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      La Terapia Centrada en Soluciones: Una opción de tratamiento para la dependencia al alcohol Translated title: Solution-focused therapy: An alcohol dependence treatment option

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          Abstract

          En México, el consumo excesivo de alcohol representa uno de los principales retos de salud pública a escala nacional. Aunque existen diversas estrategias de intervención que pretenden incidir en este problema también hay un gran vacío con respecto a si dichas intervenciones son un factor causal en el cambio producido por el consumidor y la manera en que dicho cambio se produce después del tratamiento. Una vía para conocerlo es evaluar sus resultados. La Terapia Centrada en Soluciones (TCS) constituye una alternativa a las que tradicionalmente se utilizan para tratar el consumo de alcohol. Sus resultados se han documentado en diferentes países de América y de la Comunidad Europea, pero no en población hispana. Objetivo Evaluar los resultados de la Terapia Centrada en Soluciones en dependientes al etanol y determinar las diferencias entre quienes buscaban modificar los problemas asociados al consumo de alcohol y los que pretendían cambiar su manera de beber. Método Se trabajó con un diseño longitudinal de tipo O1-X-O2, comparativo, con un seguimiento a doce meses. La muestra se integró con 60 consumidores de alcohol de 18 a 50 años de edad que acudieron al Centro de Ayuda al Alcohólico y sus Familiares (CAAF) del Instituto Nacional de Psiquiatría Ramón de la Fuente. Todos fueron seleccionados de manera intencional, consumieron alcohol en el último año, cubrieron los criterios de dependencia al alcohol según el DSM-IV y brindaron por escrito su consentimiento informado. La muestra se dividió en 30 dependientes al etanol que acudieron al CAAF en busca de modificar su nivel de consumo y 30 dependientes que pretendían modificar los problemas asociados a su consumo. En la presente investigación, los resultados de la intervención se definieron a partir del tiempo transcurrido desde que un dependiente asistía a la última sesión de terapia hasta que presentaba una recaída y continuaba con los problemas asociados al consumo de alcohol. La historia de consumo de alcohol de los sujetos se caracterizó por medio del patrón de consumo, nivel de dependencia, número de criterios del DSM-IV, antecedentes de tratamiento, problemas de consumo de alcohol en la familia de origen en dos generaciones previas y problemas asociados al consumo de alcohol. El número de sesiones, servicios y tratamientos adicionales se consideró como mediador de los resultados de la intervención. Resultados Del total de la muestra, 78% era casado; 38% tenía instrucción básica; la edad promedio fue de 35.5 años; la mayoría pertenecía a un nivel socioeconómico bajo; 39% era consumidor de alto nivel; 43% se ubicó en un nivel de dependencia sustancial y 70% contaba con antecedentes de tratamiento. La necesidad de tratamiento más alta se registró en los problemas familiares asociados al consumo de alcohol con 48%. Del total de la muestra, 63% asistió de una a dos sesiones y los restantes asistieron a más de dos, con un seguimiento de 83% de la muestra. En el análisis de sobrevida, los primeros cuatro meses después de tratamiento se identificaron como los meses de mayor riesgo para recaer. Se observó que la TCS tuvo mejores resultados en dependientes que buscaban modificar los problemas asociados al consumo de alcohol. Éstos se ubicaron en los niveles socioeconómicos más bajos y presentaron un nivel de deterioro importante por el consumo de alcohol.

          Translated abstract

          In Mexico, excess drinking constitutes one of the main public health challenges nationwide. The 2002 National Addictions Survey documented the existence of 11 035 262 heavy drinkers, 3 226 490 habitual drinkers, 2 841 303 persons with alcohol dependence and 2 343 71 0 persons who started arguing with their spouse or partner when drunk. Illnesses that are directly or indirectly associated with drinking are among the ten leading causes of death in Mexico among the general population: specifically, men die from attacks or homicide, self-inflicted wounds, alcoholic liver disease and other chronic diseases of the liver and alcohol dependence syndrome. Although there are various intervention strategies that attempt to influence this problem, it is not known whether these interventions are a causal factor in the change produced by the consumer and the way in which this change is produced after treatment; one way of determining this is by evaluating their results. Although Solution-Focused Therapy constitutes a different alternative to those that have traditionally been used for treating alcohol consumption, most research conducted in Mexico and other countries is carried out using a social learning model. Although the results of the Solution-Focused Therapy have been documented in various countries in America and the European Community, the findings are insufficient for it to be regarded as an optimal treatment for modifying excess alcohol consumption among the Mexican population. Objective To evaluate the results of the Solution-Focused Therapy in ethanol-dependent persons and to determine the differences between those that seek to modify problems associated with alcohol consumption and those that seek to change their drinking styles. Method A comparative O1-X-O2 longitudinal design was used, with a 12-month follow-up. The sample comprised 60 intentionally selected alcohol consumers, ages 18 to 50, who attended the Center of Assistance for Alcoholics and Their Relatives (CAAF) at the Ramón de la Fuente National Institute of Psychiatry. They had consumed alcohol in the past year, met the Alcohol Dependence Criteria according to the DSM-IV and gave their written consent. The sample was divided into 30 ethanol-dependent persons who attended the CAAF in an attempt to modify their drinking levels and 30 ethanol-dependent persons who sought to modify problems associated with their consumption. In this study, the results of the intervention were defined on the basis of the time elapsed between an ethanol-dependent person's last therapy session and the time when he or she experiences a relapse and continues with the problems associated with alcohol consumption. The subjects' history of alcohol consumption was characterized by their pattern of consumption, level of dependence, number of DSM-IV criteria, history of treatment, problems of alcohol consumption in the previous two generations of their families of origin, and alcohol-related problems. The number of additional sessions, services and treatments were regarded as mediators of the results of the intervention. The information was obtained through various instruments, such as the pre-consultation and initial consultation cards, the Scale of Ethanol-Dependence and a version of the Index of the Severity of Addiction drawn up by the Center of Assistance for Alcoholics and their Relatives. The procedure was carried out in three stages: the baseline, the application of Solution-Focused Therapy and a follow-up beginning twelve months after the last therapy session. The field operation began in April 2002 and ended in August 2004, with the last phase being carried out on both the subjects that had completed their treatment and on those that had interrupted it and requested assistance again at any of the services offered by the CAAF. Results Seventy-eight per cent of the sample were married; 38% had completed elementary school; the average age was 35.5, and most had a low socio-economic level. A total of 39% were heavy drinkers; 43% displayed a substantial level of dependence, and 70% had a record of treatment. The highest need for treatment was recorded in family problems associated with alcohol consumption, totaling 48%. Sixty-three per cent of the sample attended one to three sessions, while the remainder attended over three. A follow-up study of 83% of the sample showed that most sought assistance at two of the Center's treatment services, while 55% of the dependents received treatment at the CAAF alone. Thirty per cent cut short their treatment because they did not want to stop drinking or did not need help or were annexed; 28% stopped for work or financial reasons, while only 2% reported that the treatment failed to cover their expectations. Fifty-six per cent of the sample did not relapse, and successfully modified the problems associated with alcohol consumption; 32% relapsed and failed to modify their alcohol-related problems, while the remainder relapsed yet managed to modify the problems associated with alcohol consumption (12%) with a value of χ² = 29.94 and p equivalent to 0.00. The heterogeneity tests did not display statistically significant differences between the subjects that relapsed and continued with their alcohol-related problems (44%) and those that did not relapse and modified their alcohol-related problems (56%) by either alcohol consumption characteristics or the factors mediated by the results of the intervention. The study showed that the first four months after the last therapy session are those during which subjects experience the highest risk of relapsing and continuing with problems associated with alcohol consumption. Just 47% of the patients that cited modifying their drinking levels as the reason for seeking treatment proved not to have relapsed and to have successfully modified the problems associated with their drinking at the 1 2-month follow-up as opposed to 83% of those that sought to modify the problems associated with their drinking, with a statistical significance of less than 0.01 in the log-rank test. The intervention was observed to achieve better results among alcohol-dependent persons that sought to modify problems associated with alcohol consumption, had a lower socio-economic level, a record of treatment for their alcohol consumption, high levels of dependence, a medium-high need for treatment in psychological, work problems, and did not receive any form of treatment outside the CAAF. The article discusses the role of the demand for treatment as a predictor not only of the search for services, as supported by international literature, but also of the results of the intervention. It confirms the importance of conceiving alcoholism as a symptom resulting from relational systems the drinker maintains with his/her surroundings, rather than as a problem that can be solved by ensuring that the drinker remains sober. The article suggests including a control group with another type of therapeutic intervention in order to compare the results of the Solution-Focused Therapy and have more elements for making evidence-based decisions.

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          Most cited references60

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          Matching Alcoholism Treatments to Client Heterogeneity: Project MATCH posttreatment drinking outcomes.

          (1997)
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            New data from the Addiction Severity Index. Reliability and validity in three centers.

            The Addiction Severity Index (ASI) is a clinical/research instrument which has been in wide use during the past 6 years to assess the treatment problems found in alcohol- and drug-abusing patients. In a study of male veterans, a preliminary evaluation of the ASI has indicated reliability and validity. The present report presents an expanded examination of these issues; 181 subjects from three treatment centers were studied. Results of concurrent reliability studies indicate that trained technicians can estimate the severity of patients' treatment problems with an average concordance of .89. Test-retest studies show that the information obtained from the ASI is consistent over a 3-day interval, even with different interviewers. Comparisons of the ASI severity ratings and composite measures with a battery of previously validated tests indicate evidence of concurrent and discriminant validity. The reliability and validity results were consistent across subgroups of patients categorized by age, race, sex, primary drug problem, and treatment center. The authors discuss the strengths and limitations of the instrument based upon 5 years of use. The overall conclusion is that the ASI is a reliable and valid instrument that has a wide range of clinical and research applications, and that it may offer advantages in the examination of important issues such as the prediction of treatment outcome, the comparison of different forms of treatment, and the "matching" of patients to treatments.
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              Matching Alcoholism Treatments to Client Heterogeneity: Project MATCH posttreatment drinking outcomes.

              To assess the benefits of matching alcohol dependent clients to three different treatments with reference to a variety of client attributes. Two parallel but independent randomized clinical trials were conducted, one with alcohol dependent clients receiving outpatient therapy (N = 952; 72% male) and one with clients receiving aftercare therapy following inpatient or day hospital treatment (N = 774; 80% male). Clients were randomly assigned to one of three 12-week, manual-guided, individually delivered treatments: Cognitive Behavioral Coping Skills Therapy, Motivational Enhancement Therapy or Twelve-Step Facilitation Therapy. Clients were then monitored over a 1-year posttreatment period. Individual differences in response to treatment were modeled as a latent growth process and evaluated for 10 primary matching variables and 16 contrasts specified a priori. The primary outcome measures were percent days abstinent and drinks per drinking day during the 1-year posttreatment period. Clients attended on average two-thirds of treatment sessions offered, indicating that substantial amounts of treatment were delivered, and research follow-up rates exceeded 90% of living subjects interviewed at the 1-year posttreatment assessment. Significant and sustained improvements in drinking outcomes were achieved from baseline to 1-year posttreatment by the clients assigned to each of these well-defined and individually delivered psychosocial treatments. There was little difference in outcomes by type of treatment. Only one attribute, psychiatric severity, demonstrated a significant attribute by treatment interaction: In the outpatient study, clients low in psychiatric severity had more abstinent days after 12-step facilitation treatment than after cognitive behavioral therapy. Neither treatment was clearly superior for clients with higher levels of psychiatric severity. Two other attributes showed time-dependent matching effects: motivation among outpatients and meaning-seeking among aftercare clients. Client attributes of motivational readiness, network support for drinking, alcohol involvement, gender, psychiatric severity and sociopathy were prognostic of drinking outcomes over time. The findings suggest that psychiatric severity should be considered when assigning clients to outpatient therapies. The lack of other robust matching effects suggests that, aside from psychiatric severity, providers need not take these client characteristics into account when triaging clients to one or the other of these three individually delivered treatment approaches, despite their different treatment philosophies.
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                Author and article information

                Journal
                sm
                Salud mental
                Salud Ment
                Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz (México, DF, Mexico )
                0185-3325
                June 2009
                : 32
                : 3
                : 223-230
                Affiliations
                [03] orgnameInstituto Nacional de Psiquiatría Ramón de la Fuente Muñiz orgdiv1Dirección de Investigaciones Epidemiológicas y Psicosociales
                [01] orgnameInstituto Nacional de Psiquiatría Ramón de la Fuente Muñiz orgdiv1Centro de Ayuda al Alcohólico y sus Familiares
                [02] orgnameInstituto Politécnico Nacional
                Article
                S0185-33252009000300006 S0185-3325(09)03200300006
                dc190393-8ad0-4a36-9301-b0b304d80591

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

                History
                : 05 February 2009
                : 06 February 2008
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 40, Pages: 8
                Product

                SciELO Mexico

                Categories
                Artículos originales

                tratamiento de la dependencia al alcohol,análisis de sobrevida,alcoholismo,Terapia Centrada en Soluciones,Resultados,alcohol dependence treatment,survival analysis,alcoholism,Solution-Focused Therapy,Outcome

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