A case study of alcohol dependence syndrome with poor motivation and coping skills : a psychosocial perspective

This case study is an attempt to assess the impact of psychiatric social work intervention in person with alcohol dependence. Psychiatric social work intervention (brief intervention) was provided to the client focusing on building motivation for change and strengthening commitment to change. It uses a single subject design and compares preand post-intervention baseline data with that following intervention. Semi-structured clinical and socio-demographic data sheet, family assessment proforma, and readiness to change questionnaires were administered to the client. The brief psychiatric social work intervention was provided to the client and family members. The attempt has been to bring out changes in motivation level and to enhance coping skill. After brief psychiatric social work intervention, knowledge regarding the illness was enhanced. The client motivation level was enhanced, family members have better understanding about client’s illness, and interpersonal relationship has been improved.


Introduction
Alcoholism constitutes a vast syndrome of medical, economics, psychological, and social problems.Brief interventions for alcohol-related problems are time limited, structured, and directed toward a specific goal.Brief interventions can be used to change substance abuse behaviours and involve a variety of approaches, ranging from unstructured counselling and feedback to formal structured therapy.[1][2][3][4][5][6] Brief psychosocial interventions play an important role in determination of treatment outcomes in addiction [7][8][9][10].It has been shown to improve client compliance to medication and the retention of clients in treatment.It has also been shown to increase alcohol abstinence rates and enhance quality of life in persons with alcohol dependence.Psychiatric social work plays a key role in working with those affected by alcohol addiction -from client's psychosocial assessment and intervention to working with the family of the addicted person.Social workers are part of the multidisciplinary team; they are directly involved in psychosocial intervention/brief intervention and recovery of addictions.

Methodology
It uses a single subject design and compares pre-and postintervention baseline data with that following intervention.The attempt has been to bring out changes in motivation level.

1.
Semi-structured clinical and socio-demographic data sheet: A relevant sociodemographic and clinical detail was collected using this proforma.2. Family assessment proforma: The interview was done with this client based on the family assessment proforma by Bhatti and Mathew.[11] The family assessment proforma is based on the family structure, leadership patterns, role and functioning, communication, cohesiveness, and adaptive patterns.3. Readiness to Change Questionnaires (RCQ): The RCQ (treatment version) [12] is a 15-item self-report questionnaire that evaluates treatment-seeking individuals to three stages of change that is precontemplation, contemplation, and action stage of change.The RCQ (treatment version) is a 5-point Likert scale ranges from "strongly disagree" (−2) to "strongly agree" (+2).The internal consistency of scale range is between 0.60 (contemplation) and 0.70 (action).The scale's retest reliability ranges between 0.69 (contemplation) and 0.86 (action).

Case introduction
The index client was 42 years old, Hindu, married for 12 years from middle socioeconomic background, hailing from urban area of Kamrup district of Assam.The client was admitted in a hospital for alcohol-related problem.

Sources of information
The client himself, his mother, client's wife, and case record file were sources of information, which were reliable and adequate.

The reason for referral
The case was referred to the department of psychiatric social work for adequate psychosocial assessment and intervention.

Brief for clinical history
Index client Mr. BB was apparently well 15 years back.The client started drinking alcohol when he was 20 years old along with his friends at college.Initially, he was taking alcohol (30 ml) -two pegs, but then gradually his intake of alcohol had increased.In 2000, the pattern of alcohol intake was increased due to his job pressure.Mr. BB was involved in the private job.He started having decreased sleep and appetite, distress, irritability, and poor concentration.Due to the above reasons, he started drinking two to three large pegs (60 ml) daily at morning and evening, and he started giving excuses to his manager saying that he was not well.Since 2010 onward client's intake of alcohol had been increased (375 ml/day).Generally he used to take alcohol alone.Since the last three months, clients reported of decreased sleep, tremor, weakness, and restlessness.Due to the above reasons, the client came for treatment, diagnosed as F 10.2 (alcohol dependence syndrome) and was admitted in the hospital for further management.[13]

Family genogram
The client's family history (Figure 1): Client's father, 70 years old, worked as a government employee.Client's mother, she was 66 years old, homemaker.The client's second sibling was sister, 40 years old, married, and studied up to graduation.Third sibling was sister, 34 years old, married, and studied up to graduation.The relationship between client and family member was satisfactory earlier, currently they were having strained relationship due to client's alcoholic behaviour.The interaction patterns between client's parents were not adequate, client's father used to have argument and quarrel with his wife.The interaction between siblings was adequate toward client, they showed concerns and support toward the client, and they only worried about the client's alcoholic behaviour.

Family dynamic
Some level of close and rigid boundaries was evident among the subsystems.The nominal and functional of the family was client's father.Decision was reached with mutual consultation and informed to the family members.In family, each member was performing their role adequately except the client due to his illness.In communication pattern, both verbal and nonverbal communication was present in the family.Positive reinforcement was present in the family and the support system was satisfactory in nature.We feeling was not present in the family.Client's siblings came to help his family whenever the need ariose or at the time of crisis.Problem solving ability and coping strategy were found to be poor among the family.

Personal history
In personal history, the birth order of the client was the first among the three siblings.The client had a normal birth and development milestones were age appropriate and achieved normally.No major health problems were reported during the childhood.The client was an active child and there was no major behaviour problems in childhood.In educational history, the client started going to school at around four and half years of age.There were frequent changes in school, because of his father's nature of job.He was an average student, studied up to master in business administration.He had a healthy interaction with peer group.Frequent job changes were reported by the informants.The client married when he was 30 years old and spouse was 29 years at the time of marriage.She was staying with the client's family.In marital history, it was found that there was frequent quarrel, arguments, and conflict between the couple and marital satisfaction was not adequate because of client's alcoholic behaviour.Client's daughter was 11 years old, studying in sixth standard.The client was very much caring and loving toward his child.

Premorbid personality
Client was having well-adjusted premorbid personality.Table 1 shows the pre-and post-test of the clients; in pretest, it was found that motivation level was in precontemplation stage (score −8).After psychiatric social work intervention, post-test was done after one month of intervention and RCQ score suggested that motivation of client to quit alcohol had been enhanced.The client was found in the action phase (score +8).

Psychiatric social work intervention
For this case study, psychiatric social work intervention means brief intervention (psychoeducation, motivation enhancement therapy [MET], relapse prevention therapy, coping skills, supportive case work, admission counselling, and pre-discharge counselling) provided to the client and family members.The total number of sessions conducted was 14.

Rapport establishment
Rapport establishment aims to maintain a good relationship with the client, and to assess the level of cooperation and participation of the client.During the discussion, the client was informed about the importance of therapy and benefit he would gain.Repeated reassurance and positive attitude toward the client made the session successful.The client was able to open up in the initial session itself; he expressed and shared about his drinking problem.

Family assessment and intervention
The family assessment was done with the client's wife to address the psychosocial issues of the family and also to investigate the level of knowledge regarding mental illness due to prolong period of alcohol abuse by the client.On family assessment, it was found that due to client's alcoholic behaviour wife had reported depressive and anxiety symptoms, codependency was present, crying spells, and poor interpersonal relationship with client.In marital assessment, it was found that there was frequent quarrel and arguments between them.Supportive intervention was provided to the wife.Coping skill was taught to the client's wife.The therapist provided psychoeducation to the family members so that there was a better understanding toward the client's illness.

MET
MET evokes change in individuals.It is a systematic approach and is based on motivational psychology.MET is considered to produce change through mobilising the person's internal resources.Thus, the intervention is brief and used during the client's first contact although repeating it during subsequent sessions may prove helpful.It is particularly useful when contact with the client is limited to one or few sessions.The treatment outcome research supports MET as effective in producing change in problem drinkers.[14][15][16][17][18] The model for stages of behavioural change developed by Prochaska and DiClemente [19] can be utilised in understanding how people change their behaviour and in assessing the individual's readiness to change a particular behaviour.The model includes the following stages of change: precontemplation, contemplation, determination/preparation, action, and maintenance.
The index client was exposed to motivation enhancement and relapse prevention therapy.A baseline assessment on understanding the drinking pattern, abstinence period, locus of control, coping pattern, internal relationship problems, and client's attitude toward drinking was done.Throughout the MET sessions, the therapist recognised the client's individual efforts, appreciated his strengths, and feedbacks were provided.Further, in MET the client was provided warmth, advice, empowerment, and support.

Craving management skill
Craving management skills were taught to the client."5 Ds", i.e.Delay, Deep breathing, Distraction, Drinking water, and Discussion was taught to the client to deal with the craving.

Coping skills
Coping skills' training was provided to the client with objectives to teach how to avoid high-risk situations, to recognise urge "triggers", and handling stressor.

Social group work interactive sessions
A group is a collection of individuals with similar problems.Group work intervention helps them to discuss and share their experiences with one another, and through this process, learns skills of coping, decision making, and problem solving.The goal of the group work was as follows: • Accepting the fact that alcohol is a problem The number of members in the group was eight with two psychiatric social work trainees.Each session for 45 minutes once in a week.The client's level of awareness was increased, and he got insight regarding his problem of drinking.

Predischarge counselling
A brief psychoeducation was given to the client regarding mental illness and negative effects of alcohol.The following areas were discussed: • The nature of mental illness • The need of regular medication • The harmful effects of alcohol • The importance of getting involved in productive work • Dealing with stigma • Follow-up.

Discharge counselling with client and family
Client and his wife attended the session.The session focused on the illness and treatment modalities, importance of regularity of medication, importance of regular follow-up, family involvement in treatment, importance of work engagement, adopting healthy lifestyle, and importance of family support.

Follow-up session
After the discharge, the client came for follow-up.Feedback was taken from the client and his wife.It was found that client was maintaining well and was following the instruction and advice provided to him in dealing with his alcoholic behaviour.

Discussion
In this case study it was found that after psychiatric social work intervention, there was difference in pre-and post-testscores in RCQ.In a study, Borah and Ali [20] based on psychiatric social work assessment and intervention to the person with alcohol dependence syndrome, focused on building motivation for change and strengthening commitment to change.They found that after the end of the therapy, the client developed better knowledge regarding the illness, motivation level was enhanced to action phase, and coping skills were enhanced to recover from relapse.[20] Brief psychosocial assessment and intervention have shown to be efficacious in treatment and also improving psychosocial functioning in individual with alcohol abuse and dependence.[21][22][23][24][25][26][27][28][29][30] A brief psychosocial intervention along with pharmacological treatment is necessary in the management of alcohol dependence to bring back to normal life.In the case study, it was found that client motivation level was enhanced and coping skills to deal with the problems were improved; further it was found that interpersonal relationship had been improved.

•
Z 56 -Problems related to employment and unemployment • Z 71 -Alcohol use • Z 72.3 -Lack of physical exercise • Z 72.4 -Inappropriate diet and eating habits • Z 73.3 -Stress, not elsewhere classified.

Figure 1 :
Figure 1: Family genogram Psychiatric social work interventions for the treatment of alcohol and drug problems cover a diverse array of treatment interventions.These interventions generally focus on the individual (their beliefs, feelings, and behaviour), their social context, including family and community.

Table 1 :
Pre and post-test in RCQ RCQ: Readiness to Change Questionnaires