Help from without is often enfeebling in its effects, but help from within invariably invigorates.
Self-help approaches to addiction encompass those strategies designed to reduce or eliminate substance use and/or associated negative consequences. As a construct, the boundaries that define self-help are potentially blurred. Virtually all successful and lasting change involves some degree of self-help and some measure of support by others. For the purposes of this chapter, we suggest two concrete boundary conditions that distinguish self-help strategies from other strategies: (1) the strategies are self-initiated and self-maintained and (2) the strategies do not involve enduring relationships with professional care providers, professional supervision or authority, or illicitly obtained prescription drugs. Under this umbrella fall techniques such as nonprescription substance replacement, bibliotherapy, helplines, spirituality and mindfulness, and Internet resources, as well as a variety of self-help groups. Interventions range in cost, intensity, accessibility, and efficacy, depending on the nature of the substance use.
This chapter begins with a brief review of relevant literature related to self-help in addiction, including reviews of natural recovery and natural processes of change described in the Transtheoretical Model of Change. Following a description of this literature, with the exception of self-help groups, this chapter reviews several self-help approaches and their applicability to the problematic use of specific substances.
Why Use Self-Help?
There are several reasons that an individual may opt for self-help methods as an alternative to professional care to manage substance use, including barriers in accessing treatment. In a national telephone survey of 14,985 residents from 60 randomly selected US communities, of those who reported that they needed help for substance abuse, well over one-third received no professional treatment, less treatment than they needed, or delays in treatment. A commonly cited barrier to pursuing formal services for addiction concerns the high cost of treatment, which can lead some individuals who want help, but do not believe they can afford it, to manage their own care. Stigma and the associated negative attitudes that practitioners, medical staff, and other health professionals may convey toward the person seeking treatment often deter people from seeking professional rehabilitation services. Feelings of shame, embarrassment, and failure only act to further embed fears of stigma. In these instances, self-help methods can provide an affordable, easily accessible, and anonymous point of entry into the recovery process.
Is Self-Help Good for Everyone?
Addictive behaviors can be and often are identified, modified, and resolved through self-initiated processes. As reviewed later in this chapter, individuals who were once dependent on addictive substances have demonstrated the ability to change those maladaptive behaviors, often through means of self-help alone. Notwithstanding this, isolative and self-administered recovery, particularly in advanced cases of substance use disorders, may be ill-advised. With the exception of natural recovery (see subsequent text of this chapter), individuals fully entrenched in profound and active addiction are unlikely to manage successful and enduring recovery by relying exclusively on their own resources. In those cases, self-help interventions may best be understood as an initial stage in a multifaceted intervention approach, helping to facilitate a greater appreciation of the nature, symptoms, consequences, and resources available to combat substance use disorders.
Self-Help as Empowering
Although there are risks associated with self-administered treatment, there are also benefits in addition to alterations in substance use, which occur on an idiosyncratic level. Lacking professional intervention or guidance, individuals pursuing self-help interventions run the risk of potentially acquiring inadequate or ineffective information. However, self-help has the advantage of enabling individuals to achieve the internal resources necessary to feel a greater sense of autonomy and mastery over their behavior and their environment. This cultivated sense of power can have positive effects on self-esteem, self-efficacy, and personal responsibility. These personal tools can breed the confidence and internal fortitude necessary to sustain recovery and prevent or recover from relapse. Such changes in coping and identity may be instrumental and necessary for individuals to seek professional help in the process of recovery.
Can Individuals Help Themselves?
At least two somewhat overlapping and extensive bodies of research literature have directly addressed the extent to which people can and do transition from problematic substance use, abuse, or dependence to less problematic use, moderate use, or abstinence without treatment or attendance in self-help groups such as 12-step or fellowship programs. These bodies of literature roughly correspond to the topics of natural recovery and the Transtheoretical Model of Change.
Natural recovery refers to the process by which many individuals who experience considerable difficulties related to their substance use successfully implement change without any formal assistance. Some individuals appear to simply “mature out,” whereas others change in response to a specific event or set of circumstances. Sobell et al. seminal examination of natural recovery from problematic alcohol and/or drug use (excluding tobacco) considered 40 samples of participants in 38 studies published between 1960 and 1997. Carballo and colleagues subsequently examined 22 studies published between 1999 and 2005 but used a more liberal time period in designation of substance use problem resolution. Although the majority of studies of natural recovery have focused on alcohol, earlier studies also included heroin. In recent years, there has been a substantial surge in studies examining natural recovery from problematic cannabis use. These studies of natural recovery have largely relied on retrospective reports of participants’ reasons for changing. These narrative accounts raise questions regarding potential memory distortions, self-serving biases, and/or inaccurate attributions of the effectiveness of specific factors leading to change. Nevertheless, they provide potentially important insights into successful self-help strategies. Combining the 40 studies from 1960 to 1997 reviewed by Sobell and colleagues with the 22 studies from 1999 to 2005 examined by Carballo and colleagues, we found that the most frequently reported reasons for reducing or eliminating substance use by successful self-changers were health-related (45%), financial (37%), negative personal reasons (e.g., shame and guilt, 35%), family-related (34%), significant other (32%), and religious reasons (31%). Factors most strongly associated with successful maintenance of change were social support (40%), family/significant other (34%), avoidance of substance use situations (24%), religion (23%), and developing non–substance-related interests (23%).
Related to the idea of natural recovery is the process of maturing out. Epidemiological literature and studies of natural history indicate that the highest rates of alcohol and other substance use occur during late adolescence and early adulthood. Increasingly referred to as “emerging adulthood,” the period corresponding from about high school graduation through the early 20s is associated with increased risk behaviors and experimentation across a range of high-risk behaviors, including substances of abuse. The majority of young adults who use substances during this developmental stage, even at problematic levels, reduce or eliminate use as they assume career and family responsibilities. Individuals who experience substance use later in life and who reduce use without formal help tend to be in their mid-40s and report their heaviest use to be in their mid-to-late 20s, further suggesting that, for many, natural recovery may be a maturational process.
With respect to research related to natural recovery, the majority of the literature has focused on alcohol. Other specific substances have also been examined in the context of natural recovery, including nicotine, marijuana, cocaine, and heroin, with relatively similar findings across substances. Natural recovery from nicotine, alcohol, and marijuana is reviewed below.
The vast majority (>80%) of individuals who quit smoking do so without treatment. Narrative accounts of individuals who are successful with smoking cessation versus temporary cessation or current smokers suggest that the former who are successful report more severe consequences, more focused reasons for cessation, and more negative affect in describing reasons for quitting. Successful quitters are also more likely to have and/or take advantage of good social support for cessation, to change their environment, and to feel less ambivalent about changes associated with the cessation process.
To date, the literature on natural recovery from substance use disorders has focused predominantly on alcohol. Consistent evidence now suggests that a large proportion of individuals who experience problems with alcohol are able to transition to moderate use or abstinence without formal help. Heavy drinking is common in young adulthood but diminishes for most individuals as they take on traditional adult responsibilities (marriage, family, careers, and so on). Beyond the developmental period of emerging adulthood, alcohol use disorders have continued to be viewed by many as resistant or impossible to change without assistance. These sentiments are a foundation underlying 12-step programs such as Alcoholics Anonymous (AA), where the fundamental premise stipulates that an individual is powerless over addiction and although it is not possible to be fully cured, continuous abstinence and therein remission is achievable by adhering to the program outlined in the 12 steps. Within this framework, recovery is possible, whereas being cured or returned to a nonpathological use characterized by moderation, maturational effects, and natural recovery is not.
Individuals who successfully maintain natural recovery from problematic alcohol use often report initial motivation related to fear or anticipation of unacceptable life changes resulting from drinking, concern for the influence of one’s drinking on his or her children, and religious inspiration. Successful self-changers are more likely to have positive social support networks, be married, have higher self-esteem, and report less drug use and lower frequencies of intoxication.
Relatively little research has examined natural recovery in the context of problematic cannabis use. One 25-year follow-up of Vietnam Veterans found that 82.5% of cannabis cessation attempts occurred without treatment and that of those, 88.3% were successful. Consistent with findings from the alcohol literature, successful self-help in cannabis use was most often initiated in response to changing views of personal use (cognitive evaluation) as well as negative consequences associated with continued use. Strategies associated with successful change included modifications in lifestyle and the development of interests unrelated to cannabis use.
Processes of Change
Directly related to natural recovery, processes of change have been described as part of the Transtheoretical Model of Change (or Stages of Change Model). The Transtheoretical Model of Change, which has been applied extensively to the field of substance use disorders and beyond, began with interviews of former smokers regarding their experiences with change. The model describes a sequence of stages in which individuals who are not initially aware of a need to change and are not in any way considering modification (precontemplation) over time begin to consider the possibility of making alterations (contemplation) and subsequently prepare for (preparation) and implement change (action). In the absence of relapse or regression to previous stages, individuals are ideally able to maintain change successfully (maintenance) over time. In the context of developing their model, Prochaska and DiClemente defined a number of processes that individuals identified as being important in their efforts to change. The processes of change include substitution, seeking information, cognitive evaluation, seeking support from others, self-rewards for change, affirmation of commitment, and restructuring one’s environment. The Transtheoretical Model of Change and associated processes has provided a useful framework for considering how people identify, approach, and resolve problematic behavior. But it is also clear that original formulations of the model were overly simplistic.
Self-Help Drug Replacement
Substance substitution or drug replacement therapy represents a potentially valuable self-help strategy for drug addictions. Substance substitution involves the practice of replacing specific substances to assist with the withdrawal or cessation of another drug or substance, the latter usually possessed of more significant, immediate, or well-known negative consequences. This method of intervention is also employed in some instances solely during the detox period, in order to facilitate fewer extreme withdrawal symptoms. There is some controversy around drug replacement therapy based on objections regarding the replacement of one addictive substance for another; however, it is a contemporarily well-accepted method of achieving harm reduction or abstinence from various substances. This is typically achieved by providing a lower dose of the same substance, varying the route of administration, or alternative substance replacement. Whether the goal is to provide a more predictable and manageable decline in substance dependence or to facilitate rapid removal, drug replacement therapy typically acts to reduce or mitigate the withdrawal symptoms commonly associated with physical dependence. To a lesser extent, it can also act as a means to replace, shift, or decrease the psychological correlates of addiction associated through habit, socialization, peer pressure, stress relief, and celebration. Although there are many pharmacological options available to manage withdrawal and cravings, this section focuses on nonmedically monitored options for drug replacement.
Replacement and Caffeine
Caffeine is a plant alkaloid found in numerous species, which acts as a central nervous system and metabolic stimulant. Estimates have indicated that upwards of 90% of American adults consume caffeine on a daily basis ; it is also believed to be one of the most widely used psychoactive substances in the world. Caffeine is typically consumed to overcome lethargy, to promote vigilance and alertness, and to elevate mood. The major source of caffeine is coffee beans, but it is also commonly found in chocolate, tea, and soft drinks, as well as energy drinks and over-the-counter medications for headaches, pain relief, and appetite control. Although caffeine remains unscheduled and recognized by the US Food and Drug Administration (FDA) as a “safe food substance,” it is an addictive substance that can lead to withdrawal symptoms after cessation of consistent use. Caffeine may be commonly overlooked as a drug of abuse, in part due to its nearly universal legal status, prevalence as a normative food staple, and absence of commonly associated negative consequences. Furthermore, people may be unaware of or may underestimate their daily caffeine consumption, as the drug is associated mainly in connection with coffee. As a result, consumers may not be aware of the amount of regular consumption, impact on their daily functioning, or degree of physiologic and psychologic dependence.
The fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) identifies Caffeine-Related Disorders to include Caffeine Intoxication and Caffeine Withdrawal. Currently, caffeine use cannot be diagnosed as a formal substance use disorder; however, Caffeine Use Disorder was identified as a condition for further study. The symptoms of acute caffeine intoxication may include restlessness, nervousness, hyperexcitability, insomnia, gastrointestinal disturbance, muscle twitching, rambling, tachycardia, and agitation. Very rarely, high doses of caffeine (>10 g) may produce respiratory failure or seizures. Regular users commonly develop tolerance to caffeine and may experience intense cravings after discontinuation. Withdrawal symptoms include headaches, flu-like symptoms, feelings of lethargy and reduced motivation, and dysphoric or irritable mood.
Individuals seeking to reduce or abstain from caffeine may find that the cravings can be managed by substance replacement. Because caffeine is less addictive than are other socially acceptable substances (e.g., alcohol, nicotine), replacement in social settings may be more easily achieved, providing a particularly effective way to reduce caffeine and mitigate adverse health consequences. The most popular replacement for caffeine is decaffeinated coffee, which contains between 2–15 mg of caffeine per 8-ounce cup compared to between 80–100 mg of caffeine in an 8-ounce cup of caffeinated drip coffee. International standards require that decaffeinated coffee beans are 97% free of caffeine, while the European Union standard requires that coffee beans are 99% caffeine-free by mass. This small amount of the active substance may help attenuate withdrawal symptoms including headaches, nausea, vomiting, muscle pain, and stiffness. Decaffeinated and herbal teas offer another option for caffeine replacement. Those individuals who are interested in reducing their caffeine intake from soft drinks have a variety of brand options offering caffeine-free drinks. There remains scant literature concerning the effectiveness of decaffeinated substitution for caffeine use; however, replacement in this manner can be a helpful harm reduction approach to significantly reduce one’s intake of the drug (in the case of decaffeinated coffee) or to eliminate intake altogether.
Replacement and Nicotine
Both anecdotal evidence and scientific data speak to the highly addictive nature of nicotine, and more specifically, of nicotine found in tobacco products. Researchers regard nicotine as one of the most addictive recreational substances in use. Similarly, the American Heart Association considers nicotine to be one of the hardest addictions to break. Nicotine, a central nervous system stimulant, is a plant alkaloid found most abundantly in tobacco leaves and is thought to be the main factor responsible for the dependence-forming properties of tobacco smoke. Although inhalation of tobacco smoke is the most common route of nicotine administration, tobacco may also be insufflated or chewed. Tobacco smoke contains carbon monoxide, as well as a mixture of particulate substances generated by the combustion process that make up tobacco tar. Inhalation of carbon monoxide and tar is primarily responsible for the various diseases resulting from long-term use. Physiological and psychological dependence on nicotine generally develops quite rapidly, reflecting nicotine’s pharmacokinetic properties, which are characterized by rapid distribution of nicotine to the brain that reaches peak levels within 10 seconds of administration. However, the acute effects of nicotine dissipate rapidly, as do the associated feelings of reward, promoting re-administration in order to maintain the drug’s pleasurable effects and prevent withdrawal. This characteristic pattern of administration/reward and withdrawal/punishment is instrumental in maintaining nicotine use despite its negative consequences.
Rapid decreases in cigarette use can result in a variety of uncomfortable withdrawal effects including restlessness, increases in appetite, difficulty concentrating, irritability, constipation, and sleep disruption. Given the myriad of injurious and life-threatening implications of regular, heavy tobacco use, there have been massive public health initiatives to address this problem. Consistent and strong positive associations exist between cessation of use and maintaining a tobacco-free lifestyle. The US Department of Health and Human Services underscores that early tobacco use relapse is associated with difficulty coping with withdrawal symptoms. In order to increase cessation success rates, nicotine replacement strategies were introduced to mitigate the early intense withdrawal symptoms linked with relapse, and thereby improve successful cessation maintenance.
Nicotine Replacement Options
Perhaps the most widely known drug replacement approach is through the use of nicotine products. Nicotine replacement therapy is consistently found to be an efficacious front-line intervention designed to deliver nicotine with the intent to significantly reduce the severity and intensity of withdrawal symptoms. The FDA approved nicotine gum in the early 1980s, and by the mid-1990s nicotine patches were available without a prescription. The Tobacco Use and Dependence Guideline Panel reviewed and distilled more than 8700 research articles to establish clinical practice procedures in the treatment of tobacco use and dependence. Nicotine replacement was found to be so effective as a front-line treatment in tobacco dependence that it is included in five of the seven first-line medications identified as reliably curbing dependence and promoting long-term abstinence. Over time, research has demonstrated that smoking cessation can be improved by approximately 50% when coupled with nicotine replacement therapy. Nicotine replacement therapy is a recommended add-on for all smokers interested in quitting, with the exception of pregnant women, smokeless tobacco users, light smokers, and adolescents. Nicotine replacement products are available in various routes of administration such as gum, inhalers, patches, tablets, lozenges, and sprays. They are readily available over the counter in most pharmacies, drug stores, and grocery stores. Route of administration does not appear to impact outcomes.
More recently, electronic nicotine delivery systems (ENDS), such as electronic- or e-cigarettes, have become readily available and a popular alternative to tobacco cigarettes. ENDS are battery-powered instruments often manufactured to look like conventional cigarettes, cigars, or pipes, and referred to as vaporizers, vape pens, hookah pens, e-pipes, and e-cigarettes that deliver vaporized liquid nicotine. No smoke, tobacco, or combustion is part of its mechanism of action. ENDS work by heating liquid composed of propylene glycol, glycerin, flavoring, and nicotine until it vaporizes. They were developed in 2003, and by 2007 were marketed in the United States and Europe as a method to safely quit smoking. There are estimates that more than 250 different ENDS brands are currently available.
Although e-cigarettes have received a great deal of attention as a replacement for tobacco cigarettes, little is known about their addictive nature and potential harmful effects. Given that these products were not regulated by the FDA at their introduction, they were readily accessible to adolescents, and by 2012 use among this group doubled. Despite their appeal to adolescents, ostensibly new nicotine users, research suggests that most users of e-cigarettes are current or former tobacco cigarette smokers. In May 2016, the FDA extended federal authority to regulate e-cigarettes, thus prohibiting the sale of e-cigarettes to individuals under the age of 18. Prior to that, The New England Journal of Medicine reported that some e-cigarettes contain and release formaldehyde, further calling into question the possible carcinogenic effects and associated hazards, which remain largely unknown. The e-cigarette industry, which has until 2016 been essentially unregulated, also augments the vaporized liquid with supplementary additives and flavorings that have questionable safety implications.
ENDS have continued to gain momentum and popularity in recent years as a lifestyle product for smokers interested in mitigating the well-established risks associated with traditional cigarette smoking; their popularity continues to grow as they simulate the behavioral and sensory elements of smoking while being perceived as healthier. They have been noted as playing a role in smoking cessation or tobacco harm reduction techniques. A randomized controlled trial examined the efficacy of e-cigarettes compared with nicotine replacement therapy for smoking cessation and discovered moderate effectiveness in helping smokers quit with limited side effects. Reviews of research focused on the effectiveness of e-cigarettes in the reduction or cessation of tobacco demonstrate positive, although weak, associations. However, little substantive information was gleaned from a current review of the literature due to a lack of longitudinal research and consistent limitations in study designs, suggesting that more research in this domain is sorely needed.
Replacement and Alcohol
Alcohol use is common and prevalent, with estimates suggesting that three of four adults consume alcohol on at least a periodic or social basis. Low-level intoxication generally produces feelings of euphoria and relaxation and has been associated with pain relief. Higher levels of intoxication result in motor impairment, mood lability, memory loss, confusion, and toxicity. Consistent with standards established in the DSM-5, an Alcohol Use Disorder involves a repetitive pattern of use resulting in alcohol cravings, tolerance, withdrawal symptoms, and difficulty limiting or eliminating use despite overt negative consequences. Treatment of Alcohol Use Disorders often involves both mitigating and ameliorating withdrawal effects, which when left untreated tend to perpetuate drinking cycles, while concurrently improving emotional regulation and functional coping skills.
Alcohol produces one of the more severe abstinence syndromes associated with withdrawal, which has the potential to result in delirium tremens (DTs); these are characterized by severe disorientation, confusion, hallucinations, blood pressure spikes, seizures, and in some cases death. Individuals who are most likely to experience withdrawal effects are those who have maintained a high blood alcohol content (BAC) level for several days in a row, have become intoxicated every evening for at least a month, and have histories of alcohol withdrawal symptoms. In short, the heavier the consumption and longer the time period, the more likely one is to experience withdrawal effects. Mild to moderate withdrawal symptoms include sleep difficulties/fragmentation, anxiety, sweating, increased blood pressure/pulse, tremors, and gastrointestinal upset. More severe withdrawal symptoms include DTs, which typically set in 48 hours or more after decline in alcohol consumption. It should be noted that generally mild to moderate withdrawal symptoms are not dangerous, although they can be for individuals with high blood pressure who have an additional risk of heart attack or stroke. Withdrawal symptoms generally remit after 24 hours following the last drink consumed.
Consequently, medically driven and supervised withdrawal is generally recommended, especially for individuals with chronic and heavy alcohol use histories. Despite this recommendation and the constellation of medical risks upon which it is based, many individuals prefer to step down their alcohol use through tapering procedures, thereby attenuating the effects of withdrawal. And although medical detox is safer, often more comfortable, and imposes structure that increases success, issues of geographic barriers, financial limitations, and psychiatric stigma remain instrumental in determining alcohol-related withdrawal preferences. Medical facilities increasingly prohibit patients from using nicotine products, while at the same time neglecting or refusing to provide nicotine replacement therapy, contributing to an already overwhelming process of withdrawal and discomfort, and which may act to dissuade an ambivalent patient from medically supervised detox. In addition, medical detox is most commonly accompanied with a diagnosis of Alcohol Use Disorder, a historically stigmatizing label that can have an impact on contemporary and future medical treatment, health insurance, and vocational/academic opportunities. As a function of these and additional issues, many individuals make the decision to pursue self-managed tapering in order to decrease alcohol consumption while minimizing withdrawal effects.
Self-directed, nonmedical taper programs are available through online resources. Harm reduction, Abstinence and Moderation Support (HAMS) or the Harm Reduction for Alcohol network ( hamsnetwork.org ) publishes online resources regarding harm reduction approaches to alcohol use, which includes detailed instructions on a tapering program. The entirety of the program will not be repeated here; it can be accessed online through the HAMS network. Briefly, the approach involves moving alcohol consumption to beer and then drinking only a small amount to minimize or mitigate withdrawal effects. Critical to this plan is developing a personalized titration schedule in order to maximize program adherence. Although this can be a successful approach when followed appropriately, there are clearly a host of risks involved in self-managed titration of an addictive substance, including but not limited to infidelity to the program standards. If the taper schedule is self-monitored, there are no external checks in place to provide external supervision. In addition, the plan advocates the administration of a mind-altering substance that has a direct influence on frontal lobe functioning including disinhibition and impulsivity, depressant impact on motor cortex involving coordination, and additional physiological symptoms, all of which are well-established as negatively impacting decision-making. Disinhibition and impulsivity associated with alcohol may provide the user a feeling of license to deviate from the plan in a manner that is interpreted as acceptable at the time but potentially decreases the chances for successful implementation. In addition, any abrupt alteration of entrenched, heavy alcohol use including self-help taper programs increases the probability of an acute medical situation, which would occur in the absence of medical support and assistance.
Another commonly employed approach to alcohol replacement involves the consumption of nonalcoholic beer or wine in substitution of alcoholic beverages. This approach can be especially helpful in social settings, where the addition of normative peer pressure regarding alcohol consumption is relatively greater. In addition to issues of physiological dependence, the psychological facets of alcohol dependence can be overwhelming, in part because alcohol may serve an important social role in one’s life. Low-alcohol substitutes approximate beer and wine without the alcohol content. These substitutes typically contain 0.5% or less of ethanol by volume, which is the maximum content that a beverage may contain to be legally called nonalcoholic in the United States. Thus the use of nonalcoholic beverages may help in the maintenance of abstinence by allowing an individual to continue to engage in social situations.
Drug substitution for alcohol may also be achieved with the use of herbal substances. Kudzu and kudzu extract have received attention recently as a potentially viable herbal supplement to attenuate the anxiogenic effects of withdrawal and perhaps even reduce cravings and urges to use alcohol. It is thought to reduce the intoxicating effects of alcohol and therefore to have potential in assisting users in moderating or reducing consumption. Due to the paucity of research in this area, very little can be gleaned from the current literature; furthermore, this remains an untapped area for controlled studies.
Perspectives in Bibliotherapy
Bibliotherapy, the belief that psychological and behavioral change can be affected by the content of written materials, has been a consistent method of self-help throughout history. Religious materials such as the Bible, Sutras, Talmud, Quran, and the Vedas serve as enduring examples of self-directed tools for growth and change. Consistent with this, many psychiatric hospitals in the United States had established libraries by the middle of the 19th century. Bibliotherapy remains a resource- and cost-effective intervention that is widely available, self-paced, and lacks the stigma associated with other interventions, which often deter individuals from seeking assistance.
Although there are clear benefits to bibliotherapy including availability, accessibility, and approachability, its efficacy in promoting change is less clear. As noted by Scogin, many self-help books are not based on relevant theory or evidence-based treatments and therefore have predictable limitations in utility. Some research suggests that maladaptive habituated behavioral disruptions (i.e., alcohol consumption, smoking, nail-biting, and overeating) in general may not be as amenable to bibliotherapeutic interventions relative to other psychiatric conditions such as mood disorders. In addition, individuals who benefit most from bibliotherapy tend to be self-referred, thus the currently reported success rates might underestimate its effectiveness. Finally, variability in objective definition acts to diffuse the outcome of those investigations that do exist.
The concept of bibliotherapy is widely variable, such that references may describe a spectrum of behaviors and resources: from an individual reading a self-help manual to a professional care provider prescribing a relevant book chapter. For the purposes of this chapter, and consistent with a number of published studies, the term bibliotherapy will refer to any self-directed therapeutic intervention presented in a written format that is designed to motivate and guide the process of change behavior. Those empirical investigations employing congruent definitions of bibliotherapy related to substance abuse were restricted to the reduction of nicotine, alcohol, and marijuana. A review of the literature did not find empirical research evaluating the efficacy of bibliotherapy for cocaine, opiates, or opioids.
Bibliotherapy for Nicotine
Smoking remains the leading annual cause of preventable premature morbidity and mortality annually in the United States. Despite the fact that 40% of smokers attempt to quit each year (Centers for Disease Control and Prevention), only about 5% are successful in maintaining abstinence for one year. Various methods of assistance for smoking cessation, including counseling, nicotine replacement therapy (NRT), and pharmacotherapy such as buproprion have been demonstrated to improve success rates. Despite this, the majority of smokers who try to quit do so without seeking assistance or intervention. Those smokers who employ interventions may represent the more nicotine-dependent proportion of the population, who are at proportionally greater risk of relapse. Relapses, especially recurrent relapses, are generally detrimental to perseverance and successful cessation, underscoring the importance of efficacious treatment interventions.
A vast array of bibliotherapeutic materials designed to promote smoking cessation exist, from brief motivational pamphlets to comprehensive manuals addressing initial cessation through relapse prevention. These manuals are often based on cognitive behavioral models (e.g., social learning, transtheoretical model, relapse prevention) and designed as translations of therapist-administered multicomponent cessation programs. Despite the assortment of literature available, the evidence regarding the efficacy of bibliotherapeutic tools and, particularly, as applied in isolation is less compelling.
Although there appears to be preference for self-administered treatments such as bibliotherapy among individuals seeking to quit smoking, research has not consistently demonstrated the ability of such materials to increase cessation and maintenance rates. Rather, only marginal benefits are associated with generic self-help materials (e.g., pamphlets, booklets) relative to no intervention. Alternate treatment options including natural recovery, telephone counseling, and NRT have demonstrated greater efficacy than generic bibliotherapy. Although research does not generally support the efficacy of generic bibliotherapeutic materials in isolation, there is evidence of increased cessation and maintenance rates when they are integrated with other treatments.
Tailoring written materials to specific individuals and populations whether in-person or via technology appears to increase the effectiveness of bibliotherapy. Self-help materials that are tailored to individual smokers appear marginally more effective than generic materials. Meta-analytic studies have found that tailored materials have demonstrated greater efficacy for smoking cessation beyond no intervention and relative to generic manuals (N = 20,414; odds ratio [OR] 1.42, 95% confidence interval [CI] 1.26 to 1.61). Bibliotherapeutic materials were found to be efficacious in cessation and maintenance within intensive group programs when individuals participated in the prescribed activities associated with the reading. This may be due to compliance with the program, inasmuch as individuals who are able to utilize and integrate self-help materials successfully are better able to adapt programmatic change into long-term lifestyle changes. Although attempts to tailor self-help material to firefighters by employing language common to the fire service did not produce benefits beyond the American Lung Association’s generic guide, the combination of tailored smoking outcome and self-efficacy–enhancing information produced a significant effect on smoking cessation. Thus the most promising effects for bibliotherapeutic interventions appear to be found in combinations of personalized adjuncts, such as written feedback in conjunction with outreach telephone counseling or web-based, personalized feedback. In sum, bibliotherapeutic interventions for smoking cessation appear most likely to be effective when tailored to specific population characteristics and include empirically based enhancements.
Bibliotherapy for Alcohol
Bibliotherapeutic materials designed to reduce maladaptive alcohol use are conceptually similar to smoking cessation publications in that they are often based on cognitive behavioral models, which are intended as easily digestible translations of multicomponent, professionally administered programs. The evidence regarding these resources is mixed but appears promising, particularly with the addition of technologically driven enhancements and when construed as the initial intervention in a stepped-care approach to alcohol treatment.
Meta-analytic reviews of self-help programs designed to address problematic alcohol use have revealed differentially effective rates, somewhat dependent on the nature and severity of the treatment target. Research has not consistently revealed significant gains associated with bibliotherapy. Greater efficacy has been associated with interpersonal intervention compared to bibliotherapy among at-risk users and those with severe alcohol use disorders. At-risk drinkers participating in individual or group alcohol skills training programs demonstrated greater preference, perceived assistance, and enduring change in alcohol use relative to those provided with bibliotherapeutic intervention only. Among heavy drinkers, bibliotherapy alone was not found to be as effective as bibliotherapy in conjunction with brief advice or counseling.
Despite this, other studies offer support for the efficacy of bibliotherapeutic interventions, particularly for early stage intervention. Bibliotherapeutic interventions appear better suited to address at-risk or mild cases of alcohol use disorders. Apodaca and Miller’s meta-analysis revealed a small to medium effect size for bibliotherapy versus no intervention, and moderate support for bibliotherapy to reduce at-risk alcohol use. Consistent with these findings, a self-help manual in conjunction with limited professional contact (10 minutes) was found to be effective beyond treatment as usual in promoting alcohol cessation among pregnant women with mild alcohol abuse. In a series of studies involving only limited professional contact (i.e., brief telephone contact and one 1-hour session), Miller and colleagues found reductions in alcohol consumption associated with a self-help manual that matched reductions associated with more involved treatment options, which were found to be enduring. Thus, there is mixed evidence regarding bibliotherapeutic efficacy. Based on this information, it appears likely that bibliotherapy is at least marginally more effective than no intervention, and may be more influential in early intervention than in later stages of addiction.
The most promising innovations in written interventions for alcohol use disorders appear to be within self-guided, technologically delivered interventions. It is important to note that these web-based interventions include significant professional contributions in development and thus may not be considered strictly bibliotherapeutic self-help; however, as noted earlier, the most effective print interventions are also the product of substantial professional contributions. Based on this, web-based interventions that were self-administered and self-directed were included in the current review. Self-help information presented within a technologically enhanced platform (e.g., web-based programming) appears to afford greater usability, and has demonstrated efficacy across the range of alcohol use disorders. Interactivity and personalization appear to be essential features of successful web-based self-help interventions. For example, Riper and colleagues found greater reductions in alcohol use among at-risk drinkers participating in a web-based, interactive, self-administered alcohol intervention relative to a web-based, generic, self-administered brochure. Similar web-based, personalized, self-administered programs have demonstrated efficacy in altering the motives that promote maladaptive alcohol use while also reducing contemporary alcohol consumption, with demonstrated persistence in positive change. These programs were also effective in reducing event-specific binge-drinking among at-risk drinkers (e.g., 21st birthday). These findings extend to heavy drinkers, an area that bibliotherapeutic techniques have historically not been robustly effective. Reductions in alcohol consumption were found among heavy drinkers following participation in a web-based, self-administered intervention with gains persisting at 3 months. Some research suggests that the addition of traditional bibliotherapeutic self-help materials to web-based interventions may produce additive benefits. Furthermore, independent meta-analysis and reviews support the efficacy of technology-assisted self-help treatments, although some professional contact may be optimal for sustained reductions in addictive behaviors.
All told, although the research regarding bibliotherapeutic interventions for maladaptive alcohol use and web-based, personalized interventions appear promising, several caveats exist. Traditional and contemporary bibliotherapeutic interventions have the benefit of being nonintrusive, inexpensive, and, based on existing research, are perhaps best framed as an initial intervention in a stepped-care approach for mild or moderate alcohol abuse. Bibliotherapeutic interventions that utilize interactive, fluid, web-based platforms demonstrate promising efficacy across a range of alcohol use disorders but perhaps particularly among at-risk drinkers. It is likely that continued development and adaptation in this area will contribute significantly to prevention and treatment in the future. These advances are most likely to be effective among groups with less access to traditional alcohol-related services such as women, younger individuals, and at-risk users. In summary, when determining whether self-help is an appropriate treatment modality, individual characteristics, familiarity with web-based computer resources, access to professional care, and the severity of the substance use disorder should all be taken into consideration.
Bibliotherapy for Marijuana
Based on a review of the literature to date, it is difficult to come to any conclusions regarding the utility of bibliotherapy as an intervention for marijuana use, particularly as a stand-alone intervention. A Canadian mental health study revealed that individuals acknowledging weekly cannabis use were more interested in receiving a self-help book or a computerized normative use summary than telephone counseling or individual psychotherapy. Cannabis users may be well-suited to minimally intrusive interventions, since the majority, including those who meet criteria for dependence, will never seek treatment. However, further research is required to elucidate the appropriateness and enduring benefits of bibliotherapy within this population.
Expressive writing is the practice of reflecting upon and ultimately writing down one’s deepest thoughts and feelings, often regarding a specific topic. Expressive writing was first introduced by Pennebaker and Beall as a means of examining whether writing about one’s deepest thoughts and feelings about a traumatic event would improve one’s health. Thirty years later, hundreds of research investigations have harnessed the power of writing to improve individuals’ health and well-being and to decrease negative health behaviors (see references 160 and 161 for reviews). Expressive writing is thought to exert its effects by allowing individuals to disclose emotions that they may have been afraid to express previously, cognitively restructure and find meaning in their experiences, and learn how to better regulate themselves and their emotions. Since its creation, the expressive writing paradigm has been modified and applied more broadly as a health and well-being promoting intervention. Recent research has begun to explore the use of expressive writing as a self-help intervention for individuals engaging in substance use behaviors. The basic premise of expressive writing is that writing and reflecting on one’s substance use behavior may result in a better understanding of one’s feelings toward his/her substance use behavior and the impact that drug use has on his or her life and the lives of those close to them. This process of self-reflection may then motivate individuals to change their behavior and formulate plans for how to enact change in their lives.
Expressive Writing and Nicotine
The first study to implement an expressive writing paradigm to promote smoking cessation among young adult smokers found that adding a four-session expressive writing component to an existing counseling intervention did not improve intervention efficacy 6-months postbaseline. The authors proposed that effects may not have been found because of the short follow-up period, so they conducted a second trial extending the follow-up period to 52 weeks and adding an additional writing session. After 8 weeks of treatment, the expressive writing plus counseling group had significantly higher abstinence rates compared to the counseling only group; however, abstinence did not differ between treatment groups at 24- and 52-week follow-ups. Although the research is limited, these studies do provide some support for adding an expressive writing component to an existing empirically supported intervention to potentially boost its efficacy. Furthermore, they suggest that using longer follow-ups and more frequent expressive writing sessions may be more likely to result in smoking abstinence, which can inform future expressive writing interventions to reduce smoking and promote change for other health behaviors.
Expressive Writing and Alcohol
To date, three studies have examined whether expressive writing leads to reductions in intentions for future drinking as well as reductions in actual drinking behavior. One study found that writing about a recent job loss reduced alcohol use at 6-week follow-up. More recently, the expressive writing paradigm has been adapted to ask individuals to write about a negative heavy drinking episode. Results from two studies found that expressive writing about a negative heavy drinking occasion was associated with increased readiness to change one’s drinking behavior, and decreased intentions for engaging in future drinking. Although expressive writing is itself not a new paradigm, adapting this approach for individuals to help them reduce their substance use is novel and largely unexplored. More investigations are needed to examine the efficacy of expressive writing as a brief intervention to reduce substance use behavior.
A helpline is a telephone-based service that provides information, support, and advice to callers with a wide range of problems or concerns. This section focuses more specifically on quitlines/helplines through telephone intervention alone, since a separate section of this chapter is devoted to self-help through the use of web-based technology. Burgeoning web-based and phone applications have emerged as a means for providing accessible intervention in curbing the use of drugs and alcohol. More recently, in an effort to become increasingly accessible, some helplines are also offered in tandem with web-based programming. A thorough review of the current literature did not reveal significant new contributions since the previous edition of this text. It is suspected that as technology has advanced, movement/interest has shifted away from telephone helplines and toward smart-phone and web-based applications. This section remains included, as quitlines remain a cost-effective, accessible, and viable option for specific groups, including older, lower income, rural, and minority populations.
Helplines offer a variety of distinct advantages unique to other forms of self-help, which may make them more accessible or appealing than seeking face-to-face counseling or professional treatment. Helplines provide an efficient means for delivering treatment to populations across wide geographic areas by eliminating barriers of access (e.g., transportation, child care, or scheduling conflicts). Many helplines are government funded and free of charge to callers, which enables them to reach more underserved populations (e.g., under/uninsured, low socioeconomic status). Indeed, research has suggested that lower income, less educated, nonwhite, and older individuals tend to utilize telephone-based helplines (versus helplines coupled with Internet), suggesting that this remains a viable source of help for some populations. Finally, helplines provide immediate treatment and support while preserving the caller’s anonymity, a feature that may attract drug users who are already battling with stigma associated with their drug use.
Helplines for Nicotine
The majority of published research on substance-abuse helplines has focused primarily on nicotine dependence, often referred to as “quitlines.” Although quitlines are generally regarded as effective in helping smokers quit, less in known about the effectiveness of helplines to treat other drug or alcohol use. Therefore the majority of this section has been devoted to the evidence-based literature regarding quitlines. In the 1980s, television antismoking campaigns began in Australia and public service messages about the risks of smoking were introduced in the United States via 1-800-4-Cancer, which was launched as a call-in center to receive advice on smoking risks/cessation. Both programs demonstrated effectiveness in increasing motivation to quit, and as a result, quitlines gained both popularity and momentum. Quitlines have since spread throughout North America, Europe, parts of South America, Asia, Australia, and South Africa. Although many smokers are aware of quitlines as an adjunct support to smoking cessation, generally less than 5% of smokers actually access them.
Nicotine Helpline Services
At a minimum, the majority of quitlines offer free self-help resources and other bibliotherapeutic information to callers. This is the most ubiquitous and standard service provided by quitlines. Another common feature includes reactive smoking cessation counseling—reactive in the sense that the call is initiated by the smoker, who is able to speak with a counselor. Other services may include proactive counseling (counselor calls the client), replacement or cessation medication, chat rooms, referrals to other cessation resources, and recorded messages.
Characteristics of Nicotine Helpline Callers and Specific Protocols
In general, smokers are four times more likely to use quitlines than face-to-face clinics. Studies examining the characteristics of callers to a national reactive telephone quitline found an overrepresentation of disadvantaged (i.e., African-American, women, poorer, urban, less educated, older) and heavier smokers compared with the general population. Due to the wide range of consumers, many quitlines have adopted specialized protocols to address the unique concerns of specific populations. Common specialized protocols exist for pregnant women, older adults, adolescents, ethnic minorities, smokeless tobacco users, and callers with multiple addictions.
Nicotine Helplines and the Transtheoretical Model of Change
Although individuals committed to smoking cessation appear to benefit most from quitline support, research suggests that quitlines may be efficacious for individuals across a wide range of readiness to change. Previous research suggests that many first-time callers to smoking quitlines have already made plans to quit, and that these individuals tend to benefit most from the quitline intervention. Helgason and colleagues found that 22% of first-time callers were in the action stage (had quit for 6 months or less), 76% were in the preparation (planning to quit within the next 4 weeks) or the contemplation (interested in trying to quit within the next 6 months) stage, whereas only 2% were in the precontemplation stage (not interested in trying to quit within the next 6 months). Although callers who were smoke free (action/maintenance) at the start of the intervention had the highest likelihood of being abstinent at the end of the study, there were also positive outcomes for callers in the other three stages. Half of the first-time callers in the precontemplation stage advanced to either the contemplation or the action/maintenance stage by the end of the quitline intervention. Similarly, for callers in the contemplation stage at baseline, half progressed to either the preparation stage or the action/maintenance stage, whereas only 10% regressed to an earlier stage. Of interest, although this research suggests that quitlines can help move callers from one stage of change to the next (e.g., from contemplation to action), many quitlines in the United States restrict services to callers who are planning to quit.
Helplines for Alcohol and Illicit Drugs
In a controlled experiment based in Wisconsin, researchers recruited nearly 900 patients from clinic waiting rooms who were not necessarily seeking help for their drinking problems. Half of the participants received pamphlets about healthy living, while the remaining participants received telephone counseling in which counselors assisted in setting drinking goals and overcoming barriers to behavioral change. Telephone counseling reduced alcohol consumption by 17.3% for men and 13.9% for women, compared with 12.9% and 11%, respectively, for pamphlet-only conditions.
The most promising research on alcohol helplines has been conducted on the UK telephone-based service known as “Drinkline.” Established in 1993, Drinkline receives about 6000 calls a month, the majority of which are problem drinkers seeking help for themselves. Callers are given information about safe drinking levels, advice about how to control drinking or avoid alcohol, and suggestions for how to overcome any related problems. A survey of callers showed that 81% received the information that they needed and 91% intended to carry out a plan of action after calling Drinkline. An extensive search failed to identify any comparable literature for alcohol helplines in the United States.
Despite the abundance of alcohol helplines, there remains a dearth of research on their protocol, services, and effectiveness. In a recent review of the effectiveness of alcohol and illicit drug use helplines, only 36 publications were identified. In total, 29 articles investigating or reporting on 19 different drug or alcohol helplines, (located in the United States, Europe, Australia, Asia, and Canada) were reported, further illustrating the paucity of research available in this domain. A thorough review of the literature suggests that, for the most part, helplines focus primarily on alcohol and nicotine use. Unfortunately an exhaustive review of the literature did not reveal any new investigations on helplines for alcohol.
Helplines for Anabolic-Androgenic Steroids
One of the most advanced, established, and researched helplines that specializes in steroid use remains the Anti-Doping Hot-Line founded by the Swedish health authorities with the support of the Swedish National Institute of Health. This helpline provides information about side effects and risks associated with anabolic-androgenic steroids, as well as facilitating contact between users and health care agents. The telephone service not only reaches out to anabolic-androgenic steroid users and concerned family and friends but also informs health professionals and organizations (e.g., public schools) about doping issues. In fact, the majority of callers to the Anti-Doping Hot-Line are nonabusers. Since the implementation and subsequent success of this Sweden-based helpline in 1993, Japan, France, Denmark, and other nations with high rates of anabolic-androgenic steroid abuse have followed suit with their own steroid helplines (primarily targeting athletes and adolescents).
Helplines for Cocaine, Methamphetamines, and Opiates
Due to the highly addictive and harmful nature of drugs like cocaine, methamphetamines, and opiates, strictly outpatient and self-help methods of recovery, such as helplines, are less common. It is telling that there is nominal research on the topic. However, 24-hour, 7-days-a-week phone services remain available (e.g., Moderation Management, National Meth Helpline, Cocaine Addiction Helpline, and Heroin Addiction Helpline) that offer no-cost assessments and dispense advice on how to stop, how to help a loved one quit, interventions, information, and hallmark signs of addiction.
In recent years, prescription drug abuse has surged as a very serious public health concern. In an effort to address the rapid increase in prescriptive drug overdoses and deaths, the West Virginia Prescription Drug Abuse Quitline (WVPDAQ) was developed. The primary mission of the WVPDAQ is to provide support, information, and viable referral sources for individuals addicted to prescription medication. It was the first remotely operated quitline to provide telephone assistance for prescription drug addiction. Only one investigation has been conducted on the WVPDAQ. Results indicated that between 2008 and 2010, there were 1056 calls received and self-report measures indicated that among callers, daily drug use declined.
Helplines as Self-Help
Helplines ride a fine line between self-help and assisted interventions. On the one hand, many first-time callers to drug abuse helplines have taken proactive and self-initiated measures to make the call. From there, it is often up to the caller to decide the extent or breadth of services that he/she desires. Staying within the definition of self-help, callers can have a few questions answered or request that some information be sent to their homes. Helplines start to cross over into the zone of assisted, professional help when multiple counseling sessions are involved, the individual is referred to the helpline by a hospital or medical professional, or the caller enters proactive counseling with multiple phone sessions initiated by the counselor.