Application of transtheoretical model in management of individual with alcohol dependence: A case study.

Studies have focused on the efficacy of transtheoretical model in the management of substance dependence, but not much have focused on the changes with respect to the patient's mood, life skills, and interpersonal relationship issues that take place during the therapy. The present study explores a case by using motivational interviewing and relapse prevention strategies to qualitatively record the applicability of the transtheoretical model in terms of readiness to change, action taken, relationship conflicts, assertiveness, and depression in an individual with alcohol dependence. The intervention was carried out over 3 months for ten sessions followed by follow-up for 8 months. The results indicated improvement in the patient in the dimensions of level of action taken for increasing abstinence period, decreasing the level of depression, enhancing readiness to change, and improving assertiveness and improvement in marital adjustment with spouse, which were observed and reported during the post follow-up sessions. Copyright:

Many psychological models for the management of alcohol dependence have been studied. Among such models, transtheoretical model (TTM) is considered to be highly influential,[1] as it adopts an approach to make the clients understand the complexities of change and to prepare them to adapt to it creatively. The model focuses on incorporating counseling procedures based on motivational interviewing and relapse prevention strategies in the treatment approaches. Hence, the present study aims to examine the efficacy of TTM with the combination of motivational interviewing and relapse prevention strategies in the dimensions of readiness to change, action taken, relationship conflict, assertiveness, and depression in individuals with alcohol dependence.

CASE REPORT AND CONCEPTUALIZATION

Mr. A, a 37-year-old, married Hindu male, employed as a laboratory technician, hailing from a middle socioeconomic family of an urban area of Cuttack district, Odisha, reported with chief complaints such as regular consumption of alcohol, being in an irritable mood most of the time, and engaging in feud with his wife. From the point of study, he had been taking alcohol for the last 8 years, which has increased for the last 2 years. Initially, the amount used to be taken was 750 ml/day. Since the last 2 years, the quantity of alcohol taken has increased to 1500–2000 ml/every day. The period of abstinence during these years was limited to a few days; the maximum abstinence period was 16 days. The case reported of no other physiological or psychological withdrawal symptoms except feeling distress and disturbance of sleep. He reported an increased urge to take the substance during 2–5 pm and after 9 pm (critical time).

Mr. A reported that he was experiencing more stress because his wife was asking for a divorce which he did not want. He reported that due to his habit of alcohol, conflicts with his wife escalated. The patient reported that he as a laboratory technician has been able to perform his job properly. Impairment was reported more in his familial relations. The patient had gradually limited himself to few of his friends; he had started avoiding his relatives as they used to ask him to quit alcohol.

He had attempted few times to quit alcohol but was unable to maintain the sobriety for long. He had willingly come for therapy with his wife to save their relationship. A detailed therapy structure was planned out based on the client's problems, which is discussed in the later part of the article.

His maintaining factors of addiction can be summed up as follows: proximity of bar to his clinic, difficulty in coping with familial tensions, withdrawal symptoms (insomnia and psychological distress), lack of assertiveness, and impulsive behavior.

Protective factors were his attachment to his son, love for his wife, and willingness to save his marital relationship.

METHOD

The present study adopted a case study, a single-subject approach. The participant was selected purposively from MHI, SCB Medical College, Cuttack, Odisha, India, for the study upon his consent. A detailed clinical history was taken. After baseline assessment, using outcome measures, intervention for 3 months, consisting of ten sessions, was administered, followed by re-assessment in post follow-up sessions and all subsequent follow-up periods for 8 months.

Outcome measures

During the initial interview, information related to precipitating, maintaining, and protective factors was taken. All outcome measures were assessed at baseline, post assessment, and at follow-up stages.

Beck Depression Inventory-II: It is a 21-item self-report scale used to assess the severity of depression[2]

Stages of Change Readiness and Treatment Eagerness Scale: It is an instrument designed to assess readiness for change in alcohol abusers[3]

The Relationship Assessment Scale: It is a 7-item scale that measures overall general satisfaction in couples[4]

The Rathus Assertiveness Schedule: It is a 30-item schedule that measures assertiveness.[5]

RESULTS

As shown in Table 1, the result had been analyzed in terms of preassessment, postassessment, and follow-up measures; additionally, a narrative report on session basis had also been provided.

Table 1

Scores on outcome measures at different preassessment, postassessment, and follow-up stages

Measures	Preassessment	Postassessment	FU 1	FU 2	FU 3	FU 4	FU 5	FU 6	FU 7	FU 8
BDI-II	22	17	19	17	17	18	19	15	11	9
Relationship Assessment Scale	PS-20WS-17	PS-35WS-33	PS-35WS-33	PS-35WS-33	PS-35WS-35	PS-35WS-33	PS-35WS-35	PS-35WS-35	PS-35WS-35	PS-35WS-35
The Rathus Assertiveness schedule	8	17	17	17	19	19	19	21	20	22
SOCRATES	R-34AM-18T-29	R-35AM-18TS-38	R-35AM-18TS-38	R-35AM-17TS-36	R-35AM-14TS-38	R-35AM-14TS-37	R-35AM-14TS-35	R-35AM-14TS-38	R-35AM-12TS-39	R-35AM-15TS-39

PS – Patient score; WS – Wife score; R – Recognition; AM – Ambivalence; TS – Taking Steps; BDI – Beck Depression Inventory; SOCRATES – Stages of Change Readiness and Treatment Eagerness Scale; FU – Follow-up

Course of treatment and assessment of progress

The therapeutic package was conducted in ten structured sessions incorporating various strategies and techniques adopted from the TTM, motivational interviewing, and the relapse prevention paradigm.

Session 1: The session began with training in coping skills in high-risk situations, interpersonal conflict, and crisis intervention involving his wife as a co-therapist. Homework session involved risk–benefit analysis

Session 2: Homework assignments were analyzed, and discussion on decisional balance and motivational interviewing[6] was done. Techniques employed were asking open-ended questions, affirmation, reflective listening, and summarizing

Session 3: In this session, we discussed on how to handle possible triggers and introduced the FRAME technique (Feedback, Responsibility, Advice, Menu of alternative change options, Empathy, and Self-efficacy)

Session 4: In this session, strategies for “Coping with Urges” through the use of urge surfing technique were done

Session 5: In this session, further discussion and elaboration on assertiveness skill was done

Sessions 6, 7, and 8: These three sessions were meant for couple therapy exclusively. We focused on behavioral contacting, communication, and receptive skills between them

Sessions 9 and 10: These sessions focused on relapse prevention strategies.[7] The patient was encouraged to develop activities such as meditation, exercise, or yoga.

Post assessment

The scores on “taking steps” reflect that the patient is already doing things to bring a positive change in his drinking behavior, and he may have experienced some success in this regard. The scores on “ambivalence” indicate that he has become more accepting and open about his drinking problem. Change is underway; he is motivated such that he may want help to persist or to prevent backsliding. Subjectively, he reported improvement in his skills in relation to coping with urges and assertiveness along with marital adjustment and satisfaction level.

Follow-up

Both the patient and his spouse were called for follow-ups twice in the 1st month and once in a month for the next 6 months. During the 1st month, the patient reported that he had consumed alcohol once in a party with his friends during the past month. His relationship with his uncle has become affable, but still he is not willing to meet any of his friends and relatives.

In the 2nd-month follow-up, the couple reported development in marital adjustment and also he has started meeting his friends and relatives and is trying to express assertiveness when required.

In the last 6-month follow-up sessions, the patient's spouse reported that he has taken alcohol twice but spent more qualitative time with the family members and started his own business. The patient reported that he has been dealing earlier reported triggers of drinking very comfortably and is able to deny his friends when they offer him a peg, and his drinks limited to social parties averaging 30–60 ml/month.

DISCUSSION

The findings of the present study were supported by a similar study which was conducted[8] to measure the effectiveness of a short-term alcohol-focused intervention for women with marital distress and to see the changes in their relationship functioning. At 1-month follow-up, the results indicated that the intervention was associated with quantitative reduction in alcohol use, marital distress, relational issues, and depression, and these changes were maintained at 12-month follow-up. However, in our study, in addition to similar variables, i.e., alcohol use, marital satisfaction, and depression, we have also included assertiveness. Our results showed improvement in all the above-mentioned dimensions of the study, which was maintained till the last follow-up. Another randomized controlled trial study was done[9] which had used motivational enhancement therapy (MET) for mild-to-moderate alcohol dependence. The results indicated that for patients with mild-to-moderate alcohol dependence, MET is more effective in reducing unequivocal heavy drinking than either a feedback/education session alone. Similar findings in other studies supported the effectiveness of motivational interventions and TTM with multiple components for reducing drinking problems in individuals.[10]

Limitations of the study

Findings gathered from a case study are difficult to generalize. In the present study, certain factors such as the patient's insight, support from his wife, and support from his family members might have played a role in the improvement of the patient, which were not measured in the study.

CONCLUSION

The present study supports the application of TTM in the management of individuals with alcohol dependence on increasing the level of action taken for prolonged abstinence period, decreasing the level of associated depression, enhancing readiness to change, improving assertiveness related to dependence, and bringing improvement in marital adjustment with spouse.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.