in what effec-

tively becomes a daily battle to hold the self in check

(P5). Alcohol is always waiting and recovery can be

temporary (P4) if one forgets that one is an

alcoholic; however, the only limitation it places on

the individual is the inability to drink (P1). LTR is

typified not only by its simplicity (P4; P5); the

development of outside interests (P4; P5; P8),

(cooking, gardening, reading, walking), but also

changes of personality especially the need for hon-

esty (P3; P4) and integrity (P3). Such changes can

be seen as an essential part of the phenomenon of

spirituality. LTR is not predicated by a clear defini-

tion of a Higher Power (P5) but may involve a belief

in a benign, religious, deity (P1; P3; P6; P8).

Gratitude replaces the fear of recidivism, which

characterised the early stages of recovery. Yet the

fear of ‘relapse’ is potent. Maintaining, or earning

sobriety (P8), precisely because of previous tragedy

and disaster (P5) of the severely dependent lifestyle,

acts not only as a deterrent (P4), but also creates

defiance (P1) against complacency (P4) and the

threat of future relapse. It takes time to heal the

wounds of living with the shame of the past,

metaphorically expressed as an ongoing process of

keeping the slate clean (P1), yet, those in LTR

believe that it is necessary that the recovering

alcoholic takes his/her place within society (P2) as

recovery is no barrier to ‘becoming a useful, energetic

and valued member of society’ (P5). It was generally

acknowledged (P1; P2; P3; P4; P5; P7) that service,

helping the group and other individuals, or in

society, was essential to the maintenance of LTR.

The sense of a debt of gratitude, which needed to be

repaid (P7), as well as making amends to the family

(P5) was prominent, but amends had to be made

slowly and not hurried (P8). Recovery provided a

sense of personal freedom (P4; P7), but is also the

means of personal survival (P3; P4). Over time, the

LTR gains feelings of self-affirmation, satisfaction

and real achievement, even feeling superior, in the

domain of emotional management, to others. LTR is

a daily self-reflection in an ongoing process, pre-

dicated by a belief in abstinence.

Discussion

This study found that individuals understood LTR

to be a threefold phenomenon: sober, maintaining

sobriety, and recovery. Abstinence is measurable in

days, and the individual expected little of them-

selves for up to the first 10 years, beyond that of

being patient (P5, P8) and remaining abstinent or

sober. Developing a mode of behaviour to include

regular association with the group, sponsor, or

specified friends, meant that the configuration of

‘self-without-alcohol’ accrued. The tenor of the DS

became less shame-based. The configurations were

not static, but changed and as self-efficacy im-

proved, the self-talk became more positive. For

them, the threat of relapse was always present and

that there was at no time, a threshold point where

relapse could be said to be reduced (Betty Ford

Institute Consensus Panel, 2007). There was no cure.

It was the slowness of their recovery that typified

this cohort.

Secondly, what had brought them into AA were

the consequences of their AD and it was now dealing

with those consequences, which were not easy to

forget (P2, P5). Turning shame into appropriate

guilt, viewed more as moral shame (Kaufman, 1989;

Van Vliet, 2008; 2009), acted as part of the intricate

web of motivation. Their awareness of remaining

sober began to impact on the way they interpreted

and interacted with their surrounding environment

(Baldwin et al., 2006). Unresolved feelings of shame

and the growing awareness of guilt, through daily

self-reflection, were no longer barriers to a successful

life (Ehrmin, 2001). Self-efficacy was also enhanced

by the ability to help others. This not only increased

the motivation to stay sober, but reduced the impact

of a self-focus on the self. After assimilating the

concept of being sober, the individual moved to

differentiate him/herself by developing a view of

sobriety which they interpreted as developing a

‘quality of life’ (Gust, 1982). Sobriety is, therefore,

not necessarily a measure of outcome, but indicates a

continued affiliation to the process (Neto & Mullet,

2004; Neff & MacMaster, 2005).

Limitations

This study has several limitations: it was restricted to

membership of AA and may not be considered as

Long-term recovery from chronic alcohol addiction 207

being a normative representation of all recovering

chronic alcoholics with LTR; and the study was

constrained by the sample size.

Implications

The implications for the addiction field are several:

. That LTR is achievable and sustainable and provides hope for the severely dependent alco-

holic and his/her family. This is important, as

the shift to a recovery-based paradigm is

increasing within social care;

. Therapeutic modalities must look beyond the goal of simply getting the individual sober and

instead, focus on the development of self-

efficacy, self-determination, shame reduction

and an improved dialogical self;

. An holistic approach to helping develop a new way of being for the individual � emotional, social, psychological, spiritual and physical � needs to be incorporated in any treatment

plan;

. Relapse must not be treated as a shameful act;

. Being sober, and acclimatising the self to this state, takes several years. Brief motivational

therapies are not sufficient for LTR;

. On-going, supportive treatment involving peer- support, and the individual’s wider social en-

vironment is essential, as is establishing a

therapeutic working alliance with the individual

based on a felt-experiencing of empathy, UPR

and congruence, and minimising confrontation

which could heighten shame. The referential

nature of the group dynamic questions how

beneficial solely one-to-one therapy is;

. Allowing the individual time to develop his/her own unique form of sobriety, and the idiosyn-

cratic process of gaining that sobriety, must be

based on the predicate of total abstinence;

anything less will be futile.

. Recovery-based interventions should seek to encourage the individual to create a broad range

of interests, pro-social activities, and aids to

personal development beyond a myopic focus

on the need to resist temptation. For some,

attendance at AA will be beneficial, but other

socially supportive networks, which aid inter-

personal development, should be encouraged to

provide on-going therapeutic intervention,

especially where the individual can develop

their self-narrative.

If the therapeutic goal of treatment is to encourage

recovery, it requires a move away from the acute

model of aiming to cure the client by brief, time-

limited therapy, towards a model of sustained,

on-going and life-long recovery management; the

fundamental assumption being that recovery un-

folds, gradually, over time. This would be combined

with pro-social aid resources and focusing, in the

initial stages, on helping the individual stay sober

and, when needed, swift re-intervention (White,

Boyle, & Loveland, 2002). Any strategy that en-

courages problem recognition should be based on

the assumption that an individual may struggle to

recover on his/her own, and encouragement should

be given to combining therapeutic intervention

with AA, or similar affiliation, which can increase

sustained abstinence in the post-treatment phase

(Laudet, 2010). Individuals need to observe, and

hear, the success narratives of others, and the

therapeutic conditions of empathy, UPR and con-

gruence need to be strongly felt by the individual

(Castonguay & Beutler, 2006).

Acknowledgements

The authors would like to thank Richard Davis

(colleague) and Janette Torrance (ex-colleague), at

the University of Central Lancashire, for their input

into this research.

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Biography

Peter Madsen Gubi, PhD, MBACP (Snr

Accred), is senior lecturer in Counselling and Psy-

chotherapy in the School of Health at the University

of Central Lancashire, Preston.

Howard Marsden-Hughes, MA, MBACP, is the

lead therapist (Addictions) at the Priory Hospital,

Preston.

Long-term recovery from chronic alcohol addiction 209

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