DEVELOPING A WILLINGNESS TO CHANGE: TREATMENT-SEEKING PROCESSES FOR PEOPLE WITH ALCOHOL PROBLEMS

ANNIKA JAKOBSSON*, GUNNEL HENSING and FREDRIK SPAK

Department of Social Medicine, The Sahlgrenska Academy at Göteborg University, Göteborg, Sweden

* Author to whom correspondence should be addressed at: Department of Social Medicine, The Sahlgrenska Academy at Göteborg University, Box 453, 405 30 Göteborg, Sweden. Tel.: *46 31 773 6864; Fax: *46 31 162847; E-mail: annika.jakobsson{at}socmed.gu.se

(Received 5 May 2004; first review notified 24 June 2004; in revised form 28 October 2004; accepted 4 November 2004)


    ABSTRACT
 TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX
 REFERENCES
 
Aims: The study explores treatment-seeking processes in men and women with alcohol problems, focusing on promoting and hindering factors. Methods: Open interviews were held with five women and seven men within a month of their first voluntary treatment for alcohol problems. The interview protocols were analysed consecutively in accordance with grounded theory methodology. Results: Developing a willingness to change was found to be the basic psychosocial process that lead to treatment-seeking. Categories that constituted sub-processes and supported willingness to change were: (i) actuating inner forces; (ii) dealing with conflicting feelings and thoughts; and (iii) hoping to turn the situation around. These processes were continuously assisted by demanding and caring support from partners, friends or professionals. Conclusions: The processes that precede treatment-seeking were highly complex, and both internal and external factors promoted and hindered treatment entry. The social significance of alcohol and the grief related to thoughts of abstaining were the most striking hindering factors. Such feelings need to be considered when motivating people to seek treatment for alcohol problems.


    INTRODUCTION
 TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX
 REFERENCES
 
Not until misuse has caused severe health and social problems does seeking help or treatment seem to become an option (Bongers et al., 1996Go). Earlier identification of individuals with less severe alcohol problems is thus a challenge, and strategies for prevention programmes, aimed at referral to treatment, need to be developed (Weisner et al., 2003Go).

Cunningham et al. (1994)Go explored 10 different motivations for seeking treatment for alcohol problems, and found that ‘weighing the pros and cons of drinking or drug use’ and ‘warnings from spouse’ were the most frequently cited reasons. People who had experienced negative life events and social pressure, and who also perceived their drinking problems as severe, were more likely to enter treatment than others, according to Finney and Moos (1995)Go. In a review of research on barriers to help-seeking for addictive behavioural change, Schober and Annis (1996)Go found that negative emotional states, stigma and insufficient social and financial resources were factors that interfered with treatment-seeking in both men and women. In a qualitative study of the barriers to treatment in women, Copeland (1997)Go identified the following principal barriers: social stigma, labelling, costs, lack of awareness of treatment options and concerns about confrontational models and stereotypical views of clients by treatment service providers. Tucker et al. (1994)Go found that ‘potential embarrassment’ and ‘not wanting to share personal problems with others’ hindered treatment-seeking.

Many heavy drinkers recover from their alcohol problems without professional assistance (Cunningham et al., 1995Go; Blomqvist, 1999Go), but it is not clear whether such recovery happens because the problems are less severe, or whether there are other factors that differ between those who recover and those who do not recover without formal treatment (Klingemann et al., 2001Go). According to Prochaska (1991)Go, people change lifestyle-related behaviours dynamically in a series of stages. Thom (1984)Go, who studied help-seeking in women with alcohol problems, has also identified treatment-seeking as a process.

Several efficient, evidence-based treatment alternatives for people with alcohol problems are available today (SBU, 2001Go), but the processes that lead people to treatment-seeking have still not been sufficiently explained. Thus, in planning prevention and treatment programmes, attention should also be paid to the inducements for treatment entry. This study explores the processes that lead to treatment-seeking in men and women with alcohol problems. The study focused on personal statements of the individuals by seeking answers to these specific questions:

  1. How do men and women with recent experience of seeking treatment describe their paths to treatment?
  2. What promotes and what hinders treatment-seeking?
We define ‘treatment-seeking’ for alcohol problems as seeking care, support or help for alcohol problems at a treatment facility.


    METHODS
 TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX
 REFERENCES
 
Since treatment-seeking behaviour is a process that stretches over time, the method of choice needs to be suited to exploring multiple experiences of people who undergo such a process. Grounded theory was chosen, as it is a qualitative method well suited to the study of social and psychosocial processes (Schreiber and Stern, 2001Go). The aim of grounded theory is to develop concepts or a theory from empirical data (Strauss and Corbin, 1998Go). The method is developed from symbolic interactionizm and sets the person in his/her social context, and assumes that people act on the basis of the meaning that life experiences have for them. Grounded theory is also tested and found to be highly suitable for studying new phenomena or old phenomena with a new approach (Strauss and Corbin, 1998Go). Furthermore, it is well known and often used within health care research (Schreiber and Stern, 2001Go). By interviewing people who had sought treatment for alcohol problems, we attempted to discover the behavioural patterns underlying the processes that precede treatment entry (Morse, 2001Go). Our intention was to develop a hypothesis and create a theoretical model that could provide knowledge for clinical use (Vehviläinen-Julkunen, 2000Go). The Research Committee for Ethics at the Faculty of Medicine of Göteborg University approved the study and participation was based on informed consent.

Settings and informants
In Sweden, most people with alcohol problems apply for treatment from public medical services; thus, we recruited our informants from three such specialist outpatient treatment facilities in the city of Göteborg. The involved staff at these facilities was informed of the study and the selection criteria. Two of the clinics specialized in substance dependence and abuse problems and one clinic was a general psychiatric outpatient clinic. To gather as rich and substantial data as possible, we strove to select informants with varying backgrounds and experiences (Glaser, 1978Go), using the following selection criteria: (i) the informant should be able to communicate their experiences in Swedish or English; (ii) alcohol problems should be the main reason for seeking treatment; (iii) treatment should have been sought freely by the informant; and (iv) treatment should have been started within the last month.

When an individual meeting the criteria for inclusion entered treatment, she/he was informed of the study by her/his counsellor. After obtaining informed consent, the interviewer (A.J.) telephoned the potential informants to describe the research project and to explain that participation in it was voluntary. Two women and one man wished to reconsider participation, and offered to call us back later; they never did, and no further contact was made with them.

Because the data collection was time-consuming and there was limited access to informants who fulfilled the requirements, we sampled on the basis of what was possible (Strauss and Corbin, 1998Go), but a balance was achieved with respect to sex, age, duration and severity of alcohol problems.

Twelve informants—five women and seven men—were interviewed during their first month of treatment. The age range was 20–69 years, and the mean age was 47.4 years; 48.5 years for men and 45.8 years for women (for further data on informant characteristics, see Appendix).

Interviews
Dates for the interviews were set according to informant preferences; seven interviews were carried out in a secluded room at the treatment unit and five were conducted in an interview room at the Department of Social Medicine, Göteborg University. One man wanted his wife to be present during the interview and one woman wanted her common-law husband to assist if problems in language arose; these conditions were accepted. We used an interview guide to cover the following themes: (i) thought process that lead to the decision to seek treatment; (ii) factors that promote treatment-seeking; (iii) factors that hinder treatment-seeking; and (iv) general perceptions in treatment of alcohol abuse. The length of the interviews ranged from 50 min to 2 h and the interviews were audio-taped and transcribed verbatim in Swedish. The transcripts were analysed in Swedish and translation into English was done as the last stage of the study.

Analysis
The analysis was conducted by the interviewer (A.J.) and started as soon as the first interview was transcribed and from then the interviews were analysed consecutively.

Data were analysed in four stages. First, the transcribed material was scrutinized line by line in search of statements describing events, objects, happenings, actions or interactions related to treatment-seeking. The statements were broken down into discrete parts and compared for similarities, differences and meaning. Conceptualization was done and written in the margin, mainly using the own words of informants. Second, the emerging concepts were listed and compared in order to identify situations in which the informant acts in a certain way and attributes a particular meaning. Concepts were then grouped into five categories and given labels that captured the phenomena. Third, relations between the categories were explored, each being analysed in terms of context, conditions and consequences. Three categories, with 2–4 subcategories, were found to constitute steps of the process; one category was found to influence the process continuously and one category linked all the categories together and was identified as the basic psychosocial process (see Fig. 1). Fourth, integration and refinement of the categories was pursued by listening to the interviews again, visualizing patterns and exposing the findings to scrutiny in seminars with co-researchers, academics and professionals from different fields. The seminars were held after five and ten interviews and added a variation of perspectives to the analysis, broadened the perceptions and contributed towards raising the level of abstraction in the emerging categories.



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Fig. 1. The treatment-seeking process for people with alcohol problems.

 

    RESULTS
 TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX
 REFERENCES
 
The basic process leading to treatment-seeking
We set out to explore the path to treatment-seeking in men and women with alcohol problems and found that the informants shared a common experience, namely that personal willingness to change one's life towards a new direction was crucial in seeking treatment. Willingness to change one's life developed over time and was identified as a process that was labelled as ‘developing a willingness to change’. The process was found to be complex and fragile and continuously influenced by the category labelled ‘demanding and caring support’.

Three more categories with subcategories were identified as steps of the process. (1) Actuating inner forces with the subcategories: (i) life events and (ii) existential threats that triggered the process. (2) Conflicting feelings and thoughts with the subcategories: (i) acknowledging the significance of alcohol, (ii) being in or out of control, (iii) managing identity and (iv) reacting to pressure, which gave rise to ambivalence with respect to the benefits and losses connected with abstaining from alcohol. (3) Hoping to turn the situation, with the subcategories: (i) anticipating a better future, (ii) seeking reconciliation and (iii) enhancing well-being, underpinned the wishes to turn one's life in a new direction (Fig. 1). An increasing insight that drinking behaviour was a problem and only the person concerned could initiate a change made treatment-seeking a realistic alternative.

Demanding and caring support
Throughout the treatment-seeking process, support from others was a modifying or enhancing factor. A support-giver could be a relative, friend, spouse or professional, such as a social worker or physician. This support could be experienced as demanding but, when the supporting person was perceived as frank, to be trusted, and genuinely wanting to help, it was beneficial. A 20-year-old woman said:

A very close friend has talked about this, that I drink a lot, and that ... I can admit ... but those who aren't as close to me as she is ... say that ... now you have to calm down so then I get so angry with those people because it feels so humiliating when they say so ...

Finding an appropriate treatment facility was important, and informants found out about the available alternatives in various ways. A physician, social worker, friend or even a stranger in a pub could recommend the treatment service. Getting help to book an appointment could sometimes be the first step into treatment. When entering treatment, caring and supporting reception from the care deliverer was crucial in the decision of the informant to continue the treatment.

Actuating inner forces
Life events. Positive life events, such as becoming a father or falling in love, supported thoughts of changing one's lifestyle. Negative life experiences, such as observing friends or associates becoming social dropouts, or being exposed to robbery or abuse while intoxicated by alcohol, created worries about the future. An unemployed man of 28 years expressed his worries:

... I started to feel...no, this more and more begins to look like one of my friends who is a pensioner, he is 33 [years old] ... and one starts to think ... what have I done with my life ... I can imagine it is a great disappointment to become old and realise that life is without meaning.

Existential threats. Experiencing existential threats would initiate a reflection on life and its meaning in general, as well as on missed opportunities for a better life. Remorse at having caused problems and harm to others was also a factor, and having been caught for drunken driving led to doubts about one's ability to make sound judgements.

Pressure from significant others could be perceived as an existential threat. One man was given an ultimatum by his girlfriend, who threatened to leave him if he did not stop drinking, and this contributed to his decision to seek treatment. The directness of a company physician gave a 57-year-old woman a choice of decisive importance:

She said to me that you ... need help, you are an alcoholic and now you may choose either so ... you get worse or else you may choose and become well ... make your own choice.

Dealing with conflicting feelings and thoughts
Ambivalence, characterized by conflicting feelings and thoughts, also influenced the decisions and actions of the informants. Such a conflict, described by most of the informants, would begin from the time the informants started thinking about changing their drinking habits, and remained even after they had sought treatment.

Acknowledging the significance of alcohol. Alcohol had a great impact on the lives of the informants and was used as medication in order to sleep, relax, kill pain or temporarily escape other problems. It was also used for consolation, catharsis or as a reward. A 33-year-old man in the construction business explained:

Beer was invented for the workers ... you come home and you are completely finished—you are dirty and your throat is dusty—you shower the body and then you shower the throat too.

Drinking has significance in one's social life and helps create a festive atmosphere; it was also an excuse to behave in an uninhibited way. Internal conflict emerged as alcohol created an immediate feeling of well-being; the aftermath of drinking was, however, followed by anxiety and panic attacks. To abstain from alcohol implied losing an important source of comfort. The feeling of loss became obvious when the informants talked with grief about their future life without alcohol: some also had tears in their eyes.

Being in or out of control. The belief that one was in control of one's drinking behaviour made the thought of seeking treatment seem irrelevant. Loss of control, however, due to blackouts or panic attacks was painful, and induced efforts to regain control. The feeling of being in control hindered treatment-seeking, while experiencing blackouts and panic attacks promoted change. Loss of control did not only concern drinking behaviour as such but also other areas of life. Awareness of being out of control increased when the authorities took control of one's finances due to loss of control over income and expenses.

Managing identity. The meaning of social identity, as interpreted from statements in the interviews, was the way in which a person looked upon her/himself, performed a role in society and felt ‘this is me’. A 69-year-old man regarded himself as a ‘car chap’, and sought treatment to prevent being caught for drunken driving and thus risk losing his identity. After many years without contact with her daughter, a 58-year-old woman wanted to regain her role as a mother and become a proper grandmother; accomplishing these goals meant an end to drinking. Handling a job is important for one's social identity, and as long as a person could work, his or her alcohol problem was not regarded as serious. Losing many roles and not recognising one's new image was distressing: a 45-year-old woman who had been caught driving drunk said, ‘I know myself and this is not me’. She regarded her behaviour as seriously deviant and this strengthened her willingness to change.

Reacting to pressure. The informants described various reactions to pressure from their social networks. Whether an informant was influenced by this pressure, however, appeared to depend on whether those exerting it were committed, caring and played significant roles in the lives of the informants. If the persons giving advice were in powerful positions, the advice was more likely to influence the process, although too much pressure could have the opposite effect. A 57-year-old woman said:

Abstaining from alcohol and seeking treatment is my own decision, nobody else can tell me what to do ... if they do I might do the opposite.

The impact of such pressure also depended on timing, and to what extent it was in accordance with the various life events or experiences of existential threats in the respondents. The informants acknowledged that pressure could make a difference in treatment-seeking as long as the decision was left to them.

Hoping to turn the situation
Three subcategories underpinned hopes of turning one's life in another direction: anticipating a better future, seeking reconciliation and enhancing well-being.

Anticipating a better future. Expectations for the future included retaining employment, regaining sound judgement and increasing self-respect. Those who were unemployed cherished expectations of returning to the labour force or finding other ways to experience a meaning in life. To start studying and resume ‘normal life’, get a better flat, be able to drink in a socially acceptable manner or go on a holiday trip were some of the goals of the informants. ‘To raise a family and not drink like my parents’, were the hopes and prospects of a 20-year-old woman.

Seeking reconciliation. Not being able to handle drinking or care for oneself, as well as causing problems for others during drinking bouts, created a feeling of shame and remorse. The feeling of not being fully socially acceptable characterized the statements of the informants. Awareness of not having caused suffering deliberately, accepting the alcohol problem as a disease and decreasing feelings of shame were steps towards reconciliation. One woman pointed out that she always drank alone at home and had never done anything to harm anybody. Needing treatment for alcohol problems was regarded as dishonourable; sometimes, it was a secret shared with only a few family members. Meeting the treatment team could change the perceptions of how persons with alcohol problems were regarded. A 49-year-old woman was surprised to be treated with respect and care by the therapists:

I felt ashamed, I didn't think I would be treated so well...

In coming to accept oneself and one's situation, it was important to be met with dignity and respect by other people. Reconciliation seemed to bridge the gap between the past and the anticipated future.

Enhancing well-being. The informants hoped for increased physical, social, and above all, mental well-being. To feel well without alcohol and decrease the risk of future health problems were factors that strengthened the willingness to change. Seeking treatment was an attempt to avert unpleasant long-term consequences and increase one's everyday well-being—in contrast to the fleeting enjoyment of being drunk. One man said that heavy drinking had already reduced his longevity, but hoped for better health in his remaining lifetime.


    DISCUSSION
 TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX
 REFERENCES
 
A complex process
Although the severity and duration of alcohol problems differed among the informants, they had reached a crossroad wherein they had to decide on the direction they wanted to proceed within their lives. The processes presented in our study demonstrate the diversity of the motives in seeking treatment for alcohol problems. Our findings indicate that there were existential, social, psychological and medical incentives to convert willingness to change into action. Reflections about life in general, its meaning and future prospects were important incentives to start the treatment-seeking processes. Conflicting feelings and thoughts both promoted and hindered treatment-seeking. These feelings and thoughts were dynamic, difficult to cope with and affected the informants even after they had sought treatment. The most striking hindering factor was the role that alcohol was perceived to play in the social lives of the respondents, and grief was expressed when talking about abstaining from alcohol. The process of abandoning values, ideas, expectations and even social relationships appears to be painful and needs to be addressed when dealing with people with alcohol problems. An orientation towards the future, i.e. setting goals for oneself, appeared to be important in promoting the treatment-seeking process. This study does not contradict the model of Prochaska wherein risk behaviours change through stages over time, but points out the nuanced and complicated underlying factors that can affect the willingness to change.

External and internal influences on the process
Similarities can be found when comparing specific categories from our findings with those found by previous studies. Palm and Storbjork (2003)Go found that 85% of the patients in alcohol treatment said that they had sought treatment on their own initiative, but also that suggestions to enter treatment were common from domestic partners or other family members. Our study indicated that the spouse or some other significant person played an important role in treatment-seeking by being both demanding and caring while exerting pressure on the person with alcohol problems. This is in accordance with Cunningham et al. (1994)Go, who found that warnings from a spouse or another key person triggered treatment-seeking. Previous research has shown that problematic events had a great impact in promoting treatment-seeking (Weisner, 1990Go; Tucker and Gladsjo, 1993Go). Our study supports that finding, but also shows that positive life-transforming events, such as becoming a father for the first time or falling in love, can act as promoting factors. Finfgeld (1999)Go found that threats to the essence of who or what individuals want to be, influenced self-resolution of alcohol problems; this can be compared with our findings that existential threats prompted treatment-seeking. Another promoting factor in our study was feeling ‘bad’ or anguished, which was attributed to mental health and created existential threats. The findings of Palm and Storbjork (2003)Go show that blackouts after heavy drinking were frightening events that contributed to treatment-seeking. Interestingly, none of our informants mentioned physical health problems as reasons for seeking treatment, as we had expected some to do, since physical health problems have been reported as main factors for natural recovery processes (Tucker et al., 1994Go).

Conflicting feelings and thoughts both promoted and hindered treatment-seeking. Feelings of self-control and concerns with respect to social identity and treatment secrecy are in accordance with the findings of Blomqvist (1999)Go. He found that a reluctance to accept being labelled as an alcoholic and strong concerns with integrity and keeping problems to oneself or one's family impeded treatment-seeking. Thom (1986)Go also found that barriers to treatment-seeking in the informants arose from a difficulty in identifying themselves and their behaviour with stereotypical conceptions of a person with alcohol problems. Cunningham et al. (1993)Go drew similar conclusions from their investigations of barriers to treatment. Belief in one's self-control was found to be a hindering factor in our study; this can be compared with the perception, ‘I believe that only I can help myself’, found to be strongly held by women with alcohol problems who had not sought treatment (Spak, 1996Go).

Methodological considerations
Our findings could well be relevant in other contexts as well, such as treatment-seeking among those with drug problems, which would indicate external validity, according to Malterud (2001)Go. The model described in our study is new and unique, but the essence of several of the processes described is supported by other studies, and this enhances the credibility of the findings. Some limitations are important to point out. First, the study elucidates factors that promote and hinder treatment-seeking, and it should be noted that at the time of the interviews, the informants had already entered treatment and hindrances to treatment-seeking were thus no longer predominant. Hindering processes should preferably be studied in people who have never been in contact with treatment providers. Second, a more varied social, cultural and ethnic distribution among the informants would have been preferable in order to create a more socially heterogeneous sample.

Practical implications
Johansson et al. (2002)Go explored attitudes and practices among general practitioners and nurses and found reluctance among them in giving advice about alcohol. This reluctance, particularly strong on the part of nurses, arose from worries that patients would react negatively to questions about alcohol. Our findings emphasize that information, advice and support from professionals such as doctors, nurses or social workers can indeed promote treatment-seeking for alcohol problems. Supporting hope, empowering reconciliation and encouraging self-change can increase motivation and initiate alterations in the lifestyle of the informants. The effect of such encouragement appeared to increase if it was accompanied by other incentives for change, so it appears prudent to make efforts in several areas concurrently to decrease impediments to treatment entry. Further exploration of treatment-seeking behaviour, particularly from a gender perspective, would be helpful when planning for future approaches in treatment.


    CONCLUSIONS
 TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX
 REFERENCES
 
The findings from this qualitative study add texture and depth to prior knowledge, and the model described in this paper should encourage health care providers to suggest treatment options to those with alcohol problems. Even when people do not specifically request help with alcohol problems, it is possible to ask questions relating to alcohol consumption. Personal willingness to change the current situation was found to be vitally important for treatment-seeking, but health professionals and social networks can facilitate this process by paying attention to the problem, supporting reconciliation and encouraging a future orientation. Our findings also point to the social, psychological and cultural importance of alcohol today when most adults in the western world are alcohol consumers. The meaning of alcohol in people's lives and the expectation of loss should alcohol be eliminated, needs to be addressed when studying willingness to change. Our study can form the basis for an investigation that focuses on gender and treatment-seeking behaviour, and our findings also emphasize the importance of a further exploration of the significance of existential factors in promoting a change in lifestyle patterns.


    APPENDIX
 TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX
 REFERENCES
 


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The informants (in the order of being interviewed)

 

    ACKNOWLEDGEMENTS
 
This study was supported by the Swedish Society of Medicine and the SRA (Systembolaget Research Council). The authors wish to thank Rita Schreiber, Associate Professor, School of Nursing, University of Victoria, BC, Canada for her valuable comments on the manuscript.


    REFERENCES
 TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 APPENDIX
 REFERENCES
 
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