Promoting Self-Change With Alcohol Abusers: A Community-Level Mail Intervention Based on Natural Recovery Studies Linda Carter Sobell, Mark B. Sobell, Gloria I. Leo, Sangeeta Agrawal, Lisa Johnson-Young, and John A. Cunningham Background: By using a public health approach to the treatment of alcohol problems, this study analyzed the efficacy and cost analysis of two versions of a community-level mail intervention to promote self-change among alcohol abusers who had never sought help or treatment. Methods: A total of 825 participants who responded to media solicitations were randomly assigned to one of two interventions: (a) for bibliotherapy/drinking guidelines (n = 411), they were given two pamphlets with information about the effects of alcohol and guidelines for low-risk drinking and self-monitoring, and (b) for motivational enhancement/personalized feedback (n = 414), personalized advice/feedback was provided on the basis of the participants’ assessment of their drinking and related behaviors. Results: Although both groups exhibited significant reductions in drinking from 1 year before to 1 year after intervention, there were no significant differences between the two interventions for any variable. This suggests that the materials, irrespective of whether they were personalized, facilitated the reduction of drinking. Cost analysis revealed that a brief mail intervention could reduce drinking at a very low cost per participant (US$46 to US$97). Conclusions: A brief community-level mail intervention for problem drinkers who had never sought treatment resulted in sizable reductions in alcohol use over the year after the intervention compared with the year before. Furthermore, many of those with poorer outcomes engaged in a natural stepped-care process by seeking help. These results, coupled with the low cost to deliver the intervention, suggest that public health campaigns could have a substantial effect on reducing alcohol problems and associated costs as well as getting some individuals into treatment. Such an approach would represent a shift from the alcohol field’s long-standing clinical focus to a broader public health perspective. Key Words: Natural Recovery, Alcohol Abuse, Self-Change, Community, Public Health. A LTHOUGH THE STUDY of natural recoveries has received increasing attention over the last 10 to 15 years (Klingemann et al., 2001; Sobell et al., 2000a), for many years the topic of self-change was viewed as taboo (Chiauzzi and Liljegren, 1993), was ignored (Sobell et al., 2000a), or was given little credence (Klingemann et al., 2001; Sobell et al., 1993). For example, Dupont (1993) has claimed that “addiction is not self-curing,” and he and others have argued that not to seek treatment is fatal (Dupont, 1993; Johnson, 1973; Winick, 1962). Today, such beliefs have been shown to lack an empirical basis. Fur- thermore, in the areas of mental health and health behav- iors, self-change is a well recognized phenomenon. With respect to mental health, Toro (1986) asserted that the majority of “psychological” problems people experience are never brought to mental health professionals or trained paraprofessionals. Rather, they are often shared with “nat- ural helpers” who possess no training. Commenting on health behaviors, Davison et al. (2000, p. 205) found em- pirical support showing that “more Americans try to change their health behaviors through self-help than through all other forms of professionally designed pro- grams.” They also reported that self-change populist ap- proaches are often overlooked by professionals “because of a bias toward professionalism on the one hand and a lack of awareness on the other hand.” Multiple and converging lines of evidence have led to the recent recognition of self-change as an important pathway to recovery from alcohol and drug problems (American Psychiatric Association, 1994, 2000; Institute of Medicine, 1990; Klingemann et al., 2001; Sobell et al., 2000a). Re- search in this area has also led to the development of From the Center for Psychological Studies (LCS, MBS), Nova Southeast- ern University, Fort Lauderdale, Florida; the Center for Addiction and Mental Health Services (GIL, JAC), Toronto, Ontario, Canada; the Department of Psychology (JAC), University of Toronto, Toronto, Ontario, Canada; the College of Nursing (SA), University of Nebraska Medical Center, Omaha, Nebraska; and St. Joseph’s Health-Care Hospital (LJ-Y), Hamilton, Ontario, Canada. Received for publication March 6, 2002; accepted April 12, 2002. Supported in part by NIAAA Grant AA08593. Presented in part as an invited plenary lecture at the annual meeting of the Research Society on Alcoholism, June, 2001, Montreal, Quebec, Canada. Reprint requests: Linda C. Sobell, PhD, Nova Southeastern University, Center for Psychological Studies, 3301 College Ave., Fort Lauderdale, FL 33314; Fax: 954-262-3895; E-mail: sobelll@nova.edu. Copyright © 2002 by the Research Society on Alcoholism. 0145-6008/02/2606-0936$03.00/0 ALCOHOLISM:CLINICAL AND EXPERIMENTAL RESEARCH Vol. 26, No. 6 June 2002 936 Alcohol Clin Exp Res, Vol 26, No 6, 2002: pp 936–948