1 Medical School Hannover, Hannover and 2 Johann-Wolfgang-Goethe-University, Frankfurt, Germany
* Author to whom correspondence should be addressed at: Medical School Hannover, Department of Clinical Psychiatry and Psychotherapy, D-30625 Hannover, Germany. Tel.: +49511/5326559; Fax: +49511/5322415; E-mail: schneider.udo{at}mh-hannover.de
(Received 30 July 2003; first review notified 15 October 2003; in revised form 19 November 2003; accepted 6 December 2003)
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ABSTRACT |
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INTRODUCTION |
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Treatment strategies for addictive behaviour in Germany, particularly those for alcohol dependence, differ in some important aspects from those in most other countries. First, different therapies are carried by different branches of social insurance. Inpatient detoxification treatment (about 800 000/year) is paid for by health insurance companies. One of the strategies during this therapy is attempting to motivate patients by giving information. According to the concept of qualified rehabilitation formulated by Stetter et al. (1995), the process of physical detoxification should be supported by a variety of therapeutic modules.
Second, in Germany, in-patient long-term therapies are very common. About 35 000 alcoholics per year undergo long-term in-patient treatment lasting up to 16 weeks in a specialized hospital. This form of therapy is regarded as a rehabilitative treatment and is, according to German Social Law, financed through pension funds. It is performed by multiprofessional teams, mostly consisting of psychiatrists, psychologists and social workers. Psychodynamic as well as cognitive behavioural oriented psychotherapy is provided in these hospitals.
The expectations of the patients themselves particularly those undergoing detoxification on elements or components of their further treatment, previously have not been adequately studied. That is the subject of this paper.
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PATIENTS AND METHODS |
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Subjects were asked to complete a questionnaire, which was an extended version of a questionnaire described by Wetterling et al. (2001a,b
) comprising 20 items on patients' aspirations for the outcome and 23 items on expectations about the constitutive elements of treatment. The items were rated according to importance on a scale consisting of the degrees not important (value = 0), important (value = 1) and very important (value = 2).
Of 336 patients approached, 32.4% patients refused to cooperate or insufficiently completed the questionnaire, leaving 227 patients, 47 women (20.7%) and 180 men (79.3%). They comprised four groups:
The sample is described in Table 1.
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RESULTS |
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Setting
As to the patients' expectations in the treatment procedure, the most important aspects were found to be: individual sessions during therapy; duration of therapy until improvement; a therapist/doctor should be in charge of treatment; a distinct programme should exist (see Table 3).
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The questionnaire also contained questions concerning the required topics of treatment. A visit to a bar or a supermarket as well as a drinking experiment was rejected by most alcoholics.
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DISCUSSION |
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The representativeness of patients in our study must be considered. A large proportion belonged to the group given in-patient treatment and detoxification. Nevertheless, patients in out-patient groups, individual therapy and counselling were also included. The percentage of women (20.7%) and the mean age, correspond to previous studies in German alcoholism treatment populations (Küfner et al., 1998; Türk and Welsch, 2000
). However, extrapolation to wider samples of alcohol dependent people must be guarded for the following reason. Almost all of those questioned indicated that they took the initiative in finding treatment for their addiction because they consider their drinking habit to be harmful to their health, and that they regard their consumption of alcohol as an addiction. Many patients had already gone through therapeutic treatment before. It can be assumed that most were patients who are aware of both illness and treatment methods and can be situated in the action phase of the stages of change proposed by Prochaska and DiClemente (1983)
. In addition, patients may have answered according to standards of social expectation, a factor that would apply to both sexes and to all studies of this kind. In our sample, both men and women consider a life free from alcohol and support in managing and discussing the problems of alcohol to be of vital importance. The goal of total abstinence is a controversial issue, as not all addicts can make this a long-term aspiration. However, because many therapeutic programmes attempt to change patients' attitudes towards the problems of their addiction, the results derived from this first explorative study on the clients' expectations of their alcohol therapy are of interest, as it shows that the process of physical detoxification should be supported by psychotherapeutic measures.
Opinions diverge as to the optimal duration of treatment. Miller and Hester (1986) found short-term and long-term treatments as well as in-patient and out-patient therapy to be of comparable efficiency. Others believe that especially patients with a less than favourable prognosis and patients lacking social integration could profit from long-term therapy (Mann 2000
). Individualized treatment can be flexible about duration of therapy, once the prerequisite of the patients' financial support (i.e. health insurance) is given. The alcoholics in our sample considered a therapy till improvement as important and disliked a maximal duration of the therapy of only 4 weeks.
Women placed greater importance in discussing the treatment's programme and deciding on therapeutic steps themselves, measures which support the flow of information as well as the patients' autonomy (influence on therapy). Patient autonomy is a key factor in the patients' satisfaction (Spießl et al., 1999). In the evaluation of psychiatric care, subjective criteria like the patients' feelings of satisfaction and success are gaining significance (McLellan and Hunkeler, 1998
). The possibility for patients to decide on the different steps of their treatment is likely to increase their level of contentment (Hansson et al., 1993
).
Although most patients already possessed prior experience of therapies and rehabilitation programmes, discussing addiction to alcohol and learning how to deal with relapses was of great interest to both men and women. Female alcoholics tended to exhibit a greater interest in obtaining as much information as possible in order to critically view their problem and to counteract the risk of relapses. They also seemed to be in greatest danger of suffering from relapses when the prevailing mood was loneliness and melancholy (see Rist et al., 1989).
The differences we found in ratings of importance between genders cannot be attributed to socio-demographic factors, such data showing no significant differences between men and women. Although strengthening of self-esteem was important for both gender groups, it was rated to be of even greater importance by women, as was the criteria learning how to deal with pressure and learning how to organize my life. Also tranquillity and security were considered to be essential elements of treatment by women. This may relate to what has been noted elsewhere, that women are often exposed to the double pressures posed by their responsibilities toward both family and occupation (Eisenbach-Stangl, 1997).
Out-patient treatment and treatment near the patient's home were considered to be of higher importance by women than by men in our sample. Reasons for this discrepancy could lie in family or professional situation 54.2% of men as opposed to 44.7% of women lived on their own; 18% of men and 14.9% of women were divorced. Integration, connection with reality, feeling of autonomy, and speedy return into the working life are made possible to a larger extent by out-patient treatment (John, 1993). During recovery, the functioning and maintaining of a frame of reference (Schwoon et al., 1989
), and the integration of relatives into the therapeutic process are crucial (John et al., 1995
). Other patients may need to distance themselves from their surroundings due to problems connected to the environment in which they live. Treatment involving a residential programme in a clinic allows a patient's family to gain distance and to consider the situation from a different point of view (McLellan et al., 1983
). However, in our sample women more often judged outpatient treatment as desirable.
Individual interview sessions as part of their treatment were appreciated. Other surveys show that these sessions, along with receiving information on substance abuse and therapeutic possibilities, are regarded as valuable elements of treatment (see Watzl and Rist, 1987; Stetter et al., 1995
). Moreover, many patients emphasize the importance of professionally trained medical staff and personnel (LoSciuto et al., 1984; Spießl et al., 1999
).
In our sample the possibility of joining out-patient groups after therapy was more appreciated by women than by men. The period immediately after treatment carries with it a greater risk of relapse (Küfner et al., 1998; Lange et al., 1999
). Joining a self-help group is associated with abstinence (Veltrup and Driessen, 1993
; Lange et al., 1999
).
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CONCLUSION |
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