A Process Study
- Abstinence Preparation Groups (APG) were effective in reducing the severity of drinking and symptoms of dependence during the intervention and at 1-month follow up.
- Urges to drink, self-efficacy, and positive expectancies towards drinking changed during the intervention and continued to change at 1-month follow up. These changes were in the direction predicted by the theory.
- Negative expectancies towards drinking did not change during the intervention but change significantly at 1-month follow up. This was in the direction predicted by theory.
- The underlying process of the APG intervention seems to be consistent with the Cognitive Behaviour Therapy predictions and process.
Dr Christos Kouimtsidis, Consultant Psychiatrist, Surrey and Borders Partnership NHS Foundation Trust; iHEAR Partnership, 1 Prince Regent Road, London TW3 1NE.
Kelly Jo Charge, Substance Misuse Specialist, Surrey and Borders Partnership NHS Foundation Trust, iACCESS, Abraham Cowley Unit, Chertsey, KT16 0AE.
Joanna Patrycja Moch, Recovery Worker, Surrey and Borders Partnership NHS Foundation Trust, Integrated Care Team, Cedar House, Ridgewood Centre, Old Bisley Road, Frimley, GU16 9QE.
Dr Daniel Stahl, Department of Biostatistics, Institute of Psychiatry, King’s College London, De Crespigny Park, BOX PO20, London SE5 8AF.
There is evidence to suggest that repeated alcohol detoxifications have an adverse negative cognitive impact, which may contribute to relapse. It has been suggested that people with more than two previous detoxifications show withdrawal‐induced impairment in prefrontal subfields and an inability to perform a task that captures two of the basic features of addictive behaviour – cue-induced motivation to seek a reward, and failure to inhibit such motivation when reward seeking is inappropriate. Furthermore, under emotional challenge, multiple detoxified alcohol dependent people show an increase in the integration of neural networks in sub-cortical regions, underlying a bottom-up emotional input. These changes may confer inability in conflict resolution and increased sensitivity to stress, both of which may contribute to relapse (Duka et al., 2004; Duka et al., 2011).
The Abstinence Preparation Group (APG) is based on Cognitive Behaviour Therapy (CBT) and aims to help drinkers to regain control over their drinking, initiate lifestyle changes and enhance self-efficacy before they start medically assisted detoxification. Similarly to other CBT interventions, the APG focuses on the reduction of positive expectancies towards drinking, the development of negative expectancies towards drinking, the development of self-efficacy and coping skills in relation to specific high risk situations, and finally the development of overall lifestyle changes compatible with an abstinent way of living (Marlatt and Donovan, 2005; Monti et al., 1989). Fundamentally, APG aims to initiate those changes while people are drinking prior the detoxification – and not, as in other relapse prevention interventions, after the detoxification. This is considered important because although relapse prevention interventions have been proven to be effective (Raistrick et al, 2006), empirical evidence suggests that less than 60% of clients completing a medically assisted detoxification will attend aftercare interventions (Kouimtsidis et al, 2012).
This group intervention, was first implemented and evaluated in Hertfordshire in 2009 with the name “Preparation for Alcohol Detoxification” (PAD) (Kouimtsidis et al., 2012). Since 2013 it has run is Surrey under the name “Abstinence Preparation Group” (Kouimtsidis et al, 2015). This is the only intervention reported in the literature that puts primary emphasis on the preparation for detoxification, rather than the detoxification process itself. Previous evaluations indicated that APG is effective (Kouimtsidis et al, 2012) and acceptable by clients (Croxford et al, 2015).
The current project builds on previous evaluation of the intervention and aims to explore the theoretical mechanisms behind the effect of the APG. Specifically, the objectives were:
- To explore whether self-efficacy, urges to drink, positive expectancies and negative expectancies towards drinking changed during the group therapy.
- To evaluate if these changes are consistent with theory prediction.
- To assess if those changes are correlated with reduction of drinking as expected
Participants were recruited from the Windmill Drug and Alcohol community team. This team also piloted the Abstinence Preparation Group in Surrey and evaluated its first six months (Kouimtsidis et al, 2015). All clients who had presented to the service, were assessed as alcohol dependent and were able to enter the APG were invited by their keyworker to participate in the evaluation. Participants were assessed at baseline just before starting APG (time 0), immediately after completion of the group and before entering detoxification (time 1) and one month post completion of detox/withdrawal (time 2). Participants received a £5 incentive for each follow-up assessment (which are additional to the standard clinical practice).
Thirty-five participants were recruited (74.3% male). SADQ scores were significantly lower at the end of APG and continued reducing at 1-month follow up (t0=32.03, sd:12.76; t1=25.91, sd:13.69; t2=10.83, sd:10.37). The results suggest that APG was effective in reducing the amount of alcohol consumed and the associated symptoms of dependence both during the period of intervention and in 1-month post detoxification.
Urges to drink, self-efficacy and positive expectancies from drinking changed significantly both during the period of intervention and 1 month afterwards. These changes were significantly correlated with changes of SADQ score and were consistent with theory prediction. While negative expectancies did not change during the intervention, they changed significantly in the expected direction (i.e. the relevant SADQ scores increased), in 1-month post detoxification.
The APG is the only reported intervention that puts emphasis on the preparation received by alcohol dependent clients before receiving medically assisted detoxification, in order not only to increase effectiveness and reduce relapse rates but in order to protect the brain from the cognitive side effects of the detoxification process itself.
Offering APG is consistent with a shift from the existing treatment paradigm that considers medically assisted detoxification as the main treatment intervention for alcohol dependence. The proposed new treatment paradigm acknowledges the evidence of adverse effects arising from medically assisted detoxification. It also highlights the limitations of existing medication used in detoxification and the limited participation of detoxified clients in relapse prevention interventions, which are proven to be effective.
An adequately powered Randomised Controlled Trial would be needed to confirm whether this intervention is safe and effective in reducing relapse rates and cognitive side effects; however, preliminary evaluation in Hertfordshire and Surrey has provided preliminary evidence of effectiveness and acceptability to both clients and service providers. Furthermore an earlier qualitative study with clients indicated that APG is well accepted (Croxford et al, 2015).
The findings of the current evaluation contribute to the scientific understanding of how the intervention works. Given that it is based on CBT, results have proven that the APG works as predicted by theory. This is important for further development of the intervention. It makes the case that beyond the generic group factors, and social ingredients necessary for lifelong abstinence, APG can offer a theoretically informed intervention that works by modifying urges, self-efficacy, and both positive and negative expectancies.
In the current era of austerity, major reductions in funding for specialist substance misuse services and the associated reduction in specialist skills within the workforce, there is a great risk of returning to a-theoretical, non- evidence based innovations. The results of this study further demonastrate the need for evidence-based clinical interventions.
A Randomised Controlled Trial remains essential to provide concrete evidence for the effectiveness of APG. More research is also required to investigate the cognitive implications of medically assisted detoxification, and their potential contribution to relapse. However, this evaluation suggests that APG is promising intervention which should be further developed.
Dr Christos Kouimtsidis MBBS, FRCPsych, MSc, PhD;
Consultant Psychiatrist in Addictions; iHEAR Partnership;
1 Prince Regent Road; London; TW3 1NE.