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 [1,2]. In addition, the estimated number of patients with AUD is almost 1.6 million individuals, and the one-year prevalence is 4.4% (6.6% in males, 2.1% in females), which is considerably higher than that for other mental disorders.

In Australia, the percentage of AUD patients receiving treatment is 22.4% [3], whereas it is no more than 6.6% in Korea. This emphasizes the need not only to intervene in AUD at a policy level and provide pharmacotherapy, but also to develop an effective way to intervene more systematically at the psychological level. The psychosocial intervention that is commonly applied to patients with AUD and proven to be effective includes the Twelve Steps of Alcoholics Anonymous, motivation-enhancement training, cognitive behavioral therapies, stress management, relapse prevention, and emotion regulation program [4,5]. However, these therapeutic methods may have different effects depending on the patient’s symptoms and level of motivation to change, therapeutic environment, and therapeutic aim (e.g., abstinence or moderation) [6].

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 [7,8]. Therefore, rehabilitation and maximized functioning in everyday life are important for patients with AUD. Nevertheless, they rely mainly on specialized treatment for AUD, which can control the cues for drinking, instead of adaptation training in everyday life, due to realistic limits. Moreover, most of the programs mentioned above are generally sobriety-centered interventions. Putting an emphasis on the short-term goal of sobriety, in absence of long-term life goals, can be a limitation to enhancement of the motivation to change.

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 [9,10]. However, life goal intervention is utilized for those who have a high functional level, largely in non-clinical aspects such as occupation, education, and sports [11].

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 [12,13], one of the self-regulation theories and 2) identify its effects on alcohol self-control failure, life goals, abstinence self-efficacy, and optimism in patients with AUD.

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) [14] and received specialized treatment for AUD were included. Those who revealed their interest in participation after publication of the advertisement, but 1) showed serious aggression and hostility because they were psychologically very unstable, 2) were illiterate, 3) could not fill in a self-report questionnaire due to issues such as visual impairment or head injury, or 4) were difficult to enroll in this program because their judgment was deteriorated or their decision-making was impaired, were excluded.

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.

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” [16], which is similar to mental contrasting [31,32], known as one of the self-control strategies, is considered to be helpful for enhancing positive thoughts for patients with AUD. Therefore, interventions that can enhance optimism in groups with low motivation for change in behavior, as is the case with AUD patients, will be helpful for avoiding the learned helplessness caused by recurring frustration. Furthermore, as goal setting relies on expectations for the future, it will contribute toward setting a realistic goal by encouraging patients with AUD to recognize, approach, or avoid goals [33]. This is because this approach helps patients with AUD not only imagine the best possible future but also consider the worst possible future. That is, patients with AUD whose average age is in their 50s would find it difficult to escape from the self-definition of “addict”, not only due to frustration in life goals but also relapse. Therefore, the self-balancing training may have potential a clinical significance in the future, in that it can have a positive impact on enhancing the motivation to change in patients with AUD.

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 [34,35]. It has been used as a dependent measurement value in verifying the effectiveness of diverse abstinence programs. In particular, given that difficulty in emotion regulation to negative affect (i.e., anger, frustration) tends to select immediate gratification instead of long-term goal-oriented behavior by causing weakened self-control [36], the between-group difference of abstinence self-efficacy to negative affect might have been positively influenced by implementation intention training, which intends to maintain abstinence even in emotional stress situations [37], indicating that contextualized self-efficacy enhancement would be effective for generalized change. Consistent with this, the fact that abstinence-centered implementation intention training for patients with AUD has enhanced the abstinence self-efficacy to negative affect suggests that we can expect the generalization of implementation intention for various goals including future emotional regulation and health management.

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 [38], they can be effective for reinforcing motivation in the initial stage of behavioral change [39]. In particular, the fact that extrinsic life goals are maintained or increased in groups with a very low motivation to change, as in the group with AUD, may bring further research. Consistent with this, the Self-Determination Theory [40] also states that autonomic motivation is consistent with the value of an act, and ideally, is a concept that includes internal motive and external motive that can be integrated with the sense of self. Therefore, the fact that extrinsic as well as intrinsic life goals are higher in the group that completed the goal-oriented program than in the group that did not, when the program was carried out in the patients with AUD who have a low motivation level, suggests that we can expect it to be helpful for future behavioral change and subjective well-being enhancement.

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 [41,42].

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 [43-45] revealed the relation between life goal and alcohol use, but programs that help in setting life goals and facilitate their implementation have not been developed yet in Korea; verification of effectiveness has also not been performed. This suggests preliminarily that the goal setting-based self-regulation program is applicable to severe psychological disorders like AUD. Second, as GFSRP helps to enhance optimism and abstinence self-efficacy and maintain intrinsic goals in patients with AUD, it can compensate for the limitation of interventions in mindfulness enhancement, which do not induce actual behavior change.

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) [46,47]. Therefore, it is necessary to consider cognitive rehabilitation training considering the patient’s cognitive profile prior to the target intervention [48,49].

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 [50]. Thus, it seems necessary to develop a small-scale group program by age and an approach to individual cases in order to enhance the effect of the goal-focused program for patients with AUD. Further, given that self-efficacy is most important in goal-focused self-regulation, consistent practice that is based on thorough preparation, i.e. repeated successful experience, will be helpful in enhancing self-efficacy in order to achieve long-term goals.

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.