Assessing the effectiveness of brief interventional group therapy on severity of illness, readiness for change, self-efficacy and motivation levels in patients with alcohol use disorder: A pre-post study

Abstract

Background:

There has been an increase in the estimated burden of alcohol use disorders (AUD) in countries like India. Treatment of AUD needs to be multi model and can be pharmacological and Psychological is their approach. Brief interventions are an effective approach to reducing drinking.

Aim:

To assess if brief group intervention has any change in the motivation stage, readiness to change scores, self efficacy levels of an individual.

Materials & Method:

Alcohol use disorder patients were included and pre intervention scales—Severity of Alcohol Dependence Questionnaire {SADQ}, Stage of change readiness and treatment eagerness, General Self efficacy scale, University of Rhodes Island change assessment scale were applied. Three Group sessions were taken on a weekly basis and scales were re applied at the end of 12 weeks.

Results:

A total of 83.33% of the participants were in early remission, the SADQ scores decreased in all participants, and 60% were in the Action phase of Motivation. Approximately 80% had a high score on the taking steps component of readiness to change scale and there was a statistically significant increase in the mean self efficacy score post intervention.

Conclusion:

Brief group intervention involving psychoeducation and motivational enhancement techniques is a low cost, simple, and time saving behavioral intervention that not only increases rates of early remission but also leads to change in motivation and self efficacy levels.

On a global scale, the average per capita consumption of pure alcohol amounts to 6.2 L annually for adults. Alcohol was responsible for 3.8% of total global deaths and accounted for 4.6% of global Disability-Adjusted Life Years (DALYs). There has been an increase in the estimated burden of Alcohol Use Disorder AUD in countries like India, China, and countries of the former Soviet Union, and decreases in Western countries and Africa.[1] Patients with AUD have an impaired ability to manage or restrain alcohol consumption, despite facing negative consequences. This condition includes the terms alcohol abuse, alcohol dependence, alcohol addiction, and the informal term, alcoholism.[2]

A characteristic of AUD that makes it challenging to treat is the high rate of relapse. The Risk factors for relapse can be psychological, social, environmental, internal, and behavioral. Among the psychological and social factors, some include lack of motivation, apathy towards recovery, doubt in one’s ability to control alcohol consumption (low self-confidence), insufficient social and emotional support network, negative emotional state, strong cravings, insufficient coping abilities, especially in challenging situations, and unrealistic hopes for getting sober.[2] Previous research has proven that the relapse rates of those who have received treatment mitigating the above factors are significantly less than those who go untreated.[3]

Many psychological therapies help people quit or cut down on drinking successfully. Treatments most effective are brief interventions which include psycho-education and motivational interviewing approaches, conditioning approaches which include contingency management and the community reinforcement approach, cognitive behavioral treatments which include training in coping skills and preventing relapse. A 12-step program is also proven to be helpful in connecting individuals with support groups. Harm reduction therapies like guided self-control training and controlled drinking interventions have been successful in supporting goals to reduce drinking.[4]

Brief intervention saves costs and is a successful preventive strategy for AUD patients in OPD settings. Research shows that drinkers who undergo brief intervention are twice as likely to reduce their drinking within 6–12 months compared to those who do not receive any intervention.[5] brief physician intervention is associated with not only a decrease in alcohol use but also impacts health care utilization and its associated costs.[6]

A study in India compared brief interventions done in the form of motivational interviewing with simple advice. They found that the former led to a significant decrease in the severity of dependence parameters.[7]

To the best of our knowledge, not many have examined the effects of a brief intervention on the psychological mindset of alcohol users including motivation levels and self-efficacy levels, especially in India. Also, data on the effect of brief intervention in the context of group therapy has not been extensively researched in India. A better understanding on this can help individuals gain a better understanding of their drinking patterns and the consequences of their alcohol use and by developing healthier coping mechanisms and social support networks, group members can work toward reducing their alcohol consumption and preventing relapse.[8]

MATERIALS AND METHODS

In this study, 30 participants who were diagnosed with mental and behavioral disorders due to alcohol use were included. All of the participants visited the psychiatry OPD of a tertiary care hospital in a metropolitan city in India for the treatment of alcohol use disorder. Patients with other psychiatric disorders, polysubstance use (except tobacco), and other medical comorbidities were excluded from this study. Ethics committee approval obtained in March 2019.

Brief intervention group therapy was conducted by a trained psychiatrist using the module as illustrated in Figure 1. A total of three sessions were taken for each participant at weekly intervals. The time duration of each group session was around 45–60 min approx. and contained 8–10 participants per group.

Figure 1.

Schematic diagram of group brief intervention in alcohol use disorder patients

Scales and questionnaires were applied before the start of the intervention (not more than 1 week before the start of the first session) and repeated 12 weeks after the initiation of the first session intervention. The scales applied are as follows:

SCALE AND QUESTIONNAIRES

The Severity of Alcohol Dependence Questionnaire (SADQ), developed by Edwards and Gross (1976), is a concise 20-item questionnaire that assesses the severity of dependenceW on alcohol. It employs a 4-point scale for each item, ranging from “almost” to “nearly always,” resulting in a total score ranging from 0 to 60. The SADQ demonstrates high reliability (α =0.8) and validity, making it suitable for clinical settings where quick and accurate assessments are crucial.

The University of Rhode Island Change Assessment (URICA) is another essential tool used to evaluate readiness to change among individuals with alcohol use disorder. This instrument consists of 32 items rated on a 5-point Likert scale and is structured into four subscales: Precontemplation, Contemplation, Preparation, Action, and Maintenance. The URICA provides a comprehensive assessment of an individual’s stage of change, allowing for tailored interventions based on their readiness level. It demonstrates good internal reliability (α = 0.82) and offers distinct scoring ranges for each stage, aiding in treatment planning and monitoring progress.

The General Self-Efficacy Scale, developed by Schwarzer and Jerusalem, is a widely used self-report measure that assesses an individual’s perceived self-efficacy across various domains. This scale utilizes a 4-point Likert scale, ranging from “Not at all true” to “Exactly true,” and has demonstrated high reliability with Cronbach’s alphas between 0.76 and 0.90. The scale’s association with emotional well-being, optimism, work satisfaction, and negative factors like depression and stress makes it a valuable tool for understanding an individual’s overall confidence in managing challenges related to alcohol use and recovery.

The Readiness to Change Questionnaire (SOCRATES) is a comprehensive instrument designed to assess readiness for change specifically in alcohol abusers. It comprises three factorially-derived scales: Recognition, Ambivalence, and Taking Steps, providing a nuanced understanding of an individual’s motivation and eagerness to change their alcohol use behaviors. SOCRATES has undergone rigorous validation and shows high reliability across its subscales (α ranging from 0.60 to 0.96), making it a valuable tool in treatment planning and outcome evaluation in alcohol dependence interventions.

RESULTS

The mean age of the study participants is 40 years with the minimum age being 19 and maximum of 58 years. The demographic characteristics of the subjects are tabulated in Table 1. The mean age at which the study participants started consuming alcohol is found to be 19 years of age and the mean duration of alcohol consumption is 20 years’ (min: 3 years and max: 42 years). Out of 30 patients with alcohol use disorder 25 that is 83.33% were in early remission and 5 patients that is 16.33% did not remain abstinent for 3 months. Before the intervention, 96% of participants scored severely on the SADQ scale, one participant scored moderately, and no participants were rated as having mild symptoms on the scale. After the intervention, no participants scored moderately or severely on the SADQ scale. The Chi-Square analysis yielded a P value of 0.01.

Table 1:

Demographic profile of alcohol use disorder patients

	Frequency (n)	Percentage
Age group
<20 Years	1	3.33
21–30	3	10
31–40	12	40
41–50	9	30
51–60	5	16.67
Religion
Hindu	27	90
Muslim	1	3.33
Christian	1	3.33
Buddhist	1	3.33
Marital Status
Married	26	86.67
Single	3	10
Divorced	1	3.33
Income
No income	3	10
<10,000 Rs	5	16.67
10,001–20,000 Rs	11	36.67
20,001–30,000 Rs	8	26.67
30,001–40, 000 Rs	3	10
Family Type
Nuclear	19	63.33
Joint	10	33.33
Extended	1	3.33
Total	30	100

As tabulated in Table 2 at week 1, all patients were in pre-contemplation stage on the change assessment scale, however, at week 12, post-intervention only two patients (7%) were in the pre-contemplation stage, 10 (33%) in the contemplation phase and the other 18 (60%) were in the preparation phase. This difference is statistically significant (P value of < 0.001). Results of all three components of readiness of change scale namely recognition, ambivalence, and taking steps [Table 3] showed that all 30 of the participants had a very low score in each of the components at week 1. At week 12 post intervention 60% showed low recognition scores and 40% had medium recognition scores. In the ambivalent component post-intervention 93.33% had low scores and only 6.67% had very low scores. The scores of the taking steps component post-intervention showed that 56.67% had moved to a high score and 23.33% reported a very high score. The mean general self-efficacy scores [Table 4] of the participants before the intervention was 25.57 (SD: ±5.38) and after the intervention was calculated as 36.4 (SD: 11.84).

Table 2:

Pre and post-brief interventional group therapy comparison of readiness to change

	Stages in Readiness for Change
	Pre-contemplation (≤8)	Contemplation (8–11)	Preparation (11–14)	Maintenance (≥14)	Total
Pre-intervention	30 (100%)	0 (0%)	0 (0%)	0 (0%)	30 (100%)
Post-intervention	2 (6.67%)	10 (33.33%)	18 (60%)	0 (0%)	30 (100%)

Table 3:

Comparison of treatment eagerness with 3 components of SOCRATES scale pre- and post-intervention

SOCRATES	Pre- intervention	Post- intervention	Paired “t”	P
Recognition
Very Low	30 (100%)	0 (0%)		<0.0001
Low	0 (0%)	18 (60%)
Medium	0 (0%)	12 (40%)
High	0 (0%)	0 (0%)
Very High	0 (0%)	0 (0%)
Ambivalence
Very Low	2 (6.67%)	0 (0%)		<0.0001
Low	28 (93.33%)	0 (0%)
Medium	0 (0%)	2 (6.67%)
High	0 (0%)	25 (83.33%)
Very High	0 (0%)	3 (10%)
Taking Step
Very Low	30 (100%)	0 (0%)		<0.0001
Low	0 (0%)	0 (0%)
Medium	0 (0%)	6 (20%)
High	0 (0%)	17 (56.67%)
Very High	0 (0%)	7 (23.33%)

Table 4:

Comparison of general self-efficacy (GSE) pre- and post-brief interventional group therapy

GSE (mean score)	Pretest	Posttest	Paired “t”	P
	25.57±1.98	38.4±5.38	11.84	<0.0001

DISCUSSION

The treatment of AUD is extremely challenging with high relapse rates post-treatment, management of this disorder typically requires a multimodal approach.[9] Brief interventions aimed at improving motivation to stop the consumption of alcohol have shown to be an effective psychological intervention in patients with alcohol use disorders.[5] The current study aims to determine if a brief intervention group therapy has any effect on abstinent rates, motivation levels, and self-efficacy among patients suffering from AUD.

This study found that at the end of 12 weeks after the brief group interventions, 83% were in early remission that is the full criteria of AUD which was previously met is now not met for at least 3 months.[10] A review of the history of alcohol consumption of these patients reveals that in the past during attempts at abstinence, more than half of the patients had completely relapsed within 1 month, and none of the patients had received any kind of brief intervention therapy in the past. The brief intervention group therapy provided to them this time could have contributed to helping them achieve remission. A study on hospitalized Taiwanese men found that a brief intervention can reduce alcohol intake after 4 months for heavy drinkers or those with an alcohol use disorder.[11]

The University of Rhode Island Change Assessment (URICA) scale measures the stage of motivation a person is in, whereas the readiness to change and treatment eagerness specifically to alcohol is measured by Socrates “Stages of Change Readiness and Treatment Eagerness Scale.”[12] At the end of 12 weeks after initiation, most of the participants were found to be in the action phase of motivation and more than 50% had reported to have taken steps and treatment necessary to change their drinking behavior. Many participants were also less ambivalent to change than before and the recognition of AUD as an illness had also increased among the participants. Previous research has proven that brief interventions have helped in increasing a person’s motivation to change behavior, this increase in motivation has been proven to have led to cutting down or quit drinking.[13,14,15]

Our study has also shown that the general self-efficacy levels of the participants at the end of 12 weeks post-brief group intervention were better than they were before the intervention. The inverse relation between drinking-related self-efficacy and alcohol-related problems has been proven in many previous studies.[16,17]

Literature in recent times not only proves that brief interventions are helpful in AUD patients but has actively sought to understand the mechanism behind their usefulness.[18] The current hypothesis states that brief interventions increase patients’ level of motivation after which the patient taps into their resources to reduce their drinking.[19] Our study findings of change in the stage of motivation, increased change readiness, and increased self-efficacy give support to this hypothesis. A matter of dispute in literature is whether increased motivation to quit alcohol necessarily means increased success in cutting down alcohol, an argument remains on what is a better measure of predicting the outcome of substance intervention programs, measure of stages and readiness of change, or measure of dependence.[19] According to Shiffman in 1996, these two could be interrelated and complementary, the stage of change predicts attempts to quit smoking better whereas dependence variables better predict those who would succeed.[20] Our study showed that not only did the patients not satisfy the criteria of AUD 3 months post-intervention but also had an increase in their motivation levels to quit or decrease consumption, thus showing that the brief intervention had led to a positive change in both variables.

The following limitations were identified during this study. A small sample size and control group was not taken. Samples were taken from one center and not from the community which decreases the generalizability. The study was done only on male patients. Alcohol use disorder with other medical and psychiatric comorbidities was not studied.

On the basis of these findings, the recommendations made for further research are as follows: Other psychoactive substance abuse patients can be studied in a similar fashion. The study can be replicated using a large sample and for a longer duration.

CONCLUSION

The management of AUD is complex and involves multiple modalities. Brief group intervention involving psychoeducation and motivational enhancement techniques is a low-cost, simple, and time-saving behavioral intervention. Brief group intervention can lead to a decrease in the severity of alcohol consumption and early remission. These interventions also lead to a change in the stage of motivation, an increase in treatment eagerness and change readiness, and an increase in the self-efficacy of an individual. These changes predict a better treatment outcome for patients in the future. Research studying the long-term outcomes of such interventions is needed.

Data Availability

Data can be made available on reasonable request.

Authors contribution

concept, design, definition of intellectual content, literature search: RB, JK, AK, SS data acquisition: RB statistical analysis: RB manuscript preparation: RB, AK, JK, SS manuscript editing and manuscript review.: AK Guarantor: JK.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.