- Email: [email protected]
First report of a psychosocial intervention for patients with alcohol-related liver disease undergoing liver transplantation
SHORT REPORT
First Report of a Psychosocial Intervention for Patients With Alcohol-Related Liver Disease Undergoing Liver Transplantation George Georgiou,* Kerry Webb,† Karen Griggs,† Alex Copello,* James Neuberger,† and Ed Day* Performing transplantations in patients with alcoholic liver disease raises great concerns for both clinicians and lay people, not least because of the fear that relapse back to drinking after the procedure may lead to poor outcomes. Therefore it is important to develop and evaluate new strategies for assessing and supporting such patients. A program of psychosocial intervention was developed to assist patients undergoing transplantation for alcoholic liver disease in coping with their alcohol problems. We describe a feasibility study of its implementation in a group of 20 such patients. This report shows that it is feasible to deliver a time-limited psychological intervention to patients undergoing assessment for liver transplantation. The intervention was readily integrated into the usual transplantation process and was acceptable to both patients and staff. Further research is required to clarify its impact on longer-term outcome measures. (Liver Transpl 2003;9:772-775.)
A
lcohol is currently the most common cause of liver disease in the United Kingdom, and increasing numbers of patients with alcohol-related end-stage cirrhosis are being assessed for transplantation. However, transplantation in patients with alcoholic liver disease has provoked concern among health professionals and lay people,1 and there are fears that a return to alcohol misuse will lead to noncompliance with treatment and so to a poor outcome.2 A number of strategies have been adopted to identify those at risk of relapse and to develop appropriate support structures to minimize this risk. With this in mind, a program of psychosocial intervention was developed at the Birmingham Liver Transplant Unit to assist patients undergoing transplantation From the *Addictive Behaviours Centre, Birmingham, England and †The Liver Unit, Queen Elizabeth Hospital, Birmingham, England. Address reprint requests to Dr Ed Day, Addictive Behaviours Centre, 120-122 Corporation Street, Birmingham, England, B4 6SX. Telephone: 00-121-685-6180; FAX: 00-121-685-6182; E-mail: [email protected] Copyright © 2003 by the American Association for the Study of Liver Diseases 1527-6465/03/0907-0020$30.00/0 doi:10.1053/jlts.2003.50152
772
for alcoholic liver disease in coping with their alcohol problems. This article describes a pilot study conducted with 20 patients over a 2-year period. It aims to consider the feasibility of delivering such an intervention to this group of patients. The unit places great importance on multidisciplinary teamwork, and this project was conducted by an alcohol liaison team consisting of a full-time psychiatric nurse and social worker in addition to regular input from a specialist consultant in addiction psychiatry.
Methods During the period of study (between January 1998 and December 1999), the Unit required all patients with nonfulminant cases of alcoholic liver disease suitable for transplantation to undertake a full multidisciplinary assessment. This occurred during an inpatient stay of approximately 1 week, and during this period the alcohol liaison nurse and the psychiatrist took a detailed alcohol and drug history. Patients and their family or friends were then offered a three-session brief psychosocial intervention with the liaison nurse and the unit social worker. The patients were free to decline, and there were no negative consequences to refusal. The intervention was based on social behavior and network therapy (SBNT),3 a treatment currently under evaluation in the National Alcohol Treatment Trial in the UK.4 The key concept underlying the intervention is the development of positive social support for change for people attempting to modify drinking behavior. This is done by involving supportive members of the patient’s social network in the treatment sessions. An important precondition for assessment for liver transplantation was the identification of a person who was willing to act as a source of support both before and after the operation. This could be a partner, sibling, parent, son, or daughter, and this person was also involved in the sessions. SBNT was adapted for the package applied in the liver unit and consisted of three sessions with the patient and network member(s) focusing on identification of social support, communication, planning of alternative activities to drinking, and relapse management. All patients undergoing assessment for transplantation for alcoholic liver disease (ALD) were offered the full treatment package, and the first 20 to accept were considered in the pilot study. There has been much debate about the need for a mini-
Liver Transplantation, Vol 9, No 7 ( July), 2003: pp 772-775
Psychosocial Intervention for ALD
mum period of abstinence from alcohol before offering a patient a liver transplant.5,6 The Liver Unit in Birmingham has adopted the policy that patients considered for transplantation should be abstinent since being advised to do so, with no fixed predetermined period of abstinence. The 20 patients included in this pilot study had been abstinent for a mean of 29.7 months (range 6 to 96) before the start of the intervention. After the initial assessment, three sessions were conducted in an outpatient setting, each lasting approximately 1 hour. In addition, the patient was allocated homework tasks to complete after sessions one and two. Intervals between the sessions varied from 2 to 4 weeks, depending on the wishes of the family. After the third session, a contract showing a commitment to abstinence from alcohol posttransplantation was agreed by all parties and signed by the patient. The alcohol liaison nurse and social worker then followed up the patient and the supportive family member(s) regularly pretransplantation and at 6 months posttransplantation. Alcohol consumption pretransplantation and posttransplantation was determined by interview and by random blood alcohol level. Any degree of alcohol consumption was noted (as detailed below), but relapse was defined as persistent use of alcohol after transplantation. The alcohol liaison nurse continued subsequent follow-up and support with the individual and the family.
773
Session 2: Enhancing Social Support and Increasing Pleasant Activities The second meeting focused on the various factors that influence a supportive relationship, including active listening and feedback. The homework on social support was reviewed, and this led to a consideration of practical strategies such as listing pleasant activities and setting specific times for each person in the network to have as pleasant activity time. Other ways of building supportive relationships were also discussed. The homework on pleasurable activities was used as a base from which the patient and their supportive network could develop a posttransplantation plan to occupy their time without alcohol. The patient and network member(s) were encouraged to discuss things together as well as completing tasks separately. Potential obstacles to the activity plan and solutions to overcome them were highlighted. Similarly, the homework on desirable changes was used to develop a discussion about the patient’s main motivations for getting well and avoiding alcohol. Homework from the second session comprised relapse management work. The network member was asked to consider how they would cope if the patient started drinking again, and the patient was asked to write down the factors motivating them to remain abstinent and to identify situations in which they might feel vulnerable to relapse.
Session 3: Planning for the Future Session 1: Introduction, Education, and Review of Social Support Network The first session introduced the purpose, format, and content of the therapy. Basic information about alcohol-related liver disease was presented, and abstinence was clearly identified as the desired goal. The patient and network member were then asked to consider whether the patient had had a problem with their drinking in the past. A motivational interviewing style was used throughout the sessions to promote self-efficacy and better understanding in a nonthreatening fashion.7 This approach lends itself to feedback of factual information about the individual’s health, developing expression of concern about the patient’s drinking and formulating plans for change, and was adopted in combination with the social components of the intervention already described. A network map depicting both supportive and unsupportive relationships, including those that encouraged continued drinking, was developed, and the patient was asked to consider how the relationships identified had been affected by their drinking in the past. The first session ended with an explanation of the homework task to be completed before the next meeting. The patient and network member(s) were asked to consider activities that they used to enjoy and others that they were looking forward to doing after the transplantation. In addition, they were asked to think of individuals who would be able to provide particular types of support, and detail how this might be arranged, e.g., help with solving problems, moral support, information, or emergencies.
The work conducted up to this stage had provided the patient with a good understanding of potential high-risk situations for drinking. Both the patient and the network member(s) were asked to complete a written plan outlining how they might go about avoiding relapse. This included a description from the network member(s) of how they coped with the patient’s drinking in the past and how they planned to deal with a possible relapse after the transplantation. This session summarized the previous work and helped both the patient and the network member(s) in formulating working plans for the future. The session ended with the patient and network member(s) signing a commitment to achieve their goal of continuing abstinence and organizing future follow up.
Results Between 1998 and 1999, 32 patients with alcoholic liver disease underwent transplantation at the Birmingham Liver Transplant Unit. Five of the patients and/or their families declined the brief intervention therapy. Three of the other 7 patients not included in this pilot study were assessed before its initiation, and 4 at times when the liaison team was not available. Cohort size was decided by the limitation of time. The details of the 20 patients included in the pilot are summarized in Table 1. We have no data to suggest that the 5 patients who refused the intervention were less motivated to remain abstinent or were a higher-risk
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Georgiou et al
Table 1. Summary of the 20 Cases Included in the Study Patient Number
Age (yr)
Liver Diagnosis
Alcohol Diagnosis
Dependence on Illicit Drugs
Period of Abstinence (mo)
Alcohol Consumption at 6 mo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
36 64 48 47 53 46 51 61 52 59 36 48 52 41 46 50 48 40 61 40
ALD ALD ALD ALD ALD ALD ALD ALD/HCC ALD ALD ALD/HEP C ALD ALD ALD ALD ALD/HEP C ALD ALD ALD ALD
HU HU DEP DEP HU DEP HU HU DEP HU DEP HU DEP DEP DEP DEP DEP DEP HU DEP
No No No Yes No No No No Yes No No No No No No No Yes No No No
84 96 15 48 14 24 24 30 18 18 12 16 18 6 28 36 22 6 28 48
Nil Nil ⬎21 units per week Nil Nil Nil Nil 4 units once Nil Nil 1-2 units per week 4 units per week Nil 1-2 units per month Nil Died 5 mo postoperatively 1 unit once 15 units per week 1 unit once Nil
Abbreviations: mo, months; DEP, alcohol dependence (according to ICD-10 diagnostic criteria10); HU, harmful use of alcohol; ALD, alcoholic liver disease; HEP C, hepatitis C; HCC, hepatocellular carcinoma.
group. One patient with lymphoma died 5 months after transplantation, but 17 of the remaining 19 completed all three therapy sessions and the homework tasks. Eight of the 19 (42%) patients drank alcohol at some time posttransplantation; 4 (21%) drank weekly, and 1 (5%) at levels of 21 units per week or more. All patients who drank posttransplantation were engaged in intensive support and treatment to address potential or actual relapse. Beliefs about safe levels of drinking posttransplantation were also addressed.
Discussion This feasibility study showed that it is possible to deliver a time-limited psychological intervention to patients undergoing assessment for liver transplantation. The goal of the therapy was to provide support and guidance to the patients and their closest family member(s), and to help them prevent a relapse to previous drinking patterns after the transplantation. The patients and their network support members made a variety of comments about the treatment when responding to a questionnaire administered during the follow-up period that encouraged them to express their feelings about the treatment. Some said that they had
felt stigmatized at their local hospital but had found the sessions less judgmental and more constructive in addressing their concerns. Partners often stated that they were able to talk about their experiences more openly in a neutral setting. A commonly stated opinion by the families was that they appreciated the opportunity to express the degree of change that had occurred in their lives since the patient had become abstinent. A small proportion of the patients, despite having agreed to the treatment, approached the sessions with skepticism, annoyance, and sometimes hostility, mainly because they did not think that alcohol had been a major issue in their illness. It is worth stating, however, that almost without exception the patients completed the three sessions. One such patient, having completed the network maps, homework, and planning to avoid drinking, when asked about things in his life that he would like to change, answered “I wish I had never started drinking,” thus acknowledging for the first time the extent that alcohol had contributed to his liver disease. A number of important questions therefore remain. In accordance with other research in the addiction treatment field, there seems to be a need to match the
Psychosocial Intervention for ALD
appropriate intervention to the individual patient history. The emphasis of the sessions needed to vary according to the length of abstinence, the extent of changes already made in the person’s life, and the psychiatrist’s view about vulnerability to relapse. Factors influencing this included how intact the patient’s supportive network seemed, the patient’s attitude toward reducing risk of relapse in the future, engagement in a rehabilitative relationship, and whether the patient was adjudged to have been alcohol dependent. It remains to be seen whether these individuals have a poorer outcome at long-term follow-up, as is suggested by other research.8 The 6-month outcomes of the group are shown in Table 1 and seem to be similar to those of another follow-up study from our unit.9 Overall we believe we achieved our goal of showing that it is possible to deliver a motivational-style network-based brief intervention therapy with a high level of acceptance in this group of vulnerable patients. It is not possible to come to any clear conclusions regarding the efficacy of such an approach from this limited uncontrolled pilot study, but we believe that results are encouraging. Ultimately a randomized trial of the intervention will be needed to judge whether the goal of preventing a return to problem drinking is possible and to elucidate the most effective elements of the treatment package. We are also not certain whether factors such as the length of abstinence posttransplantation has a bearing on success or is irrelevant, and whether refresher
775
sessions posttransplantation would be a useful addition to the intervention.
References 1. Neuberger J, Adams D, MacMaster P, Maidment A, Speed M. Assessing priorities for allocation of donor liver grafts: Survey of public and clinicians. Br Med J 1998;317:172-175. 2. Howard L, Fahy T. Liver transplantation for alcoholic liver disease. Br J Psychiatry 1997;171:497-500. 3. Copello A, Orford J, Hodgson R, Tober G, Barrett C on behalf of the UKATT Research Team. Social behaviour and network therapy—Basic principles and early experiences. Addict Behav 2002;27:345-366. 4. The UKATT Research Team. United Kingdom Alcohol Treatment Trial (UKATT): Hypotheses, design and methods. Alcohol Alcoholism 2001;36:11-21. 5. Bird GLA, O’Grady JG, Harvey FAH, Caine RY, Williams R. Liver transplantation in patients with alcoholic cirrhosis: Selection criteria and rates of survival and relapse. Br Med J 1990;301:15-17. 6. Tringali RA, Trzepacz PT, DiMartini A, Dew MA. Assessment and follow-up of alcohol-dependent liver transplantation patients. A clinical cohort. Gen Hosp Psychiatry 1996; 18(suppl):70S-77S 7. Rollnick S, Heather N, Bell A. Negotiating behaviour change in medical settings: The development of brief motivational interviewing. J Mental Health 1992;1:25-37 8. Beresford TP. Predictive factors for alcoholic relapse in the selection of alcohol-dependent persons for hepatic transplant. Liver Transpl Surg 1997;3:280-291. 9. Tang H, Boulton R, Gunson B, Hubscher S, Neuberger J. Patterns of alcohol consumption after liver transplantation. Gut 1998;43:140-145. 10. World Health Organisation. The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO, 1992.
First Report of a Psychosocial Intervention for Patients With Alcohol-Related Liver Disease Undergoing Liver Transplantation George Georgiou,* Kerry Webb,† Karen Griggs,† Alex Copello,* James Neuberger,† and Ed Day* Performing transplantations in patients with alcoholic liver disease raises great concerns for both clinicians and lay people, not least because of the fear that relapse back to drinking after the procedure may lead to poor outcomes. Therefore it is important to develop and evaluate new strategies for assessing and supporting such patients. A program of psychosocial intervention was developed to assist patients undergoing transplantation for alcoholic liver disease in coping with their alcohol problems. We describe a feasibility study of its implementation in a group of 20 such patients. This report shows that it is feasible to deliver a time-limited psychological intervention to patients undergoing assessment for liver transplantation. The intervention was readily integrated into the usual transplantation process and was acceptable to both patients and staff. Further research is required to clarify its impact on longer-term outcome measures. (Liver Transpl 2003;9:772-775.)
A
lcohol is currently the most common cause of liver disease in the United Kingdom, and increasing numbers of patients with alcohol-related end-stage cirrhosis are being assessed for transplantation. However, transplantation in patients with alcoholic liver disease has provoked concern among health professionals and lay people,1 and there are fears that a return to alcohol misuse will lead to noncompliance with treatment and so to a poor outcome.2 A number of strategies have been adopted to identify those at risk of relapse and to develop appropriate support structures to minimize this risk. With this in mind, a program of psychosocial intervention was developed at the Birmingham Liver Transplant Unit to assist patients undergoing transplantation From the *Addictive Behaviours Centre, Birmingham, England and †The Liver Unit, Queen Elizabeth Hospital, Birmingham, England. Address reprint requests to Dr Ed Day, Addictive Behaviours Centre, 120-122 Corporation Street, Birmingham, England, B4 6SX. Telephone: 00-121-685-6180; FAX: 00-121-685-6182; E-mail: [email protected] Copyright © 2003 by the American Association for the Study of Liver Diseases 1527-6465/03/0907-0020$30.00/0 doi:10.1053/jlts.2003.50152
772
for alcoholic liver disease in coping with their alcohol problems. This article describes a pilot study conducted with 20 patients over a 2-year period. It aims to consider the feasibility of delivering such an intervention to this group of patients. The unit places great importance on multidisciplinary teamwork, and this project was conducted by an alcohol liaison team consisting of a full-time psychiatric nurse and social worker in addition to regular input from a specialist consultant in addiction psychiatry.
Methods During the period of study (between January 1998 and December 1999), the Unit required all patients with nonfulminant cases of alcoholic liver disease suitable for transplantation to undertake a full multidisciplinary assessment. This occurred during an inpatient stay of approximately 1 week, and during this period the alcohol liaison nurse and the psychiatrist took a detailed alcohol and drug history. Patients and their family or friends were then offered a three-session brief psychosocial intervention with the liaison nurse and the unit social worker. The patients were free to decline, and there were no negative consequences to refusal. The intervention was based on social behavior and network therapy (SBNT),3 a treatment currently under evaluation in the National Alcohol Treatment Trial in the UK.4 The key concept underlying the intervention is the development of positive social support for change for people attempting to modify drinking behavior. This is done by involving supportive members of the patient’s social network in the treatment sessions. An important precondition for assessment for liver transplantation was the identification of a person who was willing to act as a source of support both before and after the operation. This could be a partner, sibling, parent, son, or daughter, and this person was also involved in the sessions. SBNT was adapted for the package applied in the liver unit and consisted of three sessions with the patient and network member(s) focusing on identification of social support, communication, planning of alternative activities to drinking, and relapse management. All patients undergoing assessment for transplantation for alcoholic liver disease (ALD) were offered the full treatment package, and the first 20 to accept were considered in the pilot study. There has been much debate about the need for a mini-
Liver Transplantation, Vol 9, No 7 ( July), 2003: pp 772-775
Psychosocial Intervention for ALD
mum period of abstinence from alcohol before offering a patient a liver transplant.5,6 The Liver Unit in Birmingham has adopted the policy that patients considered for transplantation should be abstinent since being advised to do so, with no fixed predetermined period of abstinence. The 20 patients included in this pilot study had been abstinent for a mean of 29.7 months (range 6 to 96) before the start of the intervention. After the initial assessment, three sessions were conducted in an outpatient setting, each lasting approximately 1 hour. In addition, the patient was allocated homework tasks to complete after sessions one and two. Intervals between the sessions varied from 2 to 4 weeks, depending on the wishes of the family. After the third session, a contract showing a commitment to abstinence from alcohol posttransplantation was agreed by all parties and signed by the patient. The alcohol liaison nurse and social worker then followed up the patient and the supportive family member(s) regularly pretransplantation and at 6 months posttransplantation. Alcohol consumption pretransplantation and posttransplantation was determined by interview and by random blood alcohol level. Any degree of alcohol consumption was noted (as detailed below), but relapse was defined as persistent use of alcohol after transplantation. The alcohol liaison nurse continued subsequent follow-up and support with the individual and the family.
773
Session 2: Enhancing Social Support and Increasing Pleasant Activities The second meeting focused on the various factors that influence a supportive relationship, including active listening and feedback. The homework on social support was reviewed, and this led to a consideration of practical strategies such as listing pleasant activities and setting specific times for each person in the network to have as pleasant activity time. Other ways of building supportive relationships were also discussed. The homework on pleasurable activities was used as a base from which the patient and their supportive network could develop a posttransplantation plan to occupy their time without alcohol. The patient and network member(s) were encouraged to discuss things together as well as completing tasks separately. Potential obstacles to the activity plan and solutions to overcome them were highlighted. Similarly, the homework on desirable changes was used to develop a discussion about the patient’s main motivations for getting well and avoiding alcohol. Homework from the second session comprised relapse management work. The network member was asked to consider how they would cope if the patient started drinking again, and the patient was asked to write down the factors motivating them to remain abstinent and to identify situations in which they might feel vulnerable to relapse.
Session 3: Planning for the Future Session 1: Introduction, Education, and Review of Social Support Network The first session introduced the purpose, format, and content of the therapy. Basic information about alcohol-related liver disease was presented, and abstinence was clearly identified as the desired goal. The patient and network member were then asked to consider whether the patient had had a problem with their drinking in the past. A motivational interviewing style was used throughout the sessions to promote self-efficacy and better understanding in a nonthreatening fashion.7 This approach lends itself to feedback of factual information about the individual’s health, developing expression of concern about the patient’s drinking and formulating plans for change, and was adopted in combination with the social components of the intervention already described. A network map depicting both supportive and unsupportive relationships, including those that encouraged continued drinking, was developed, and the patient was asked to consider how the relationships identified had been affected by their drinking in the past. The first session ended with an explanation of the homework task to be completed before the next meeting. The patient and network member(s) were asked to consider activities that they used to enjoy and others that they were looking forward to doing after the transplantation. In addition, they were asked to think of individuals who would be able to provide particular types of support, and detail how this might be arranged, e.g., help with solving problems, moral support, information, or emergencies.
The work conducted up to this stage had provided the patient with a good understanding of potential high-risk situations for drinking. Both the patient and the network member(s) were asked to complete a written plan outlining how they might go about avoiding relapse. This included a description from the network member(s) of how they coped with the patient’s drinking in the past and how they planned to deal with a possible relapse after the transplantation. This session summarized the previous work and helped both the patient and the network member(s) in formulating working plans for the future. The session ended with the patient and network member(s) signing a commitment to achieve their goal of continuing abstinence and organizing future follow up.
Results Between 1998 and 1999, 32 patients with alcoholic liver disease underwent transplantation at the Birmingham Liver Transplant Unit. Five of the patients and/or their families declined the brief intervention therapy. Three of the other 7 patients not included in this pilot study were assessed before its initiation, and 4 at times when the liaison team was not available. Cohort size was decided by the limitation of time. The details of the 20 patients included in the pilot are summarized in Table 1. We have no data to suggest that the 5 patients who refused the intervention were less motivated to remain abstinent or were a higher-risk
774
Georgiou et al
Table 1. Summary of the 20 Cases Included in the Study Patient Number
Age (yr)
Liver Diagnosis
Alcohol Diagnosis
Dependence on Illicit Drugs
Period of Abstinence (mo)
Alcohol Consumption at 6 mo
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
36 64 48 47 53 46 51 61 52 59 36 48 52 41 46 50 48 40 61 40
ALD ALD ALD ALD ALD ALD ALD ALD/HCC ALD ALD ALD/HEP C ALD ALD ALD ALD ALD/HEP C ALD ALD ALD ALD
HU HU DEP DEP HU DEP HU HU DEP HU DEP HU DEP DEP DEP DEP DEP DEP HU DEP
No No No Yes No No No No Yes No No No No No No No Yes No No No
84 96 15 48 14 24 24 30 18 18 12 16 18 6 28 36 22 6 28 48
Nil Nil ⬎21 units per week Nil Nil Nil Nil 4 units once Nil Nil 1-2 units per week 4 units per week Nil 1-2 units per month Nil Died 5 mo postoperatively 1 unit once 15 units per week 1 unit once Nil
Abbreviations: mo, months; DEP, alcohol dependence (according to ICD-10 diagnostic criteria10); HU, harmful use of alcohol; ALD, alcoholic liver disease; HEP C, hepatitis C; HCC, hepatocellular carcinoma.
group. One patient with lymphoma died 5 months after transplantation, but 17 of the remaining 19 completed all three therapy sessions and the homework tasks. Eight of the 19 (42%) patients drank alcohol at some time posttransplantation; 4 (21%) drank weekly, and 1 (5%) at levels of 21 units per week or more. All patients who drank posttransplantation were engaged in intensive support and treatment to address potential or actual relapse. Beliefs about safe levels of drinking posttransplantation were also addressed.
Discussion This feasibility study showed that it is possible to deliver a time-limited psychological intervention to patients undergoing assessment for liver transplantation. The goal of the therapy was to provide support and guidance to the patients and their closest family member(s), and to help them prevent a relapse to previous drinking patterns after the transplantation. The patients and their network support members made a variety of comments about the treatment when responding to a questionnaire administered during the follow-up period that encouraged them to express their feelings about the treatment. Some said that they had
felt stigmatized at their local hospital but had found the sessions less judgmental and more constructive in addressing their concerns. Partners often stated that they were able to talk about their experiences more openly in a neutral setting. A commonly stated opinion by the families was that they appreciated the opportunity to express the degree of change that had occurred in their lives since the patient had become abstinent. A small proportion of the patients, despite having agreed to the treatment, approached the sessions with skepticism, annoyance, and sometimes hostility, mainly because they did not think that alcohol had been a major issue in their illness. It is worth stating, however, that almost without exception the patients completed the three sessions. One such patient, having completed the network maps, homework, and planning to avoid drinking, when asked about things in his life that he would like to change, answered “I wish I had never started drinking,” thus acknowledging for the first time the extent that alcohol had contributed to his liver disease. A number of important questions therefore remain. In accordance with other research in the addiction treatment field, there seems to be a need to match the
Psychosocial Intervention for ALD
appropriate intervention to the individual patient history. The emphasis of the sessions needed to vary according to the length of abstinence, the extent of changes already made in the person’s life, and the psychiatrist’s view about vulnerability to relapse. Factors influencing this included how intact the patient’s supportive network seemed, the patient’s attitude toward reducing risk of relapse in the future, engagement in a rehabilitative relationship, and whether the patient was adjudged to have been alcohol dependent. It remains to be seen whether these individuals have a poorer outcome at long-term follow-up, as is suggested by other research.8 The 6-month outcomes of the group are shown in Table 1 and seem to be similar to those of another follow-up study from our unit.9 Overall we believe we achieved our goal of showing that it is possible to deliver a motivational-style network-based brief intervention therapy with a high level of acceptance in this group of vulnerable patients. It is not possible to come to any clear conclusions regarding the efficacy of such an approach from this limited uncontrolled pilot study, but we believe that results are encouraging. Ultimately a randomized trial of the intervention will be needed to judge whether the goal of preventing a return to problem drinking is possible and to elucidate the most effective elements of the treatment package. We are also not certain whether factors such as the length of abstinence posttransplantation has a bearing on success or is irrelevant, and whether refresher
775
sessions posttransplantation would be a useful addition to the intervention.
References 1. Neuberger J, Adams D, MacMaster P, Maidment A, Speed M. Assessing priorities for allocation of donor liver grafts: Survey of public and clinicians. Br Med J 1998;317:172-175. 2. Howard L, Fahy T. Liver transplantation for alcoholic liver disease. Br J Psychiatry 1997;171:497-500. 3. Copello A, Orford J, Hodgson R, Tober G, Barrett C on behalf of the UKATT Research Team. Social behaviour and network therapy—Basic principles and early experiences. Addict Behav 2002;27:345-366. 4. The UKATT Research Team. United Kingdom Alcohol Treatment Trial (UKATT): Hypotheses, design and methods. Alcohol Alcoholism 2001;36:11-21. 5. Bird GLA, O’Grady JG, Harvey FAH, Caine RY, Williams R. Liver transplantation in patients with alcoholic cirrhosis: Selection criteria and rates of survival and relapse. Br Med J 1990;301:15-17. 6. Tringali RA, Trzepacz PT, DiMartini A, Dew MA. Assessment and follow-up of alcohol-dependent liver transplantation patients. A clinical cohort. Gen Hosp Psychiatry 1996; 18(suppl):70S-77S 7. Rollnick S, Heather N, Bell A. Negotiating behaviour change in medical settings: The development of brief motivational interviewing. J Mental Health 1992;1:25-37 8. Beresford TP. Predictive factors for alcoholic relapse in the selection of alcohol-dependent persons for hepatic transplant. Liver Transpl Surg 1997;3:280-291. 9. Tang H, Boulton R, Gunson B, Hubscher S, Neuberger J. Patterns of alcohol consumption after liver transplantation. Gut 1998;43:140-145. 10. World Health Organisation. The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO, 1992.