|Year : 2022 | Volume
| Issue : 4 | Page : 346-350
Effect of motivational enhancement therapy and behavioral couple therapy in subjects of alcohol dependence syndrome: A comparative study
Saurav Kumar1, Mona Srivastava1, Manushi Srivastava2, Jai Singh Yadav1, Shiv Prakash1
1 Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
|Date of Submission||14-Dec-2020|
|Date of Decision||21-Jul-2021|
|Date of Acceptance||15-Aug-2021|
|Date of Web Publication||06-Jun-2022|
Mr. Saurav Kumar
Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Alcohol dependence is a wide and extending social and physical problem in the world. It affects a person at the individual, family, and society levels. The aim is to study and compare the influence of motivational enhancement therapy (MET) and behavioral couple therapy on the level of motivation in a person with alcohol dependence. Methodology: Pre- and post-test with control group design was used. A total number of 60 subjects were selected using a purposive sampling method. The sample comprised twenty subjects in the behavioral couple therapy treatment as usual (Behavioral couple therapy BCT + TAU) group, twenty subjects in the control (TAU) group, and twenty subjects in the (MET + TAU) group, respectively. The subjects recruited were in the age range of 21–60 years, educated up to primary level and above, with no comorbid psychiatric, neurological disorder, physical problem, multiple substance use coming to outpatient department and inpatient department Department of Psychiatry IMS, BHU, Varanasi, and wife having age above 18 years, married for at least 1 year, educated up to primary level and above. Tools: sociodemographic datasheets, alcohol use disorder identification test, general health questionnaire-12, and stages of change readiness and treatment eagerness scale were utilized. Results: Psychotherapeutic intervention such as MET and behavioral couple therapy plays an effective role in raising motivation to change in alcohol-dependent person to quit alcohol, which is indicated by the significant rise in motivation for the change of alcohol-dependent person's recognition (F = 4.42, P < 0.05) and taking steps (F==3.78, P < 0.05). Conclusion: The present study suggests that combining pharmacological treatment with appropriate psychosocial therapies give fruitful result in the form of a desire to quit alcohol dependence.
Keywords: Addiction, alcohol, psychotherapy, substance abuse treatment
|How to cite this article:|
Kumar S, Srivastava M, Srivastava M, Yadav JS, Prakash S. Effect of motivational enhancement therapy and behavioral couple therapy in subjects of alcohol dependence syndrome: A comparative study. Indian J Soc Psychiatry 2022;38:346-50
|How to cite this URL:|
Kumar S, Srivastava M, Srivastava M, Yadav JS, Prakash S. Effect of motivational enhancement therapy and behavioral couple therapy in subjects of alcohol dependence syndrome: A comparative study. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Dec 9];38:346-50. Available from: https://www.indjsp.org/text.asp?2022/38/4/346/346572
| Introduction|| |
The proof of the existence of alcoholic beverages has been found since the Vedic period. The beverages were utilized primarily for entertainment, as medicaments, and were taken as a relaxant. Alcohol dependence is seen as a serious health problem that affects life not only at the individual level but also at the family and society level.
World Health Organization estimated that presently, the alcohol using population is nearly 2.3 billion in the world. It was recorded that, in the world's population, above 15-year alcohol per capita consumption rose from 5.5 l of alcohol recorded in 2005 to 6.4 l in 2016. About 30 lakh deaths, which were about 5.3% of all deaths worldwide occurred due to the hazardous use of alcohol in the year 2016. The death that occurred as a consequence of alcohol consumption is more than the death that resulted from diseases such as HIV/AIDS tuberculosis and diabetes. Harmful use and abuse of alcohol can contribute to the causation and magnification of the preexisting or new psychopathology. This also contributes to an increase in economic burden in terms of medical care and work absenteeism, impaired occupational, and academic performance. Alcohol is also a major factor in road traffic mishaps.
In alcohol-related treatment, motivation is a major factor contributing to fruitful positive abstinence results. It has been seen in most of the cases that lack of motivation leads to the failure of an individual to begin to continue, comply, and succeed in the treatment. By applying motivational enhancement approaches, more involvement in the treatment process can be achieved followed by positive treatment outcomes. A major distinction between patients with other clinical ailments and alcohol-dependent individuals is the presence and absence of insight. While individuals having physical ailments have the desire and motivation to undergo treatment, individuals suffering from alcohol abuse are not willing to get treated, despite being aware of its harmful impact on health, relationships, and social standing. There are instances that the desire to quit alcohol is not matched with the awareness of medical treatments. The seriousness of withdrawal, side effects, and lack of knowledge about adapting strategies lead to a failure of treatment and finally relapse. Treatment methods such as motivational enhancement therapy (MET) and behavioral couple therapy play a pivotal role in the recovery of a person with alcohol dependence and help them in developing insight about alcohol-related harm and equip them with a strategy to overcome the craving and ultimately maintain abstinence. Motivational interviewing is defined as a “client-centered directive intervention that assists in the resolution of ambivalence present in the client.” Behavioral couple therapy is a form of psychosocial intervention approach which improves the relationship and as a result helps in the development of abstinence behavior with the support from a spouse.
The aim of the study was to study and compare the influence of MET and behavioral couple therapy (BCT) on the level of motivation to change in person with alcohol dependence.
| Methodology|| |
The study design was a pre- and post-test with control group design.
A total number of sixty subjects of alcohol-dependence (AD) fulfilling international classification of diseases (ICD)-10 criteria were selected using purposive sampling method from outdoor and indoor Department of Psychiatry in IMS BHU, Varanasi, and divided into three groups through random assignment. Group I consisted of 20 subjects of AD with their spouses; this group was given behavioral couple therapy (BCT) and the pharmacological treatment was as prescribed by the treating psychiatrist, i.e., treatment as usual (TAU). Group II consisted of 20 subjects who were the control group and TAU was given to them but no specific therapy was given; however, their queries and clarification of their doubts were addressed whenever asked. Group III consisted of 20 subjects of ADS who underwent MET session along with TAU. On completion of the intervention the postintervention analysis was done to ascertain the level of change in the motivation of the ADS subjects in all the three groups using the stages of change readiness and treatment eagerness scale (SOCRATES) scale. The study period lasted from July 2017 to April 2019.
Inclusion criteria for patients
- Those diagnosed with mental and behavioral disorders due to the use of alcohol using ICD-10 (WHO)
- Subjects in the age range of 21–60 years
- Subjects education up to primary level or above
- Those who gave written informed consent.
Exclusion criteria for patients
- Patients having any co-morbid psychiatric, neurological disorder, and physical problem
- Patients using multiple substances.
Inclusion criteria for wife
- Married for at least 1 year
- Primary education and above with the ability to read and write
- Those who gave written informed consent
- Female aged 18 years and above.
Exclusion criteria for wife
- Any kind of physical and psychiatric illness.
- Sociodemographic datasheet: A semi-structured and pretested Pro forma has been used. It contains information about sociodemographic variables such as age, sex, religion, education, marital status, domicile, and occupation
- Alcohol use disorder identification test (AUDIT) – The AUDIT is a screening tool developed to identify excessive drinking. It also helps to recognize alcohol dependence and some consequences of harmful drinking. AUDIT shows high internal consistency as the value of Cronbach alpha is = 0.80 and reliability range from 0.64 to 0.92
- General health questionnaire-12 (GHQ-12): It is a 12-item screening tool used to examine psychiatric distress having four options 0-0-1-1. A score above 3 signifies psychiatric distress
- The SOCRATES – This is a self-reported scale that is used to assess motivation to change the substance use and consists of three subscales: problem recognition; ambivalence; and taking steps. The subscales shows high internal consistency (a's = 0.60–0.85), also high test–retest reliability (ICCs = 0.82–0.94) in adults.
Based on the inclusion and exclusion criteria, subjects were recruited for the study. The tools administered were AUDIT scale, SOCRATES scale, and GHQ 12. GHQ 12 was used for screening psychiatric distress among wives. AUDIT scale was used for screening harmful and hazardous alcohol consumption, SOCRATES scale was used to assess the level of change in motivation regarding alcohol abstinence in the subjects. A total of sixty participants were selected using a purposive sampling technique and were divided into three groups. Group I consisted of twenty subjects of AD with their spouses; this group was given behavioral couple therapy (BCT) and TAU. This group was given BCT for 10 sessions which focused mainly on rapport building, improvement in communication by incorporating good listening, blame-free communication, identification and understanding high-risk situations, assertive communication skills, anger management, effective refusal, problem-solving abilities, promotion and practice of caring behavior, and shared rewarding activities. Group II was the control group and consisted of twenty subjects who were provided TAU and was also put on the waiting list. Group III consisted of twenty subjects of AD who underwent MET session along with TAU. MET was administered for ten sessions. The MET group (III) was taught lifestyle management; decisional balance; pros and cons of alcohol use; exploring values supporting self-efficacy, i.e., success stories; looking forward, raising awareness; and craving management techniques.
The present study has been approved by the ethical committee of IMS BHU, Varanasi, Uttar Pradesh, India.
For the tabulation and analysis of the data, Microsoft Excel 2013 and SPSS IBM trial version 20.0 programs (IBM, Armonk, NY, USA) were used. In all three groups, analysis of variance (ANOVA) test was used to see difference of level of motivation to change before and after intervention. Levine's test and Welch test are used for checking homogeneity of variance.
| Results|| |
[Table 1] shows that the mean value of recognition in the (BCT + TAU) group was 25.70 ± 2.75, mean value of recognition in control (TAU) group was 25.60 ± 3.54, and the mean value of recognition in (MET + TAU) group was 24.15 ± 5.20. The mean value of ambivalence in the (BCT + TAU) group was 14.30 ± 1.97, the mean value of ambivalence in the control (TAU) group was 14.15 ± 2.66, and mean value of ambivalence in (MET + TAU) group was 13.90 ± 2.46, respectively. The mean value of taking steps in (BCT + TAU) was 26.85 ± 2.39, the mean value of taking steps in the control (TAU) group was 26.65 ± 4.82, the and mean value of taking steps in (MET + TAU) was 24.25 ± 4.20, respectively. The One-way ANOVA test was applied to assess the difference in the level of motivation between the study groups. The result showed that there was no significant difference at baseline (prior to intervention) in recognition (F = 0.956, df = 59, P = 0.391); ambivalence (F = 0.143, df = 59, P = 0.867) and in taking steps (F = 2.69, df = 59, P = 0.076).
|Table 1: Mean, standard deviation and significance level of motivation to change in (behavioral couple therapy + treatment as usual), control (treatment as usual) and (motivational enhancement therapy + treatment as usual) group at baseline (before intervention)|
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[Table 2] shows that mean value of recognition in (BCT + TAU) group was 28.75 ± 0.85, mean value of recognition in control (TAU) group was 27.10 ± 3.24, mean value of recognition in (MET + TAU) group was 29.35 ± 2.68. Mean value of ambivalence in (BCT + TAU) group was 11.00 ± 1.86, mean value of ambivalence in control (TAU) group was 12.35 ± 2.15, and mean value of ambivalence in (MET + TAU) group was 10.85 ± 2.05, respectively. Mean value of taking steps in (BCT + TAU) was 30.10 ± 2.29, mean value of taking steps in control (TAU) group was 27.95 ± 5.01, and mean value of taking steps in (MET + TAU) was 31.35 ± 4.06, respectively. The One-way ANOVA test was applied to assess the differences in the level of motivation between the study groups. The results showed that there were significant differences between the groups postintervention in recognition (F = 4.42, df = 59, P = 0.016); ambivalence (F = 3.30, df = 59, P = 0.044); and in taking steps (F = 3.78, df = 59, P = 0.029), respectively.
|Table 2: Mean, standard deviation and significance level of motivation to change in (behavioral couple therapy + treatment as usual), control (treatment as usual), and (motivational enhancement therapy + treatment as usual) group at end line (after intervention)|
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| Discussion|| |
The study was carried out to examine the effect of MET and behavioral couple therapy on the level of motivation in person with alcohol dependence.
The finding of our study shows that the motivation to change in the form of recognition and taking steps had increased. There was a decrease in ambivalence in the intervention group and the levels were statistically significant (F = 4.42, P < 0.05, F = 3.30, P < 0.05, F = 3.78, P < 0.05). This finding of the present study is consistent with the finding of other studies which concluded that the MET helps in raising the level of motivation to quit alcohol and maintains the alcohol-free lifestyle.,,
A study was conducted in Taiwan using the severity of alcohol dependence questionnaire and SOCRATES scale. In this study, the subjects were given a psychoeducative program. The efficacy of this program was assessed in terms of the ability to remain abstinent. Subjects undergoing alcohol de-addiction were recruited from a psychiatric ward in northern Taiwan. The result of the study demonstrates that the experimental group, i.e., group going through a psychoeducational program showed a significant increase in recognition of problems compared to the control group; this finding is almost similar to our finding.
In a study done in the Czech Republic, the Slovak Republic, and Poland, association between motivation, and readiness to change, drinking habits and insight of persons having ADS was assessed. Pre- and post-assessment was done at the end of 6 weeks and 12 weeks after the intervention program. Following the intervention, there was a marked increase in the taking step domain of the SOCRATES questionnaire. This finding concurs with our finding.
In a study conducted to assess the effect of motivational interviewing 32 subjects with alcohol dependence were examined. During the MET sessions and at follow-up after 1-month postintervention, participants reported a decrease in ambivalence, lesser days of drinking, and reduction in the quantity of alcohol. The findings are the same as the present study.
To assess the effect of the family intervention approach along with pharmacological management in alcohol-dependent subjects, a study was conducted in Trivandrum, Kerala. Thirty subjects were given family intervention alongside medicine, while the other 30 subjects were given brief psychotherapy. The evaluation was done using the motivation scale, Michigan alcohol screening test scale, family pattern scale, and locus of control. The group which was offered family intervention showed a decrease in the severity of alcohol intake, an increase in will power to leave alcohol in comparison to the control group.
Due to a small sample, the result cannot be generalized. As the sampling was purposive and the study was hospital based, therefore a bias of severity and motivation cannot be ruled out. The subjects coming to the hospital may be severely affected and hence the motivation to undergo treatment may be higher in them than those subjects who are residing in the community. A larger sample and community-based recruitment of subjects incorporating randomization will be helpful in better generalizability of the results.
| Conclusion|| |
The present study highlights the significance of combining pharmacological treatment with appropriate psychosocial interventions to attain an optimal and longstanding abstinence in subjects of alcohol dependence. The individuals suffering from alcohol dependence also report improvement in their desire to quit alcohol. The interventional approach helps alcohol-dependent subjects to recognize the nature of their problem drinking and impart them skills and strengthen their willingness to change their alcohol abusing behavior.
We would like to thank all persons and their spouses who participated in the present study.
Financial support and sponsorship
This study was financially supported by UGC Fellowship, New Delhi.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Das SK, Balakrishnan V, Vasudevan DM. Alcohol: Its health and social impact in India. Natl Med J India 2006;19:94-9.
World Health Organization. Global Status report on Alcohol and Health Geneva:WHO;2018.p.1-450.
Peterson JV, Nisenholz B, Robinson G. A Nation under the Influence: America's Addiction to Alcohol. Newyork: Pearson; 2002.p.1-278.
Miller WR. Enhancing Motivation for Change in Substance Abuse Treatment. Pennsylvania (PA): Diane Publishing; 2000.
Bhagabati D, Das B, Das S. Pattern of alcohol consumption in underage population in an Indian city. Dysphrenia 2013;4:36-41.
Miller WR, Moyers TB. Eight stages in learning motivational interviewing. J Teach Addict 2006;5:3-17.
Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. The alcohol use disorders identification test (AUDIT). Guidel Use Prim Care 2001;2:1-7.
Gautam S, Nijhawan M, Kamal P. Standardisation of hindi version of Goldbergs general health questionnaire. Indian Journal of Psychiatry. 1987; 29:63-6.
Miller WR, Meyers RJ, Tonigan JS. Engaging the unmotivated in treatment for alcohol problems: A comparison of three strategies for intervention through family members. J Consult Clin Psychol 1999;67:688-97.
O'Farrell TJ, Fals-Stewart W. Behavioral Couples Therapy for Alcoholism and Drug Abuse. New York: Guilford Press; 2012.
Ingersoll KS, Wagner CC, Gharib S. Motivational Groups for Community Substance Abuse Programs. Richmond, VA: Mid-Atlantic Addiction Technology Transfer Center; 2000.
Rani S, Maheshwari SK, Arora K. Motivational enhancement therapy for Substance abusers: A quasi experimental study. Delhi Psychiatry J 2014;17:349-56.
Angami MA, Baruah A, Ahmed N. Motivational intervention among patients with alcohol dependence syndrome: A quasi experimental study in a selected de-addiction centre in Assam. Dysphrenia 2014;5:91-7.
Shakya S, Chaudhary JM, Pradhan PM, Ojha SP, Rana M. Effectiveness of inpatient alcohol detoxification and psychotherapeutic support program: A prospective self-controlled study at a tertiary hospital in Nepal. Asia Pac J Clin Trials Nerv Syst Dis 2019;4:66. [Full text]
Yeh MY, Tung TH, Horng FF, Sung SC. Effectiveness of a psycho educational programme in enhancing motivation to change alcohol-addictive behaviour. J Clin Nurs 2017;26:3724-33.
Slepecky M, Stanislav V, Martinove M, Kotianova A, Kotian M, Chupacova M, et al.
Discrepancy between readiness to change, insight and motivation in alcohol-dependent inpatients. Neuro Endocrinol Lett 2018;39:135-42.
Bacio GA, Lunny KF, Webb JN, Ray LA. Alcohol use following an alcohol challenge and a brief intervention among alcohol-dependent individuals. Am J Addict 2014;23:96-101.
Suresh Kumar PN, Thomas B. Family intervention therapy in alcohol dependence syndrome: One-year follow-up study. Indian J Psychiatry 2007;49:200-4.
[Table 1], [Table 2]