Therapieprozess- und Ergebnisforschung in der Ambulanten Langzeit-Intensivtherapie für Alkoholkranke (ALITA)

Abstract

This thesis comprises two articles which investigate the mechanisms of action of the Outpatient Longterm Intensive Therapy for Alcoholics (OLITA).Article 1Context: Studies on supervised longterm administration of alcohol deterrents (AD) in comprehensive integrated outpatient alcoholism treatment are lacking.Objective: (1) To perform a 9-year study of abstinence, lapse, and relapse in 180 chronic alcoholic patients, participants of the Outpatient Longterm Intensive Therapy for Alcoholics (OLITA); (2) To investigate the role of supervised AD in relapse prevention and as an adjunct for maintenance of long-term abstinence.Method: This prospective open treatment study evaluates the long-term course of drinking outcomes and AD use of 180 chronic alcoholics consecutively admitted from 1993 to 2002. Subsamples are compared for (1) sham-AD versus verum-AD (disulfiram/calcium carbimide), (2) coped lapses versus finally detrimental lapses versus malignant relapses, and (3) AD use for 13 to 20 versus >20 months.Results: In this 9-year study, the cumulative probability of not having relapsed was 0.52, and that of not having consumed any alcohol was 0.26. Despite long-term use, disulfiram/calcium carbimide was well tolerated. Patients on sham-AD (due to contraindications to verum-AD) showed higher cumulative abstinence probability than patients on verum (S=0.86 vs. S=0.49, p=0.03). Detrimental lapses and malignant relapses occurred earlier than successfully coped lapses (p<0.001); patients with detrimental lapse and with malignant relapse had fewer days of AD intake and less subsequent days without AD than patients with coped lapse (p<0.001). The cumulative abstinence probability was S=0.75 for patients with long-term intake compared with S=0.50 for patients who stopped AD between months 13 and 20 (p<0.001).Conclusions: An abstinence rate of >50% in this 9-year study strongly supports the concept of comprehensive, long-term outpatient treatment of alcoholics. Supervised, guided intake of AD, also over extended periods, can be used as a predominantly psychologically acting ingredient of successful alcoholism therapy.Article 2Background: Research on addiction treatment lacks prospective longitudinal studies that analyze with observational instruments behavior of alcohol dependent patients during therapy sessions. With the "Video-Assisted Monitoring of Psychotherapeutic processes in chronic psychiatric disease (VAMP)" this study investigates 64 chronic alcohol dependent patients at three time-points, t1 (week 3), t2 (month 6), and t3 (month 12) during the first year of the Outpatient Longterm Intensive Therapy for Alcoholics (OLITA).Aims: Change of therapeutic processes between t1, t2, and t3, prediction of cumulative abstinence probability during a follow-up of up to 4 years, construction of the TOPPS (Therapy Orientation by Process Prediction Score).Methods: 175 video recordings of therapy sessions were analyzed with the VAMP. After each video recording, patients and therapists rated their experience of the therapeutic alliance. Change of therapeutic processes over time was tested with repeated measures ANOVA, and prediction of cumulative abstinence probability by therapy processes was determined with Cox Regression Analysis.Results: Most of the processes changed only marginally between t1, t2 and t3. The TOPPS predicts cumulative abstinence probability at all of the three time-points (p < 0.001) by integrating eight process variables with the highest predictive validity: Experience of ressources, abstinence self-efficacy, implicit craving, relapse alertness, relapse risk, disease concept, dysfunctional therapeutic engagement, dysfunctional problem solving of current problems. Patients who relapsed after 12 months showed continuously low TOPPS from t1 to t3. However, patients who maintained long-term abstinence had high TOPPS at t1 which increased slightly between t2 and t3 (p < 0.015).Conclusions: The eight TOPPS processes are determined from the current behavior of a patient during a specific therapy session and indicate to which extent his common behavior predicts probability of longterm abstinence or relapse risk. The results suggest to employ the TOPPS in addiction therapy as a guideline of individual relapse prevention strategies.