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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 1School of Health, University of Central Lancashire, Preston, UK, and 2Prior y 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), wherethe 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 custodialsentencing. 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 202P. 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 themesHow alcohol became important in lifeExperiencing the transition from using alcohol to becoming addictedExperiencing 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-ter m recovery from chronic alcohol addiction203 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 andbehaviour, 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 204P. 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 recover y 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).Exter nal 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 recover y 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-ter m recovery from chronic alcohol addiction205 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 movedfrom 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.

Recover y.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 Stepsdid, appeared less important than what the stepsmeantfor those in LTR. They were seen as a backdrop (P5), baseline (P2) or moral, ethical and philosophical underpinning of sobriety (P6). Maintaining recover y.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, 206P. 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 isa 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-ter m recovery from chronic alcohol addiction207 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-ter m recovery from chronic alcohol addiction209 Copyright ofCounselling &Psychotherapy Researchisthe property ofRoutledge andits content maynotbecopied oremailed tomultiple sitesorposted toalistserv without the copyright holder'sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use.