MOTIVATIONAL INTERVENTION: AN INDIVIDUAL COUNSELLING VS A GROUP TREATMENT APPROACH FOR ALCOHOL-DEPENDENT IN-PATIENTS

U. John*, C. Veltrup1, M. Driessen2, T. Wetterling3 and H. Dilling4

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


    ABSTRACT
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Aims: The present study aimed to evaluate whether individual counselling for alcohol-dependent patients in three sessions is as effective as a 2-week group treatment programme as part of an in-patient stay in a psychiatric hospital which was to foster motivation to seek further help and to strengthen the motivation to stay sober. Of particular importance was the external validity of the results, i.e. a ‘normal’ intake load of in-patients in detoxification and a wide variety of motivation to stop drinking were to be investigated. Methods: Subjects eligible for the study were all patients with alcohol problems admitted to a psychiatric hospital, but without psychosis, as the main diagnosis, and with a maximum of 10 detoxification treatments in the past. A randomized-controlled trial was conducted with 161 alcohol-dependent in-patients who received three individual counselling sessions on their ward in addition to detoxification treatment and 161 in-patients who received 2 weeks of in-patient treatment and four out-patient group sessions in addition to detoxification. Both interventions followed the principles and strategies of motivational interviewing. Results: Six months after intervention, group-treatment patients showed a higher rate of participation in self-help groups; however, this difference had disappeared 12 months after treatment. The abstinence rate among the former patients did not differ between the two intervention groups. Conclusion: Group treatment may lead to a higher rate of participation in self-help groups, but does not increase the abstinence rate 6 months after treatment.


    INTRODUCTION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Often, alcohol-dependent in-patients admitted for the treatment of alcohol-related disease or for detoxification are not ready to stay abstinent after discharge. In these cases, motivational work with the goal of adopting an understanding of alcohol dependence and the necessity to seek further help and thus preparing a pathway to abstinence may be a valuable approach. However, the hospital may be an appropriate setting for three reasons: (1) the patient more or less is in the psychological situation of fear which makes her/him prone to comply with counselling efforts to help with their alcohol problems; (2) there is probably time left in clinical routine which may be used for motivational work with the patient; (3) the medical experts are present. Approaches used in brief intervention, and the stages of change may be helpful in such work, and the main features are: proactive, brief, work with resistance. The target individuals are predominantly those who are reluctant or ambivalent toward change. Brief intervention has been proven to be effective (Poikolainen, 1999Go; Moyer et al., 2002Go), although not in a 10 year perspective (Wutzke et al., 2002Go). Screening plus counselling of 40–60 min in a general hospital leads to a better drinking status and fewer problems for the patients, in comparison to a control group without counselling (Chick et al., 1985Go). Other studies showed that counselling may support the utilization of further help in combating alcohol dependence, as well as the rise in abstinence rates (Hapke et al., 1998Go). Most influential was the motivational interviewing approach (Miller and Rollnick, 1991Go; Dunn et al., 2001Go). It provided practical guidelines for the support of the decision to stay sober. Following these, motivational enhancement therapy with four sessions was investigated in Project MATCH (Project MATCH Research Group, 1998Go).

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, 1977Go), even if it consisted of a single session (Howden-Chapman and Huygens, 1988Go). Chick et al.(1988)Go assigned patients in an alcohol problems treatment service on a random basis to one group with the advice to stop drinking or counselling of 30–60 min (n = 96) and one group with treatment (n = 58) that included the elements: in-patient or day-care group therapy in a 2–4-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.


    SUBJECTS AND METHODS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Subjects
Eligible subjects were in-patients consecutively admitted to a psychiatric university hospital with the diagnosis of alcohol dependence according to ICD-10 (World Health Organization, 1992Go). The hospital acted as a routine care facility. All alcoholics had to be admitted who showed up if a treatment space was available. Thus, there were 425 patients eligible, of whom 74 had to be referred to another psychiatric hospital because of missing beds, two left the department on the day of admission, six were already study participants, leaving 343 patients. Patients had to fulfil eight criteria: (1) alcohol dependence according to ICD-10; (2) age 21–65 years; (3) not longer than 6 months with no fixed abode in the past; (4) living within a distance from self-help groups and the out-patient treatment facility that would enable the subject to take part; (5) consent to undertake a treatment lasting 21 days; (6) no organic brain damage; (7) no psychosis; (8) not more than 10 previous in-patient detoxification or alcoholism treatments. Criteria 3 and 4 were essential for ease of follow-up. Criteria 6, 7 and 8 were used to exclude alcoholics too severely disturbed or unable to communicate sufficiently in counselling or treatment. According to at least one of the eight criteria, 21 patients had to be excluded. The remaining 322 patients constituted the study sample. Of these, 19 (5.9%) dropped out of treatment; however, they remained as study individuals. There was no preselection of the patients according to motivation, nor to motivation to abstain or to take part in treatment. All patients were admitted on the understanding that adequate treatment would be carried out.

The sample social and alcohol-related characteristics are summarized in Tables 1Go and 2Go. Compared to specialized alcoholism treatment according to Küfner and Feuerlein (1989)Go, 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., 1993Go). 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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Table 1. Sociodemographic characteristics of the sample
 

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Table 2. Alcohol drinking-related information
 
Procedure
The admitting physician checked whether the inclusion criteria were fulfilled. If this seemed to be the case, the admitting physician opened an envelope which included the random assignment of the patient to one of the two intervention arms: the individual counselling (IC) or the group treatment (GT) intervention. Subjects in the two arms did not differ according to gender, marital status, number of years of alcohol misuse, alcohol dependence severity, and number of treatments in specialized alcoholism treatment ({chi}2 test P > 0.40). However, the GT intervention group included fewer subjects living at a private residence than the IC group ({chi}2 test P = 0.02). After admission and randomization and after the patients had given their written informed consent, they were referred to a detoxification ward or a psychiatric ward where the detoxification treatment was carried out. After an average of 6 days, the interventions started. The follow-up interviews were carried out 6, 12, 18 and 24 months after discharge.

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., 1997Go).

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, 1991Go; Miller et al., 1995Go). 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 patient’s 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, 1997Go). (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)Go 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., 1991Go) 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., 1999Go; Babor et al., 2000Go). 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 12–24 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.


    RESULTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Of the patients in group treatment, more took part in self-help groups during the first 6 months after discharge, compared with patients with counselling. Utilization of other help was equally distributed between the two intervention groups (Table 3Go). Of 35 former patients who were interviewed at the seventh month after discharge and who said that they participated in self-help groups, 31 did this at least once a week. In the IC group, 17 of 18 who participated did so at least once a week. Of those who had formerly been in detoxification treatment (n = 175), 24.0% took part in the self-help groups compared to 14.3% of those without former detoxification treatments (n = 147; {chi}2 test P >= 0.01).


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Table 3. Utilization of help, 6 months after intervention
 
In males or females, younger or older former patients, utilization was no different between the two intervention groups. Patients from group treatment living in partnership showed a higher rate of utilization of help, compared to former patients from the counselling group living in partnership (37.2 vs 22.1%: {chi}2 test P >= 0.02). From those out of group treatment belonging to the work force, more utilized help (39.8%) than those from counselling (18.2%; {chi}2 test, P >= 0.004). Those who utilized at least one help, i.e. a self help group, professional counselling or treatment, ranked higher in the severity of alcohol dependence than those who make no use of formal help ({chi}2 test, P = 0.03).

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 4Go). 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 ({chi}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 5Go).


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Table 4. Utilization of self-help groups before and after treatment, 6 months after treatment
 

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Table 5. Alcohol drinking and abstinence
 
The results showing a higher rate of former patients from the group treatment, compared to individual counselling, who participated in self-help groups remained valid after controlling for gender, age, having a partner, having a job (or being in education, housewife/-husband or being on pension), and number of years with ‘increased’ drinking before treatment (Table 6Go).


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Table 6. Utilization of self-help groups and alcohol consumption after treatment, 6 and 12 months after treatment (logistic regression)
 

    DISCUSSION
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
This study, firstly, includes a highly representative sample of alcohol-dependent patients admitted for detoxification treatment in a psychiatric hospital. In addition to admissions to general hospitals, this is the most frequent way in which alcohol-dependent patients come into contact with in-patient treatment in Germany, where it is the common way to treat alcohol dependence. The sample does not differ from larger samples of alcohol-dependent detoxification patients in other German psychiatric hospitals. Differences from the self-selected patients in the specialized alcoholism-treatment facilities that admit those patients who applied for a treatment space, and are motivated to stay sober and who ask for help, are that in our treatment were the patients with less favourable socio-economic and demographic and drinking-related characteristics. Secondly, the study shows a high ecological validity, because there is only very little sample selection bias, if any. Many of the patients being admitted to a psychiatric hospital neither perceive their alcohol drinking and related problems as alcohol dependence nor are they motivated to change it, and consequently they do not actively seek treatment themselves. Therefore, the results may be transferred to other psychiatric in-patient settings and probably to general hospital settings. There was no preselection according to treatment motivation. Those patients who were admitted to the hospital and showed any alcohol problem were investigated. Accordingly, the treatment drop-out of 5.9% during the in-patient stay was moderate.

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, 1998Go). 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, 1977Go; Chick et al., 1988Go; Howden-Chapman and Huygens, 1988Go), 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, 2001Go). (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.


    ACKNOWLEDGEMENTS
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
The study was supported by grant no. 01 EB 9421 from the Federal Ministry of Education and Research.


    FOOTNOTES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
* Author to whom correspondence should be addressed at: Institute of Epidemiology and Social Medicine, Medical Faculty, University of Greifswald, Walther-Rathenau-Strasse 48, D-17487 Greifswald, Germany. Back


    REFERENCES
 TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGEMENTS
 REFERENCES
 
Babor, T. F., Steinberg, K., Anton, R. and DelBoca, F. (2000) Talk is cheap: measuring drinking outcomes in clinical trials. Journal of Studies on Alcohol 61, 55–63.[ISI][Medline]

Chick, J., Lloyd, G. and Crombie, E. (1985) Counselling problem drinkers in medical wards: a controlled study. British Medical Journal 290, 965–967.[ISI][Medline]

Chick, J., Ritson, B., Connaughton, J., Stewart, A. and Chick, J. (1988) Extended treatment for alcoholism: a controlled study. British Journal of Addiction 83, 159–170.[ISI][Medline]

Dilling, H., Mombour, W. and Schmidt, M. H. (1991) Internationale Klassifikation psychischer Störungen [International Classification of Mental Disease]. Huber, Bern.

Dunn, C., Deroo, L. and Rivara, F. P. (2001) The use of brief interventions adapted from motivational interviewing across behavioural domains: a systematic review. Addiction 96, 1725–1742.[CrossRef][ISI][Medline]

Hapke, U., Rumpf, H.-J. and John, U. (1998) Differences between hospital patients with alcohol problems referred for counselling by physicians’ routine clinical practice versus screening questionaires. Addiction 93, 1777–1786.[CrossRef][ISI][Medline]

Howden-Chapman, P. L. and Huygens, I. (1988) An evaluation of three treatment programmes for alcoholism: an experimental study with 6- and 18-month follow-up. British Journal of Addiction 83, 67–81.[ISI][Medline]

Küfner, H. and Feuerlein, W. (1989) In-patient Treatment for Alcoholism. A Multi-centre Evaluation. Springer, Berlin, New York.

Marlatt, G. A. and Gordon, J. R. (1985) Relapse Prevention. Guilford, New York.

Miller, W. R. (2001) When is it motivational interviewing? Addiction 96, 1770–1772.[ISI][Medline]

Miller, W. R. and Rollnick, S. (1991) Motivational Interviewing. Guilford, New York.

Miller, W. R., Zweben, A., DiClemente, C. C. and Rychtarik, R. G. (1995) Motivational Enhancement Therapy Manual. National Institute on Alcohol Abuse and Alcoholism, Rockville, MD.

Moyer, A., Finney, J. W., Swearingen, C. E. and Vergun, P. (2002) Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction 97, 279–292.[CrossRef][ISI][Medline]

Mundle, G., Ackermann, K., Gunthner, A., Munkes, J. and Mann, K. (1999) Treatment outcome in alcoholism—a comparison of self-report and the biological markers carbohydrate-deficient transferrin and gamma-glutamyl transferase. European Addiction Research 5, 91–96.[CrossRef][ISI][Medline]

Orford, J. and Edwards, G. (1977) Alcoholism. A comparison of Treatment and Advice, with a Study of Influence of Marriage. Oxford University Press, Oxford.

Poikolainen, K. (1999) Effectiveness of brief interventions to reduce alcohol intake in primary health care populations: a meta-analysis. Preventive Medicine 28, 503–509.[CrossRef][ISI][Medline]

Prochaska, J. O. and Velicer, W. F. (1997) The Transtheoretical Model of health behavior change. American Journal of Health Promotion 12, 38–48.[ISI][Medline]

Project MATCH Research Group (1998) Matching alcoholism treatment to client heterogeneity: Project MATCH three-year drinking outcomes. Alcoholism: Clinical and Experimental Research 22, 1300–1311.[ISI][Medline]

Wetterling, T., Kanitz, R. D., Besters, B., Fischer, D., Zerfass, B., John, U. et al. (1997) A new rating scale for the assessment of the alcohol-withdrawal syndrome (AWS scale). Alcohol and Alcoholism 32, 753–760.[Abstract]

Wienberg, G., Andritsch, F., Bertram, W., Drees, E., Fleischmann, H., Gerber, H.-G. et al. (1993) Abhängigkeitskranke in psychiatrischer Krankenhausbehandlung. Ergebnisse einer Erhebung in 14 Kliniken der Bundesrepublik [Dependent patients in psychiatric hospital care. Results from 14 hospitals in Germany]. Sucht 39, 264–275.

World Health Organization (1992) International Classification of Diseases, 10th Revision. World Health Organization, Geneva.

Wutzke, S. E., Conigrave, K. M., Saunders, J. B. and Hall, W. D. (2002) The long-term effectiveness of brief interventions for unsafe alcohol consumption: a 10-year follow-up. Addiction 97, 665–675.[CrossRef][ISI][Medline]





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