Yearbook on Journal of the Japan Society of Nursing Research 2015

Consciousness of Abstinence to Alcoholics with Long-Term abstinence Experience
Yumi Okada1)
Key Words :Consciousness of temperanceLong-term temperance
Alcoholism

ABSTRACTThe purpose of this research is to clarify how Alcoholics Anonymous members who have long been practicing
temperance have become aware of their ability to control their temperance. Research participants were
3 male and 3 female alcoholics who had been abstinent for 5 years or more. Participant observations
and interviews were conducted and data was analyzed by inductive coding. Three categories and ten
sub-categories were found: rule-oriented temperance, constant/repeated vows of abstinence, and a new
consciousness emerging from abstinence. The results revealed that these categories influenced each other,while the alcoholics themselves were influenced by people from their environment, e.g. relatives, friends
and health care professionals. The first category also indicated that alcoholics with long-term temperance
abstained in the early stages successfully by coping with their unstable feelings which were not necessarily
related to a feeling of crisis while drinking. The findings suggest that nursing professionals should understandthe effects of temperance on alcoholics and consider support they may need.

public9), 10) but also the health and nursing professions.
Hisatomi revealed that more than 60% of nurses working ina general ward hold misconceptions such as “patients withalcoholism can control how much they drink”. In addition,
fewer nurses answered yes to the question “recoveringfrom alcoholism is worthy of respect” than did membersof the general public in a cross-cultural epidemiologic
investigation conducted in Japan and America11). Such biases
and misconceptions hinder efforts to provide more systemic
support for such patients.
Studies of alcohol dependent patients who have maintained
total abstinence have been conducted using surveys, to examine
prognosis5), 6), 12), treatment program effectiveness,13), 14) efficacy
of self-help programs, and awareness about the self, othersand drinking17). Moreover, clinicians have discussed recoveryrelated awareness based on their clinical experiences18), 19),and changes in insight and recognition throughout the process
of attaining abstinence among alcohol dependent patients
have been investigated20).
However, the structure and the condition of awarenesstowards abstinence based on actual experiences of the patientswith alcoholism still remain unknown. Thus, the present study
focuses on examining awareness about abstinence during theprocess of long-term abstinence among those who attend aself-help group.

I. Introduction
Alcoholism is one of the substance dependence disorders,which can also occur with substances such as marijuana
and sleep aids. The number of people suffering fromalcoholism has been increasing every year, and patient
statistics collected in 2003 state that an estimated 19,900
people suffer from alcoholism1). Once one has alcoholism,
he or she might find it impossible to drink in moderation,such that recovery ultimately requires total abstinence fromdrinking. Furthermore, although alcoholism is never truly
cured, abstinence is essential for patients with alcoholism
given that psychological and behavioral recoveries are
possible. However, maintenance of abstinence is reported to
be extremely difficult, even with clinical interventions2), 3), 4).
Yamane et al. reported that abstinence rate decreases after
hospitalization treatment: 44% after six months, 34% after
one year, 20% after two years, and 12 to 17% after three years
post-hospitalization5). Moreover, it has been reported that
21.2% of patients who came to seek help at a public healthcenter maintained abstinence for more than a year, and thatthe average age of death for such patients is 50 years old6).
Meeting life demands without drinking alcohol is a serious
problem for such patients, and it is therefore essential toconsider ways in which better treatments can be developed
and abstinence goals maintained.
In 1985 the Japanese council of public health stated in“opinions about issues and acts related to alcohol” that acommunity support system to help sustain abstinence isrequired for patients with alcoholism7). Moreover, “National
Health Promotion in the Twenty First Century (Health Japan21)”, which was organized in 2001, emphasizes the importanceof complete abstinence from alcohol with appropriate
support and additional establishment of an environment thatencourages self-reliant support, such as active engagementwith self-help groups8). However, stereotype, stigma andmisunderstandings about alcoholism and patients withalcoholism are propagated not only amongst the general

II. Method

1. ParticipantsParticipants in the present study were consenting membersof a self-help group whose goal is to stop drinking. All
participants had been diagnosed with alcoholism in the pastand have been alcohol free for more than five years.
2. Data collection
1) Interview
The retrospective interview was conducted in a semistructured format. At the first interview, the interviewer asked
about the participants’ lives, experiences, and thoughts “whenthey were drinking”, “when they started to stop drinking”
and “after they had stopped drinking”. There was minimal
interviewer input so that the participants could freely tell

1) Hiroshima International University

Corresponding author. Tel.: +81 823 73 8368.
E-mail address: y-okada@ns.hirokoku-u.ac.jp

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Yearbook on Journal of the Japan Society of Nursing Research 2015

their stories.
The interviewers took notes or audiotaped the interview
content after gaining the consent of the participants. We
audiotaped the first interviews of all six participants. The
second interviews of four participants were audiotaped, andthe remainder of these interviews were recorded in a notebook.
Furthermore, the families of consenting participants came inafter the second interview. Family members were included in
the interviews so that they could encourage the participants
to remember past experiences and to recall these events
more vividly. Sufficient interviews were conducted in order
to allow participants to sufficiently recall past experiences
and associated emotions, such that an average of 2.3 times
and 5.2 hours of interviews were conducted per participant.
The data were collected from February to June in 2005.
2) Observation
Upon explaining the purpose of the study to the participants,
the researchers attended the self-help group and abstinence
workshops held by alcohol dependent patients, and observed
their behaviors and attitudes at testimonies. This observation
was conducted from September 2004 to November 2005.

for validation. The participants stated that the categories do
indeed reflect participants’ awareness.
III. Results

1. Participants
The participants were six members of a self-help group(three men and three women). Their age ranged from forties
to sixties, and they were sober for five to 19 years. Five of theparticipants had the experience of slipping.

2. Formation of awareness of long-term abstinence
Two types of awareness were observed among theparticipants who had maintained abstinence: Awareness ofvalues and beliefs to maintain abstinence and behavior basedon those values. The former categories are <stop drinking
based on the determined rules> and <continue alcohol
abstinence>, and the latter category was <new awarenesscreated by being alcohol free>. Moreover, there were four
subcategories in <stop drinking based on the determined
rules>, two subcategories in <continue alcohol abstinence>,
and four subcategories in <new awareness created by being
alcohol free>.
From the following section, categories will be expressed in< >, subcategories in [ ], and raw data in “ ”. In the raw data, ( )will be used to complement subjects and to convert dialects.

3. Ethical consideration
The researchers requested referrals from a self-help groupfor alcohol abstinence from a public health nurse at a healthand welfare center, or from psychiatrists, upon explaining
the purpose of the study, and the participants were referredthrough the group committees. The study was described toparticipants in a written format, and the interviews wereconducted only after consent was provided. Participant
confidentiality was maintained. The institutional review
board at Okayama Prefectural University approved thepresent study.

<Stop drinking based on the determined rules>
The participants felt that their abstinence was owed tofellow group members and surrounding people; furthermore,they thought that attending the self-help group kept them
abstinent. Moreover, participants described insecure emotions
including a vulnerability to drinking at early stages, and they
enacted coping behavior to maintain abstinence.

4. Analysis
The analysis was conducted based on the Grounded
Theory Approach. Verbatim transcripts were created fromthe collected data; sentences and paragraphs associated withawareness of alcohol and related experiences were extracted
and chronologically organized considering the context.
Next, we interpreted the meanings of experiences and typesof awareness from extracted sentences and conceptualized
them. Interactive experiences with a flow were conceptualized
together. The obtained data were constantly compared andanalyzed, and we repeated categorization and grouping toyield categories.
The produced concepts were examined by confirming
the presence of actual examples in the data. Furthermore,
the categories were extracted based on these concepts
while paying careful attention to the interactions between
categories. Finally, the analyzed results were produced.
1) Reliability(1) Data and produced categories were repeatedly confirmed,
examined, and revised through discussions with an advisor
and psychiatrists. Moreover, a professional in qualitative
research supervised the data analysis.
(2) In addition to attending the self-help group from
September 2004 to November 2005, the researcher joined
overnight workshops and memorial events held outside theprefecture. Thus, sufficient time was spent in continuous
observation and establishing mutual trust with members.
(3) In order to confirm whether the produced categories are
sufficient, we presented the categories to two participants[Attributing abstinence to fellow members and surrounding
people]Before meeting with fellow members and the self-helpgroup, the participants had lost themselves due to binge
drinking, had deteriorated relationships with their friends
and felt depressed, “lonely”, “unlivable”, and “despairing”.
Participants who had been hospitalized or began treatments
under such conditions felt that they were “being saved”, “I
found a place to live” and “maybe I could quit drinking here”,
by meeting the members of the self-help group and trustableclinicians. They started having hope. Such awareness wasimportant for current maintenance of abstinence.
“The only treatment for this disease is regularmeetings…..medications for alcoholic abusers is theregular meeting…..”
Moreover, the participants attributed their opportunities toquit drinking to others, “for friends” and “for teachers”, when
making a decision regarding abstinence, “when trying to quit
drinking” and “when trying to go to the self-help group”.
“In the meetings, like most other people who are
here, being a part of that crowd and then goinghome. Repeating and repeating the same thing may
be stopping me from drinking…..”
The participants who had been alcohol free for more than
10 years perceived various encounters with fellow members
and clinicians as “fate and destiny for keeping abstinent” andrecognized fate as leading to future abstinence for the self.
This participant also emphasized that these people were the28This paper was published at “the Japan Society of Nursing Research” Vol.29 No.2 in 2006.

Yearbook on Journal of the Japan Society of Nursing Research 2015

key to having an opportunity to stop drinking. Furthermore,
the participant consciously used the other people as his
opportunity to quit drinking.
“At the end, when quitting, you need something,otherwise it is hard to quit.”

my disruptive lifestyle had caused trouble for mydaughter, I feel ashamed and sad…..”<Continue alcohol abstinence>
The participants tried to quit drinking as their own
decision. When they felt that it was particularly difficult not
to drink, they tried to focus on “current” abstinence as muchas possible.

[Stop drinking by sharing experiences about drinking]
When listening to the fellow members’ testimonies
about “painful experiences when they were drinking”, theparticipants also recalled their own painful experiences
associated with drinking that serve as their “foundation”. By
connecting their experiences to other members’ experiences,
they started feeling a strong urge to stop drinking.

[Having insight into the disorder and keeping abstinent]
The participants focused on abstinence without forgetting
the experiences that had brought them close to death when
they were drinking and that had caused enormous troubles
for others.
“In order to keep being sober, I must not forget what
I had done….”“I am sick. Once I have one glass, I cannot stop. Now,
I always keep that in mind.”[Stop drinking by making public statements about abstinence
and introspecting]
The participants not only listened to other members’
alcohol related experienced but also talked about theirown past related to alcohol, as “my story”, in front of othermembers. They described their lives were when they were
drinking and how the drinking caused problems that affectedsurrounding people. The stories made them aware that “Ihave a past that motivates me to stop drinking, so I need to
be abstinent now.”[Stop drinking by setting an immediate goal]
The participants maintained abstinence by having life goals
such that that they could make a decision not to drink; they
made decisions about abstinence on a short-term basis andrepeated this process, such as “I don’t drink for today” or “I
don’t drink until the next meeting”.
Moreover, when participants felt particularly insecure,they developed more immediate goals and repeated thesebehaviors so that the situation would not lead to drinking.
“At first, I aimed for three months. My rough goal isthree months, and next is six months. If I can stop
drinking for six months, then I aim for one year, andgo on like that…”“When I get angry, sometimes I don’t know what I
would do (drink again)… but then I tell myself “whynot try not to drink for one day and see.”[Coping with insecure emotions by engaging in routine
behaviors]
When feeling vulnerable to drinking, participants tried
to cope with their desire by engaging in pre-determined
behaviors such as “going to the meeting” and “talking it overwith fellow members”.
“Me…. When the dangerous feelings come up, I
instantly go to the meeting or have someone listen
to me….”
The participants did not engage in the pre-determined
behaviors only when they felt in danger of slipping. Whenthey felt emotions such as irritation, ill temper, anger, andsadness from marriage and work during their daily lives, they
engaged in such behaviors to calm these emotions.
“There are a lot of things that irritate me. Today, I
again went to the hospital (where I get treatment),and I looked at the sign (of the hospital)”.
There, the participant said that he or she reflected on theirexperience and tried to calm his emotions.
Many of the participants were determined to “talk,” in orderto deal with such insecure emotions.
“(When verbally abusing each other in theirmarriage) in such situations, we overcame theproblems by talking to each other. There are people
that I can talk to and seek advice from (veterans inthe self-help group), and I can then face my problems
and deal with them.”
Furthermore, when they experienced insecure emotions,the participants tried to engage in such behaviors as “quickly”
as possible. During observation, the participants attended theabstinence meeting in the afternoon, and gave a speech attheir turn as follows:“Today I am wearing like this (formal wear) because,in the morning, I went to decline the offer of anarranged marriage for my daughter. Why? Because
his family came from XXX while our family is amess, the father in the family is an alcoholic. We
don’t much, so I declined the offer. But thinking that

< New awareness created by being alcohol free >Throughout life without alcohol, the participants had gained
a calmer mental state, and they gradually started thinking fromtheir family and friends’ perspectives. Moreover, they founda “mission” and a role as an alcohol dependent survivor, andvalued their current lives in which they maintain abstinencewith fellow group members in order to find a unique andsuitable way of living.

[Realizing a different self from the past when they were
drinking]
The participants felt that they themselves changed alongwith achieving abstinence. They were different people from
who they were when they were drinking. They had gainedsome degree of inner peace and realized that they had support
from friends and family.
“Ummm, I’m quite calm now.” “I am more laid back.
I don’t overreact to what others say”.
“I was quite awful before (to my mother), when I
said things I made a big deal. If she prepared dinner
I was thinking ‘Leave me alone, don’t give me any
trouble’. But now I’m the total opposite. I feel thatmy mother cares about me a lot even though she
is old”.
[Taking a role as an alcohol dependent survivor]
The participants felt that they wanted to be a “sober person”

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Yearbook on Journal of the Japan Society of Nursing Research 2015

in front of important figures such as fellow members. They
became more conscious of maintaining long-term abstinencein the process of participating in activities to help othermembers who were struggling to stop drinking.
“I will (again) see them (fellow members), so I
cannot drink….”“I cannot drink (because I help other members). I
am helping them to stop drinking. Doing that kindof thing gives me a system of not drinking…”“In a moment… even there are many factors in
between, at the end, the problem is whether
you drink or not. For our members, choice at the
moment can be a really big change. (Then, I go to
the meetings) listening to other people’s stories…
the momentum leans towards not drinking, in agood direction. If I don’t drink, the sober period,
the number of days, accumulates. So if I try tonegate that, I never know when the devils comein…. I cannot drink until I die… (and) even if I havesomething like this kind of body (alcoholism), I canlive decently if I don’t drink. Now, it makes me thinkthat I have to pay my debts, so I work. If I say ‘ohh
you should go on personal bankruptcy’, then you
can skip paying debts but it doesn’t go like that. So
I quit drinking. If I keep quitting, that is really a big
deal, I think”.
This participant thought that, even during the current
period of abstinence, the decision to stay sober was momentby moment, and for those recurrent moments, the participant
attended the meetings to decide on “abstinence”, whichis <stop drinking based on the determined rules>, andrepeated making decision by choosing to remain abstinent.
Furthermore, while repeatedly making decisions about
abstinence, he or she had noticed change in his or her emotionand environments that he or she had not realized when heor she was drinking. Then, the participant perceived <newawareness created by being alcohol free> as worthwhile andvaluable, such that “I can think that I need to pay my debt andthis surprises me about myself”, and provided a meaning todecide to maintain abstinence.

[Finding value during a daily life of not drinking]The participants saw the results of their abstinence andvarious changes brought about by abstinence as a goodchange for them, and thought that the time and effort put into
abstinence was worthwhile.
“When I don’t drink for five or six years, it is a waste
to spoil that (by drinking again)”“Because I learned a lot (from fellow members), I
can say things now…..I myself benefitted from it. If
I think about whether this was a gain or loss, it’s
definitely a gain.”[Being encouraged during abstinence]
The participants were encouraged by increased understanding
regarding the disorder, the self-help group, and support
from surrounding people. Furthermore, they were trying to
respond to the support and maintain abstinence. Moreover,the participants stated that current abstinence was theactualization of what they had given up in the past, and suchawareness led them to have more self-confidence.

3. Structure of the awareness established throughout
abstinence (Figure 1)
The aforementioned three categories of awareness are
not independent from the presence of support from family
or friends, but they are interactive. Moreover, throughout themaintenance of the abstinence, these three types of awarenessalways existed without cessation inside of the participants’minds.
Moreover, <abstinence with rules> and <continue alcohol
abstinence>, often interacted throughout participants’ daily
lives. As a result of repeated interactions of these formsof awareness, <new awareness created by being alcoholfree> was formed, and then developed into new forms ofawareness, <stop drinking based on the determined rules>and <continue alcohol abstinence>. In this process, the three
categories affected each other, forming a cycle. For example,
one participant explained as follows, giving an example ofslipping.
Stop drinking
based on thedetermined rules

IV. Discussion

1. Awareness towards abstinence established by long-term
abstinence experience
1) Awareness towards abstinence affected by fellow members
and surrounding people
The participants always attributed their successes in themaintenance of abstinence from the start to the present tofellow group members, family, and clinicians. Saito states thatpatients with alcoholism, during the process of forming insight
into the disorder, “stop drinking only with willpower” andbelieve in a “higher power” to help maintain abstinence13).
In the present study, by believing in a higher power, theparticipants perceived that they consciously associatedtheir abstinence with surrounding people. Because several
participants talked about attributing their motivations for
abstinence to surrounding people, “I kind of created (or found)the moment. If I don’t do so, I could not quit”. Based on thisstatement, motivations and opportunities to keep abstinent
are not necessarily created by chance experiences and beliefs,
but rather, their awareness was motivated by thoughts suchas “I want to continue abstinence”.
Moreover, the participants actively associated theirabstinence with surrounding people, and thus they were
trying to be conscious about “the self who does not drink”
and continue abstinence.

Continuealcohol
abstinence

New awareness created bybeing alcohol free2) Awareness of abstinence with goals
The decision not to drink alcohol in daily life occurred
via setting short-term goals and acknowledging current
abstinence. Setting short-term goals for abstinence was

Figure 1. Structure of the awareness establishedthroughout abstinence

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Yearbook on Journal of the Japan Society of Nursing Research 2015

reported to be effective at the initial phase of treatment. Sucheffects then pertain to satisfaction and self-efficacy in termsof reaching a goal14). In the present study, the participants set
a goal as “I don’t drink for today”, with such goals importantfor initial efforts as well as maintenance of abstinence.
Furthermore, when the participants experienced insecurities,
they adjusted goals on their own by making them shorter termso that they could maintain abstinence. Such awareness wasconsidered to be important to avoid slipping.

coping methods is thought to be essential to maintenanceof abstinence. Moreover, the participants sensed not only
drinking problems but also insecurities experienced during
their daily lives such as marital or family problems at earlystages, and they incorporated these behaviors into their daily
lives.
2. Suggestion for nursing application
The present study emphasizes the importance of theunderstandings among nurses who deal with patients withalcoholism, not only with regards to awareness towards
alcoholism but also coping methods. Furthermore, when suchfeelings are difficult to deal with, it is important for nurses
to provide support that encourages patients to adopt coping
behaviors by, for example, providing opportunities to talk overthe patients’ emotions.

3) Determining coping behaviors for daily life and coping
while maintaining abstinence
When the participants felt in danger of slipping orexperienced emotions such as anger and sorrow, they engaged
in certain pre-determined behaviors. Those behaviors wereintended to calm insecure emotions and included suchstrategies as “go talk to fellow members” and “give a testimony
at the meetings”.
It is reported that those who have taste problems withalcohol need habitual behaviors as part of a daily routine
to keep their minds off of urges for taste behavior15). The
awareness that participants tried to cope with the danger ofslipping is the characteristic behavior found in the present
study when considering urges for this taste behavior.
Furthermore, the present study indicated that theparticipants engaged in such pre-determined behaviors not
only to avoid slipping but also to take quick action to calm
down and deal with stressors during their daily lives. Thiswas shown at the testimonies in the meetings, when themembers talked about difficult experiences of the day suchas an argument with a spouse, they went to talk to the senior
members who listened to their stories.
Quick actions taken by the participants could be attributed
to “the awareness to perceive insecure emotions at an
early stage”. At the same time, it “relives insecurities at an
early stage”, contributing to stabilization of emotions andmaintaining abstinence.
“The awareness to perceive insecure emotions at an earlystage” can be understood by considering that the behavior
to solve the problem was “to talk”. Mead insisted that one
can listen to what oneself is talking about, and that one
can communicate to oneself in the same manner as one
communicates with others16). Thus, talking over feelings suchas “sad” makes patients clearly recognize their insecurities.
Moreover, the participants not only “talked” but also “went”
to certain places, “going to see the hospital’s sign” in thecase of the present study, and described such behavior as“getting insight into the self”. Therefore, it is can be argued
that participants had “awareness to perceive their emotions”
by self-observing their own experiences.
“Calming down insecure emotions at an early stage” can beunderstood by considering that the participants dealt with
their insecurities by taking pre-determined actions, thereby“calming” or “overcoming” the emotions. Benner stated that
following one’s feelings enables one to reinterpret frompast experiences and is advantageous to self-reformation
as opposed to denying one’s emotions17). The participants
tried to perceive insecure emotions at an early stage inorder to maintain stability. This was different from before,
when participants often “drank to conceal my weakness”.
The participants gained new ways of coping. Considering
alcoholics are often those who attempt to deny daily physicaland psychological difficulties by drinking19), gaining alternative

3. Implications and limitations
The participants in the present study were limited topatients who intended to stop drinking by participating in aself-help group. Thus, in order to extent the present findings,
participants at other stages of the treatment process or who
are undergoing different treatments should be examined. An
examination of awareness by comparing the awareness of
those patients in the community with those who are greatly
affected by relationships with family, friends and clinicians
or groups are crucial.

The author shows deep appreciation for Tsuruko Ono(Okayama Prefectural University Graduate School) for her
guidance. The author also thanks the participants.
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