The aim of this study was to examine the efficacy of the life goal-focused brief intervention, or the so-called the goal-focused self-regulation program (GFSRP), for patients with alcohol use disorder (AUD).
The GFSRP was developed as an 8-week group-program, which is based on a wide range of self-regulation theories, such as goal setting and implementation intentions. Patients with AUD (n=50) took part in the GFSRP and were compared to the control group (n=48). This study examined the changes in outcome measures from baseline to follow-up (12-week) in a mixed design.
The GFSRP group had higher scores for the abstinence self-efficacy in negative affect situations than the control group at the post-test. In addition, it showed greater scores of optimisms compared to the control group. Furthermore, in the GFSRP group, there was no difference in intrinsic life goals from baseline to the 12-week follow-up, whereas the control group showed a significant decrease.
The GFSRP could increase the abstinence self-efficacy and optimism among patients with AUD. Moreover, it might prevent loss of life-goals as core factors in self-regulation among patients with AUD.
The Epidemiological Survey of Mental Disorder of Korea reports that the lifetime prevalence of alcohol use disorder (AUD) is 13.4% (20.7% in males, 6.1% in females), which is the highest percentage of lifetime prevalence among mental disorders reported in Korean adults [
In Australia, the percentage of AUD patients receiving treatment is 22.4% [
AUD is known to be one of the mental diseases in which more than 50% of the patients who are discharged from the hospital relapse within one year, and suffer severe physical, psychological, social, and economic damage [
There is increasing theoretical and empirical evidence that indicates intervention in goal setting and implementation is a key element in not only successful rehabilitation of the patients with chronic diseases (e.g., stroke, diabetes) but also in prevention of recurrence [
Therefore, this study assumed that the interventions that can maintain or enhance the intrinsic life-goals will be helpful for preventing failure in alcohol control and maximizing adaptation to everyday life. Specifically, this study aimed to 1) develop the goal-focused self-regulation program (GFSRP) centered on goal setting and implementation intention [
A total of 98 male inpatients with AUD were recruited from alcohol centers of psychiatric hospitals. Patients who met the AUD diagnostic criteria in the Diagnostic Statistical Manual of Mental Disorders, 5th edition (DSM-5) [
This study was conducted in South Korea between March and December 2015 and received ethical approval from the Ajou University Institute Review Board (201412-HR-SB-002-02). All subjects voluntarily participated in the study and signed a consent form.
In this study, the GFSRP is based on the integrated definition that includes emotion regulation as well as goal orientation and goal implementation. Therefore, this study focused primarily on understanding that there are various life goals and assisting with the selection of preferred life goals. Additionally, the GFSRP applied balancing between “best possible self” and “worst possible self” [
Accordingly, the GFSRP consisted of 8 sessions (50 min each), which was administered once a week by a licensed psychologist. Components of the GFSRP were as follows: self-regulation and mental health (session 1); searching for purpose in life (session 2); goal orientation (session 3 and 4); goal-focused emotion regulation (session 5 and 6); goal implementation (session 7 and 8). On the basis of the previous research outcomes, the treatment duration was selected as 8 weeks to maximize the effects of the brief intervention. The treatment group took part in the GFSRP as well as a usual addiction specialized program, including addiction education, 12-steps therapy, and cognitive behavioral therapies (CBTs), whereas the control group received only the specialized addiction program.
To achieve homogeneity between the groups, severity of alcohol dependence, smoking preference, frequency of hospitalization, initial drinking age, recent period of abstinence, longest period of abstinence, blackout experience, and family history were investigated, in addition to the demographic variables.
The Korean version of Alcohol Dependence Scale (ADS-K) [
The Aspiration Index (AI) [
Alcohol abstinence self-efficacy was assessed with the Alcohol Abstinence Self-Efficacy Scale (AASE) (DiClemente et al., 1994). The AASE evaluates an individual’s efficacy in abstaining from drinking in 20 situations (four categories) that represent typical drinking cues. The Korean version of the AASE [
To measure the optimism, the Korean version [
To identify pre-test homogeneity between GFSRP group and control group, χ2 test was conducted for categorical variables and independent sample t-test for continuous variables. In order to test the effects of treatment, different analyses were used for each dependent measurement based on the results from the normality test (Kolmogorov-Smirnov & Shapiro-Wilk’s test) of each scale. In other words, if normality could be assumed and pre-test homogeneity was achieved, repeated ANOVA or ANCOVA with pre-test score as covariate was conducted. In contrast, if the normality of measured values could not be assumed, “within-effects” were identified by conducting a Wilcoxon-Singed Rank Test W test (W test) and “between-effects” by conducting a Wilcoxon-Mann-Whitney U test (U test) [
At the same time, to compensate for limited significance testing that is affected by sample size, we aimed to closely investigate the effect of the program by considering the effect size. In relation to the effect size in ANCOVA, partial η2 [SSeffect/(SSeffect+SSerror)] provided by SPSS is likely to overestimate the effect size [
The mean age of the entire group was 50.68 years (SD=8.82); the GFSRP group, 51.56 years (SD=7.94), and the control group; 49.77 years (SD=9.66). The mean education period of the entire group was 12.08 years (SD=2.82); GFSRP group, 12.20 years (SD=2.79), and the control group, 11.93 years (SD=2.88). The differences in age and education period for the all groups were statistically insignificant (
In addition, in relation to alcohol use, there was no statistically significant difference in initial drinking age, recent abstinence period, longest abstinence period, blackout experience, and family history. At the same time, there was no significant difference between groups in terms of severity of AUD-K.
The difference between groups in life goals and optimism was not statistically significant and abstinence self-efficacy to negative affect was also not significantly different.
To know the effect of GFSRP, return-to-hospital-after-drinking cases when they went out or slept outside hospital were investigated from post-test to follow-up as behavioral measure and regarded as alcohol self-control failure. However, contrary to expectations, the difference in alcohol self-control failure between GFSRP group and control group was not statistically significant (χ2=4.511, p=0.105).
In W test, intrinsic life goals were not significantly different for both GFSRP group and control group, compared to pretest, while in U test, the between-group difference of intrinsic life goals was not significant at post-test, and the effect size was also small (
As the abstinence self-efficacy to negative affect did not meet normality, W test and U test were conducted. In the W test, the abstinence self-efficacy to negative affect showed a significant increase at post-test in both the GFSRP group and the control group, but did not show a significant difference with pretest scores at follow-up (
Optimism did not show a significant increase at each point of measures compared to pre-test in W test. However, in U test, optimism was significantly higher in the GFSRP group at post-test than in the control group. Moreover, the effect size was also medium or higher (U=102.500, p=0.013, Wendt’s r=0.466), but there was no significant difference between groups at follow-up (
To identify the practical effect of the program developed by this study, the ANCOVA with pre-test score for each variable as a covariate was conducted to determine whether there is a difference in life goals at post-test between participants who completed all eight sessions (n=14) and those who could not complete one or more sessions (n=36). Prior to analysis, to assess the possibility of systematic elimination, homogeneity test for education drinking severity, alcohol control failure, initial drinking age, and frequency of hospitalization was conducted. As a result, it was found that the between-group difference for all variables was not statistically significant. Additionally, even after controlling the effect of the pre-test score in the total score of life goals, the group that completed all the sessions showed a high tendency compared to the group that did not complete the sessions (F=4.071, p=0.057, η2=0.048). Subfactor analyses revealed that the between-group difference of extrinsic life goals was statistically significant (F=5.138, p=0.034, η2=0.044). In addition, intrinsic life goals showed that the GFSRP group had a tendency to be higher than the control group (F=3.307, p=0.083, η2=0.060).
This study aimed to develop the GFSRP as one of the psychosocial interventions for patients with AUD and identify its effects on alcohol control failure, life goals, abstinence self-efficacy, and optimism. The study results indicated that group difference in optimism was significant at post-test. In other words, balancing between “best possible self” and “worst possible self” [
In addition, the between-group difference in abstinence self-efficacy to negative affect was significant at post-test. A number of previous researches predicted that abstinence self-efficacy determines future alcohol consumption and is considered an important predictor for recovering from AUD [
Furthermore, the between-group difference of intrinsic life goals appeared consistently until follow-up; this is not because the life goal level of the GFSRP group increases linearly after pre-test, but because the life goal level of the control group after hospitalization tended to decrease gradually. This suggests that goal-focused self-regulation program is likely to have an effect in preventing the loss of goal that might occur after alcohol control failure. Especially, implementation intention training including action plan and alternative plan for achieving goals, rather than just setting an indefinite goal, is likely to maintain the orientation of life goals at follow-up.
Additionally, there was no difference in total score of life goals level between the group that completed the program and the group that could not complete the program at post-test. However, the group that completed the program had a higher interest in extrinsic life goals than did the other group. Further, the level of intrinsic life goals showed that the GFSRP group had a higher tendency compared to the control group. In other words, the group that completed the program showed a tendency for a varying goal range. In several previous researches, although extrinsic life goals had a negative impact on subjective well-being and were related to psychological dysfunction [
Contrary to expectations, however, the between-group difference in alcohol control failure as a behavioral measurement value after the completion of the program was not significant. Given that the initial drinking age of study participants was 18.52 years on average (SD=6.25), and most of them were patients who had experienced a relapse, there would be a limit in improving alcohol control failure directly because the program was a self-regulation program targeting AUD Type 2 [
This study has some limitations as follows. First, alcohol control failure could not be assessed accurately due to the study participants’ sudden discharge from the hospital and outpatient follow-up failure. Second, random assignment for both GFSRP group and the control group could not be performed. Third, the degree of participation in the existing hospital ward program could not be determined. Finally, this study was analyzed without an additional control group such as sham program or non-treatment condition. Considering these factors, the GFSRP may only be considered an empirically supported treatment, needing to replicate using more deliberate design.
Despite these limitations, this study has clinical implications as follows. First, previous researches [
Finally, we have some suggestions for future research. First, this study could not keep monitoring strictly over study participants when the GFSRP was conducted as part of the hospital ward program. Furthermore, the number of participants who completed the eight-session program was considerably low. Therefore, it seems necessary to select subjects who have a high motivation to participate in the program, implement the goal-focused self-regulation program in a short-term intensive way, and verify the effectiveness. Second, this study examined the alcohol control failure as a behavioral measurement value; however, it was difficult to evaluate this value accurately due to lack of follow-up. To identify the long-term effect of the program systematically, it seems necessary to examine the abstinence rate and actual behavioral change by applying the outpatient follow-up after discharge from the hospital into the study design process (e.g., using the experience sampling method). Finally, given that maximized functioning is emphasized in AUD rehabilitation and other various clinical settings, it is necessary to check if the short-term intensive program has an effect in improving function. In particular, given that the motivation for goal setting is low due to chronic alcohol control failure, it is necessary to add therapeutic interventions that can enhance the motivation to change before goal setting and implementation intention formation. As an alternative, it is necessary to develop a program that integrates individual sessions and small-scale group sessions for reinforcing motivation.
In contrast, goal setting, or the more relevant goal adherence, requires good executive control. Long term alcohol use impedes executive control (or, as some would argue, poor executive control precedes an AUD) [
Generally, life goals are formed in early adolescence and adulthood and are known to be as a rather stable variable that determines one’s life. However, the content of life goals depends on an individual’s age [
As the GFSRP is under development, the expectations of appreciable changes in patients with chronic AUD through short-term psychosocial interventions, which might be inadequate for affecting a behavioral change, may not be realistic. Nevertheless, numerous researchers and therapists’ efforts in developing psychosocial interventions, considering the characteristics of patients, and verifying their effectiveness are expected to be instrumental in life goal setting and implementation for patients with AUD.
The authors thank Min-Kyu Lee for his supervision of the development of this article.
Changes in intrinsic life goals from baseline to 12-week follow-up among patients with AUD. *p<0.05. GFSRP: Goal-Focused Self-Regulation Program, Goals-IN: Intrinsic life goals, Pre: pre-test, Post: post-test, 12 wk: 12-week follow-up.
Changes in alcohol abstinence self-efficacy to negative efficacy scores from baseline to 12-week follow-up among patients with AUD. **p<0.01. GFSRP: goal-focused self-regulation program, AASE: alcohol abstinence self-efficacy to negative affect, Pre: pre-test, Post: post-test, 12 wk: 12-week follow- up.
Changes in optimism from baseline to 12-week follow-up among patients with AUD. *p<0.05. GFSRP: Goal-Focused Self-Regulation Program, Pre: pre-test, Post: post-test, 12 wk: 12-week follow-up.
Demographic and clinical characteristics of subjects
Variables | M (SD) or frequency (%) |
t/χ2 | p | ||
---|---|---|---|---|---|
GFSRP (N=50) | Control (N=48) | Total (N=98) | |||
Age | 51.56 (7.94) | 49.77 (9.66) | 50.68 (8.82) | 1.004 | 0.32 |
Years of education | 12.20 (2.79) | 11.93 (2.88) | 12.08 (2.82) | 0.462 | 0.65 |
Marriage | 2.390 | 0.50 | |||
Married | 14 (31.1) | 13 (30.2) | 27 (30.7) | ||
Unmarried | 17 (37.8) | 13 (30.2) | 30 (34.1) | ||
Divorced | 11 (24.4) | 16 (37.2) | 27 (30.7) | ||
Bereaved | 3 (6.7) | 1 (2.3) | 4 (4.5) | ||
Religion | 2.342 | 0.13 | |||
Yes | 32 (69.6) | 21 (51.2) | 53 (60.9) | ||
No | 14 (30.4) | 20 (48.4) | 34 (39.1) | ||
Occupation | 0.000 | 1.00 | |||
Yes | 10 (22.7) | 8 (20.5) | 18 (21.7) | ||
No | 34 (77.3) | 31 (79.5) | 65 (78.3) | ||
Cigarette | 0.998 | 1.00 | |||
Current smoker | 41 (89.1) | 40 (87.0) | 81 (88.0) | ||
Ex-smoker | 5 (10.9) | 5 (10.9) | 10 (10.9) | ||
Non-smoker | 0 (0.0) | 1 (2.2) | 1 (1.1) | ||
ADS-K | 20.40 (9.92) | 24.33 (11.05) | 22.33 (10.62) | -1.856 | 0.07 |
Age of first alcohol drinking (years) | 18.52 (6.25) | 19.02 (8.19) | 18.77 (7.24) | -0.328 | 0.74 |
Number of admissions | 8.42 (8.12) | 7.52 (6.93) | 7.99 (7.54) | 0.553 | 0.58 |
Recent abstinence | 4.60 (8.93) | 4.00 (9.93) | 4.31 (9.38) | 0.313 | 0.76 |
Months of longest abstinence | 15.09 (16.07) | 11.87 (21.75) | 13.50 (19.05) | 0.796 | 0.43 |
Blackout | 2.930 | 0.24 | |||
No | 7 (14.0) | 2 (4.3) | 9 (9.3) | ||
Partial | 31 (62.0) | 30 (63.8) | 61 (62.9) | ||
Full | 12 (24.0) | 15 (31.9) | 27 (27.8) | ||
History of familial loading | 0.534 | 0.47 | |||
Yes | 10 (20.0) | 6 (12.5) | 16 (16.3) | ||
No | 40 (80.0) | 42 (87.5) | 82 (83.7) |
GFSRP: Goal-Focused Self-Regulation Program, ADS-K: Korean version of Alcohol Dependence Scale
Descriptive of all outcome measures by groups and Times
Variables | Pre-test |
Post-test |
12-week follow-up |
|||
---|---|---|---|---|---|---|
GFSRP (N=50) | Control (N=48) | GFSRP (N=24) | Control (N=16) | GFSRP (N=24) | Control (N=10) | |
Life goals | 108.12 (19.60) | 105.58 (23.49) | 108.92 (21.85) | 104.06 (18.60) | 108.96 (21.73) | 100.40 (21.61) |
Goals-EX | 48.63 (12.63) | 49.31 (13.23) | 48.75 (14.80) | 49.13 (10.18) | 48.67 (15.47) | 48.40 (10.90) |
Goals-IN | 59.49 (10.00) | 56.27 (11.61) | 60.17 (9.29) | 54.94 (10.62) | 60.29 (8.92) | 52.00 (12.07) |
AASE | 12.87 (3.83) | 11.52 (4.54) | 16.17 (4.47) | 12.38 (3.26) | 15.00 (4.64) | 12.73 (4.47) |
Optimism | 19.08 (3.75) | 18.82 (3.59) | 20.13 (3.40) | 17.56 (3.18) | 19.61 (4.00) | 17.91 (2.34) |
GFSRP: Goal-Focused Self-Regulation Program, Goals-EX: extrinsic life goals, Goals-IN: intrinsic life goals, AASE: alcohol abstinence self-efficacy to negative affect
Group differences of outcome measures by times
Variables | Time | Wilcoxon-Mann-Whitney U | Effect size |
---|---|---|---|
Goals-IN | Pre-test | 1,027.5 | 0.144 |
Post-test | 144.0 | 0.250 | |
12-week follow-up | 67.0 |
0.442 | |
AASE | Pre-test | 947.0 | 0.211 |
Post-test | 87.0 |
0.547 | |
12-week follow-up | 91.0 | 0.281 | |
Optimism | Pre-test | 1,120.0 | 0.067 |
Post-test | 102.5 |
0.466 | |
12-week follow-up | 93.5 | 0.221 |
p<0.05,
p<0.01.
Goals-IN: Intrinsic life goals, AASE: alcohol abstinence self-efficacy to negative affect