Institute of Epidemiology and Social Medicine, University of Greifswald,
1 Hospital Parber,
2 Hospital Gilead,
3 Department of Psychiatry and Psychotherapy, University of Frankfurt and
4 Department of Psychiatry and Psychotherapy, University of Luebeck, Germany
Received 7 May 2002; in revised form 10 December 2002; accepted 3 January 2003
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ABSTRACT |
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INTRODUCTION |
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It is largely unknown what the most adequate way of providing motivational work might be in alcohol-dependent in-patients who do not seek specialized alcoholism treatment. Controlled trials with alcohol-dependent patients largely included individuals who were interested in the abstinence-oriented therapy. These studies could not reveal better outcomes after group treatment than after individual counselling (Orford and Edwards, 1977), even if it consisted of a single session (Howden-Chapman and Huygens, 1988
). Chick et al.(1988)
assigned patients in an alcohol problems treatment service on a random basis to one group with the advice to stop drinking or counselling of 3060 min (n = 96) and one group with treatment (n = 58) that included the elements: in-patient or day-care group therapy in a 24-week programme. While there were fewer alcohol-related problems after treatment, no difference in the rate of abstinence between the two intervention groups was found. With respect to outcome measures, these studies were focused on alcohol-related problems, and less on further help-seeking. However, given the long-term development of coping with alcohol dependence, it might be a valuable approach to declare the seeking of further specialized help as an intervention goal for those dependents who do not actively seek help by themselves.
The aim of the present study was therefore to examine the question of whether, within the detoxification programme in a psychiatric hospital, individual counselling is as effective as a more costly group treatment approach in: (1) enhancing the motivation to seek further help in dealing with alcohol problems; (2) to live abstinently. The sample selection bias should be as low as possible, so that conclusions could be provided for routine care settings. Hypothesis 1 states that group treatment does not outperform motivational counselling in the rate of those seeking further help 6 months after treatment, and hypothesis 2 states that group treatment does not outperform motivational counselling with respect to the rate of former patients remaining abstinent during the first 6 months after treatment.
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SUBJECTS AND METHODS |
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The sample social and alcohol-related characteristics are summarized in Tables 1 and 2
. Compared to specialized alcoholism treatment according to Küfner and Feuerlein (1989)
, just 26.4% were married (alcoholism treatment: 54.7%), 36.6% belonged to the workforce (alcoholism treatment: 63.1%), and more had been in-patients in detoxification treatment before (54.3%) than in alcoholism treatment (33.0%). The subjects did not differ from patients in other detoxification treatment units in German psychiatric hospitals (Wienberg et al., 1993
). The patients were referred to the hospital by their general practitioners, self-help groups, counselling services or the emergency unit of the university hospital to in-patient treatment, or, the patients came of their own accord.
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Treatment
Detoxification. The patients, according to the clinical judgement of the treating physician, had to be free of severe withdrawal symptoms and any medication for treatment had to be stopped, with the exception of carbamazepine. Detoxification treatment was carried out using chlomethiazole, if necessary, according to the Alcohol Withdrawal Scale (Wetterling et al., 1997).
Common components of both interventions. Both interventions had further help-seeking as their primary goal and motivational interviewing as their central organizing approach (Miller and Rollnick, 1991; Miller et al., 1995
). This included encouraging the patient to keep in contact with the out-patient service after the in-patient stay. According to the drinking of alcohol, the attitude of the patient was accepted, be it that s/he wanted to drink in the same manner as before, to cut down or to abstain from drinking. However, the treatment personnel displayed the clear attitude that according to the experts experience, abstinence is the best way to survive and a basic requirement for being able to cope adequately with the problems. In both interventions psychotropic substance use was not allowed. This included prescribed medication, for example benzodiazepines. The patients were supported in developing a more satisfying living situation. The IC intervention was carried out on a psychiatric ward and the GT intervention on a ward that was specialized for this intervention only. There were the following common provisions of routine care for the patients of both intervention groups: medical support from the physician in case of any problems with regard to a prolonged detoxification or psychiatric problems, availability of a social worker for support in case of problems with money, housing, family, applying for a job, and for help in writing the application that was needed for the patients to get a treatment space in alcoholism therapy if s/he wanted to. A working training was provided which included easy-to-learn handicrafts and painting.
Interventions under study. The IC intervention consisted of three individual counselling sessions of 40 min each. No systematic motivational work was included in the routine care of the ward. The first IC session dealt with the development of an adequate understanding of the substance-use problems, including the patients need to make a decision about his further drinking behaviour. Arguments in favour of, as well as against, the maintenance of abstinence were staged. The second session dealt with the actual living situation. This session began with the description of a typical day. After that, strains of everyday life were elaborated on, as well as perspectives for the future. One goal was that the patient should realize that long-term abstinence would be aided by psychosocial support, including the partnership or place of work. The third session dealt with the need for further counselling, treatment or participation in self-help groups. With every patient, an individualized solution was developed. The counsellor was a physician, not responsible for the medical care of the patients, who carried out the counselling on the ward in a counselling room. Each version was allowed to fall below or exceed the 40-min duration by only 5 min.
The GT intervention followed the same goals as the IC intervention in the same priority ranking: first came the support of the motivation to seek further help for the substance-use problems. Second was to support the motivation to stay sober. In order to follow both of these goals, the GT intervention focused on: (1) the development of an adequate understanding of the problem; (2) fostering self-efficacy; (3) motivating the patient to ask for further help if needed instead of withdrawing from those relevant for help. The GT intervention included a 14-day standardized treatment programme followed by four out-patient group sessions within the first month after discharge. Treatment groups consisted of eight to 12 patients.
The programme included the following elements: (1) nine GT sessions of 90 min each were led by a psychologist, who had 5 years of experience in alcoholism group treatment, and a co-therapist. In the focus was that the patient should become convinced of the fact that s/he is able to influence his/her own behaviour. Included was a half-hour of training in applying for a job. Since the group was heterogeneous according to the stages of change, those in the action stage functioned as models for the patients in the lower stages. However, the intervention did not follow strictly the stages of behaviour change as part of the Transtheoretical Model (Prochaska and Velicer, 1997). (2) The patients spent 1 day at the first and 2 days at the second, weekend at home. This was planned and evaluated within the GT. (3) The patients visited four meetings of different self-help groups of alcohol dependents in the community. (4) Relapse-prevention training according to Marlatt and Gordon (1985)
was included. There was one in vivo training of each patient with a treatment buddy in an individually risky situation. (5) There was one additional treatment session together with the most relevant others. This session was designed to lead to a concrete agreement concerning the future way of dealing with the patient, including at-risk situations. (6) For information about alcohol dependence, two films were shown, each in one session, and another two group sessions were conducted about healthy diet and about personal hygiene. (7) In the out-patient GT sessions, led by the therapist, the main subjects of discussion were how to cope with situations at-risk for drinking, to seek further help and to stay sober. (8) Every morning, the patients had the opportunity to exercise. Altogether, the GT was a multi-component intervention, the focus, however, was on the support of the motivation to seek further help for the substance-use problems.
The patients were checked for whether they stayed sober or not during treatment. Relapse during the in-patient treatment phase occurred in less than 1% of the patients. Although all members of the treatment staff accepted individual goals of moderate drinking, they expressed that, according to their experience, abstinence would be the best way for recovery. The first of the four out-patient sessions took place on the day of discharge, the following three after 1, 2 and 3 weeks. At the first session, 77.6% of the 161 patients took part. This rate dropped to 62.1% at the second, 51.6% at the third and 40.4% at the fourth session. Of the 161 patients, 39.1% took part at all four sessions.
Assessments
During treatment. Sociodemographic factors, ICD-10 alcohol dependence diagnosis, drinking history, and psychiatric comorbidity of the patient were assessed. Abstinence was proved by random tests of breath-alcohol concentration. If alcohol consumption was thus detected, it was discussed in the group session; however, it was not followed by discharge. The ICD-10 criteria were checked according to the German language ICD (Dilling et al., 1991) by the trained treating physicians or psychologists.
Follow-up assessment. Abstinence was estimated by questions concerning whether the former patient had restarted drinking alcohol and, if yes, at what date after treatment. We did this without using validation of the answers by statements of significant others or laboratory parameters, mainly because it was impossible to obtain information from significant others for more than half of the sample, since 53.6% of the former patients lived alone. This report is restricted to abstinence vs drinking. We did not use laboratory parameters, since evidence shows that, in such samples, it does not add significantly to the information already received (Mundle et al., 1999; Babor et al., 2000
). We expected that taking blood samples after treatment would have reduced the number of those with valid data. Data in this report are restricted to 6 and 12 months. We checked the patient records at our and a second psychiatric hospital that was responsible for the catchment area, to see if any of our former patients had been readmitted within 6 months after treatment.
Follow-up time frames started with the day of hospital discharge for both intervention groups. We used all the information we received up to 24 months after hospital discharge, to make up the time of the first 6 months after the in-patient stay. By doing so, we have interview information from 69.3% of the former patients according to these first 6 months. The information was gathered during the seventh month in 190 (59.0%) of the 322 patients. From an additional 33 (10.2%), we obtained information on the 1224 months after treatment, from a further 18 (5.6%) after 12, a further 10 (3.1%) after 18, and a further 5 (1.6%) after 24, months. Of the 322 patients, in total two had died during the first 6, six in the first 12, 9 in the first 18 and 14 during the whole 24, months. For reasons of comparability, rates are always given on the basis of n = 161 patients in both of the subject groups. All patients who had begun participating in one of the two intervention groups were included in the sample for follow-up. This includes 19 patients who dropped out of treatment from both groups.
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RESULTS |
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Patients after group treatment showed a higher gain in taking part in self-help groups, compared to patients in counselling. Twenty-nine patients from group treatment participated in a self-help group after treatment the first time, compared to 17 former patients of the counselling intervention (Table 4). Between the seventh and the twelfth month after discharge the difference between the IC and the GT groups regarding the rate of those participating in self-help groups no longer existed (
2 test, P = 0.34). The two interventions did not differ in the rate of abstinent individuals, neither 6 nor 12 months after discharge (Table 5
).
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DISCUSSION |
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Hypothesis 1, which stated that the GT does not outperform the IC intervention in the rate of those seeking help after 6 months, has to be rejected. During the first 6 months after intervention, there was more help-seeking in former patients of the GT intervention. This result remained after controlling for confounders. The GT intervention during an in-patient stay in a psychiatric hospital leads to a higher rate of help-seeking in self-help groups in alcohol-dependent in-patients, than does counselling. In both types of intervention, a considerable number of first-time users of formal help followed. Of all 322 patients, 14.3% participated in self-help groups, 5.0% took advantage of addiction counselling for the first time after treatment, another 10.9% utilized out-patient treatment for the first time. This leads to the conclusion that counselling as well as the much more resource-consuming group treatment may contribute to raising the rate of abstinence in former patients.
Well known prognostic criteria differ between the two interventions. More patients living in partnership, and more patients belonging to the work force from group treatment fulfil the goal of utilizing formal help, than those of the IC group. After the first half year following treatment, the differences in the utilization of help disappear. The data according to the participation in self-help groups reveals some similarity with that of Project MATCH, which for twelve-step facilitation treatment showed a higher rate of Alcoholics Anonymous attendance than motivational enhancement treatment (Project MATCH Research Group, 1998). In our study, therapists placed emphasis on taking part in self-help groups. Thus, there might be an effect of supporting the motivation to join a group. This provides resources of social support for staying sober in a long-term perspective. Once the patients are experienced in participating in self-help groups, they can utilize this kind of help more easily when they are more ready to change.
Neither intervention led to a higher abstinence rate. Hypothesis 2 is therefore confirmed by the results. Thus, of the counselling-intervention patients, 27.3%, and of the group-treatment patients, 29.2% said that they did not drink any alcohol during the first 6 months after treatment. There was a trend, however, that from the patients living with a spouse or belonging to the work force, and with the first detoxification treatment, more stayed abstinent, compared to those who did not live with a spouse, were without work and who had at least one former detoxification treatment. According to other studies (Orford and Edwards, 1977; Chick et al., 1988
; Howden-Chapman and Huygens, 1988
), there is a similar trend towards interventions that need less resources, yet lead to a similar effect as those interventions which need more resources. We used abstinence as an outcome measure, since all patients were diagnosed as alcohol-dependent and since the intervention goal was to induce action which, in a more or less long-term process, should lead to abstinence. The treatment personnel demonstrated a clear attitude according to this long-term perspective. It should be mentioned, however, that abstinence was not the primary treatment goal. Accordingly, a considerable number of former patients claimed abstinence. It must be taken into account that any motivational intervention in a long-term perspective is probable to initiate the development of the intention to abstain, which may come into effect beyond the time frame of this study.
The results have several limitations. (1) The validity of the information about abstinence as well as utilization of help given by the former patients has only been proven with respect to admissions to a further psychiatric hospital. Although evidence shows that we can rely on self-reports, this might be true only in part for the sample under study. However, if there is under-reporting of relapse, it should be equal among the two treatment groups. Since the patients had contacts with several individuals of the treatment personnel, we assume that there was only a little shame in admitting relapse, so that drinking was not denied. Instead, one treatment goal was to motivate the patients to seek contact in case of drinking. (2) There has been no monitoring of motivational intervention, in the sense that, in the counselling as well as treatment sessions, the statements of the experts have been counted as conforming with motivational interviewing or not (Miller, 2001). (3) The rate of former patients reached for follow-up showed that there were limitations in the meaningfulness of the results in samples especially relevant for routine care.
In conclusion, our results show that counselling intervention is an alternative in hospital settings and may be applied easily. Group treatment leads to a higher rate of participation in self-help groups. In the long-term, this may strengthen self-efficacy and self-change via the support given by the group. However, the effect is only short-term, as is shown by the disappearance of the difference between the intervention groups with respect to help-seeking. Brush-up efforts seem to be useful, such as providing counselling contacts after 6 months with dates fixed at discharge and a reminder letter. This might be a cost-saving approach.
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ACKNOWLEDGEMENTS |
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FOOTNOTES |
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