Factors Associated with Abstinence Among Men with Alcohol Use Disorder: A Qualitative Study

Abstract

Background:

Recovery in Alcohol Use Disorder (AUD) is a complex process and is characterized by periods of relapse and remission. Sustained abstinence is an essential element of the recovery process and the primary treatment objective for AUD in many cases. This study aimed to explore factors that promoted abstinence in men with AUD who relapsed frequently and were hospitalized more than twice in a year.

Methods:

Men with AUD who relapsed frequently (n = 29) were screened, consented, and recruited for the study. The data were collected through six Focus Group Discussions (FGDs) over four months. The FGDs were audio-recorded, transcribed, and translated. ATLAS. ti 23 software was used for coding, group coding, organizing, and analyzing data. Inductive thematic analysis was employed to identify themes related to factors associated with achieving and maintaining abstinence.

Results:

Five themes emerged as factors that promoted abstinence in the past: (a) employment, (b) treatment, (c) fear, (d) social support, and (e) responsibility. The study found that post-discharge therapeutic support, including after-care services, such as periodic telephonic follow-up, provision of free medication, and therapist availability during a crisis, was beneficial. Family recognition, emotional support, aversion therapy (disulfiram), fear of losing jobs, commitment to create a secure future for their children, and connection with non-drinking friends were the factors that supported abstinence.

Conclusions:

The findings underscore the importance of enhancing after-care services, fostering workplace support, and family-based interventions. Integrating abstinence-promoting factors into the treatment plan may reduce relapse risk and support sustained abstinence.

Keywords

Alcohol dependence sobriety recovery recurrent relapse qualitative inquiry

Key Messages

Post-treatment therapeutic support, regular employment, workplace support, family emotional support, and family responsibilities are facilitators of abstinence.

Involving family members, treating other affected family members, and involving their adult daughters as co-therapists in the treatment process may be beneficial for persons with AUD to sustain abstinence.

Alcohol Use Disorder (AUD) is a significant risk factor for deaths and disabilities globally.¹ AUD is defined as a chronic, relapsing brain disease characterized by compulsive alcohol use, loss of control over alcohol intake, and a negative emotional state when not using.² Recovery from AUD is complex and is characterized by periods of remission and relapse. There is considerable debate about whether abstinence from alcohol is a necessary component of recovery from AUD, with studies suggesting that recovery is possible even without achieving complete abstinence.³ Despite this, abstinence is a desirable goal, particularly for individuals with severe AUD with physical or psychiatric co-morbidities. Abstinence from alcohol significantly improves psychosocial functioning, quality of life, and neurocognitive functions in individuals with AUD.^4,5 Globally, studies have found that baseline low drinking frequency, effective coping mechanisms, self-efficacy, spirituality, early treatment seeking, treatment retention, participation in self-help groups (Alcoholics Anonymous), and utilization of after-care services facilitate remission.^6–9

Indian studies have found that lower exposure to relapse precipitants, such as negative emotional states, undesirable stressful-life events, euphoria, and cognitive fatigue, perceived expressed emotions, craving, and an absence of a family member having AUD were associated with short-term abstinence. The presence of active coping, emotional support, stable employment, perceived better social support, self-efficacy, positive thinking, and family social support led to longer-term abstinence.^10–18 Employment opportunities, workplace support, availability and accessibility of treatment, and healthy family relationships were found to be facilitators of abstinence.¹⁹ Indian studies predominantly used quantitative methods and primarily focused on comparing individuals who relapsed with those who maintained abstinence. Notably, individual perception of what helped them to maintain abstinence from alcohol in their past has not been well studied in the Indian context. An in-depth understanding of these individual perspectives on factors that promoted abstinence in the past will allow addiction medicine specialists to formulate targeted interventions for frequently relapsing individuals with AUD. Therefore, the study aimed to explore the individual perspectives on factors associated with abstinence in the past among persons who frequently relapsed and were hospitalized more than twice in a year for the treatment of AUD.

Methods

Study Design and Setting

Our study is grounded in a social constructivist paradigm to explore the subjective perspectives of factors that promoted abstinence in the past. An interpretive framework posits that reality is not objective and fixed, but instead is constructed through social interactions and shared meaning.^20–22 Our study was conducted in the inpatient department of a tertiary care teaching hospital in southern India. Consecutive subjects admitted to inpatient care for relapse were screened, and consenting participants were recruited using consecutive sampling techniques from January 2023 to April 2023. The severity of alcohol dependence was assessed using the Severity of Alcohol Dependence Questionnaire (SADQ).²³ A Focus Group Discussion (FGD) was used for data collection. We followed the Consolidated Criteria for Reporting Qualitative Research guidelines for designing and reporting²⁴ (Supplementary 1).

Ethical Considerations

Ethical approval was obtained from the Institutional Ethics Committee. Written informed consent was obtained from all participants.

Study Participants

Individuals aged between 18 and 55 years, diagnosed with AUD as per the Diagnostic and Statistical Manual of Mental Disorders,²⁵ who relapsed frequently and were hospitalized more than twice in a year for AUD treatment, had a history of abstinence for at least two months, and consented to participate in the study, were included. Individuals with active withdrawal symptoms, cognitive issues, other substance dependence, except for nicotine, intellectual disability, schizophrenia, bipolar disorder, obsessive-compulsive disorder, and those who expressed unwillingness to participate in the study were excluded. A total of 48 individuals with AUD who relapsed frequently were identified from January 2023 to April 2023. Of these, 19 were excluded (cognitive issues-12, severe withdrawal symptoms-two, and refused consent-five). Finally, 29 individuals with AUD who frequently relapsed were included. During the study period, three female patients were hospitalized for frequent relapses at different times. Due to the limited numbers and unwillingness to participate, it was not feasible to conduct an FGD with women with AUD.

Data Collection

The research team developed the FGD guide, which subject experts subsequently validated. All authors had more than five years of experience in the area of addiction medicine. The first author is a research scholar with prior experience working with individuals with AUD and their families. The first author was trained to conduct the FGD and also received training and attended workshops on qualitative research. Rapport was established with the participants individually, and the study process was explained to them before the discussion began. The FGD was conducted in a safe and comfortable environment, allowing participants to share their experiences without interruption or judgment, and ensuring confidentiality and anonymity. We used open-ended questions, a set of questions prepared before the study and approved by experts (Appendix 1). We often asked participants to narrate a story with examples, acknowledge their responses, and summarize the session at the end of each FGD to minimize socially desirable responses. The first author conducted six Focus Group Discussions (FGDs) with 29 men with AUD who frequently relapsed. The FGD was conducted in Kannada; each session lasted 45–60 minutes, and each group comprised at least four participants. To minimize conformity bias, a psychiatric social worker (native language speaker) who was not part of this study observed the FGD and recorded the participants’ behaviors and discussions. Discussions in the focus group were audio-recorded using a digital audio recorder, and the data were stored on a laptop protected by a password. We followed the guidelines for improving the security of qualitative data.²⁶ After each FGD, the first author reflected with the research team to minimize the researcher’s biases and the influence of previous experience on the results. We followed up with continued collaborative and reflective exercises at each stage of the study.^27,28 During the FGD, the researcher identified psychosocial problems with some participants, which were communicated to their treating physicians, and appropriate referrals were made. Data collection was halted once data saturation was reached and confirmed using a comparative method for theme saturation.²⁹ No new themes were merged following the fifth FGD; the fifth FGD themes were aligned with the previous FGDs themes. To reconfirm theme saturation, we compared the sixth FGD theme with previously merged themes, but the sixth FGD theme was also merged with previous themes.

Data Analysis

The audio-recorded FGDs were transcribed and translated into English; two bilingual mental health professionals examined the transcripts to ensure the accuracy and originality of the data. Furthermore, two FGD participants verified the transcripts (reviewed their portion of the transcript) and confirmed that the transcripts accurately reflected what they had shared during the FGD. ATLAS. ti 23 software was used for coding, group coding, organizing, and managing data. Inductive thematic analysis was used to identify emerging themes.³⁰ The transcripts were read carefully several times to familiarize myself and find meaning. Semantic coding was used to capture the original content of what a participant said.³¹ In parallel, two PhD research scholars who were not part of the study independently coded the data to ensure credibility and accuracy. The codes were reviewed, refined, and categorized, and a codebook was created. The degree of consensus between independent coders was measured using Cohen’s kappa,^27,32 and the agreement between coders was 0.90 and k 0.75, indicating substantial inter-rater agreement. A total of 220 codes were identified, and similar codes were merged. Finally, 160 codes were collated, and all relevant codes were grouped based on conceptual similarity into potential themes. Insignificant codes were then deleted. Sub-themes were generated from the aggregated codes of the central theme and compared to each other to identify coherent patterns within the broader theme. Themes and sub-themes were reviewed by two experts who were not part of this study. Finally, five main themes and thirteen sub-themes were defined.

Results

Characteristics of the Participants

The mean age of the participants was 39.93 (±5.35) years, and the year of education was 9.20 (±2.14). Half of the participants belonged to the upper or lower economic status; the majority (76%) resided in urban areas, and 90% of the sample were Hindu. A substantial proportion (83%) were employed, primarily in manual and semi-skilled occupations, such as loading and unloading, painting, electrical work, security services, and driving. 17% of participants were unemployed. The mean age at dependence was 22.62 (±3.57) years, and the severity of the alcohol dependence score was 41.55 (±4.53), indicating that all of them had severe alcohol dependence. The mean duration of the most extended period of abstinence in the past was 9.48 (±7.18) months. Notably, two participants had maintained abstinence for 2–3 years, seven had abstained for 12–16 months, 13 reported a maximum abstinence period of 6–8 months, and seven participants had sustained abstinence for 2–6 months. During inpatient treatment, 55% of the primary caregivers were the participants’ elderly mothers (aged >60 years), whereas 27% of the caregivers were their spouses (Table 1).

Table 1.

Characteristics of the Participants.

Socio-demographic Characteristics (n = 29)	Mean (SD)/f
Mean age (in years)	39.93 ± 5.35
Year of education	9.20 ± 2.14
Domicile
Urban	22
Rural	07
Occupation Status
Unemployed	05
Employed	24
Socio-economic Status
Lower	05
Upper lower	15
Lower middle	07
Upper middle	02
Religion
Hindu	26
Christian	03
Caregiver
Mother	16
Wife	08
Other family members	05
Clinical Characteristics
Mean age at dependence (in years)	22.62 ± 3.57
Maximum duration of abstinence (months)	9.48 ± 7.18
Duration of treatment (in years)	6.55 ± 2.01
Severity of alcohol dependence (SADQ)	41.55 ± 4.53

Themes Associated with Abstinence

Five main themes and thirteen sub-themes were identified after a thorough thematic analysis. The main themes are (a) employment, (b) treatment, (c) fear, (d) social support, and (e) responsibility.

Theme 1: Employment

Under the superordinate theme of employment, three subordinate themes were identified: regular work, being fully immersed in one’s work, and fear of losing one’s job. Individuals with AUD, regular employment, and a commitment to their work are closely associated with abstinence. Fear of losing their jobs motivates them to stay sober, as work keeps them focused and reduces alcohol-related thoughts.

“I used to go to work at 8 AM and return home around 7 PM. I was regular and involved with my work; then, I stopped drinking alcohol for more than nine months” (P15). “Work helped me to stay away from alcohol; I was regular to work and then did not get a craving for alcohol because my entire focus was on work” (P 20). “I had a fear that I might lose my job if I continued to drink alcohol, so I stopped drinking alcohol” (P6).

Theme 2: Treatment

Three sub-themes emerged within the overarching treatment theme: patient adherence, continuous therapeutic support, and disulfiram treatment. Consistent medication adherence, frequent follow-up visits, family intervention, provision of free medicine, connection with a therapist, and availability of a therapist on-call during crises facilitate abstinence. Additionally, frequent telephonic follow-ups by the social workers and disulfiram treatment promoted sustained abstinence in the past.

“I stopped drinking because of medication and regular follow-ups” (P 15). “After regular counselling provided by a social worker, my family problems were reduced, and relationships with my wife improved” (P7). “A social worker assisted me in obtaining free medication, and they used to call me and counsel me over the phone, which was highly beneficial” (P 14). “My doctor gave me aversion medication (disulfiram) last time; it works for me. With that fear, I stopped drinking for almost three years” (P19).

Theme 3: Fear

Two subordinate themes, the fear of losing dignity and the fear of health-related issues, converged under the theme of fear. Concerns about their children’s future, fear of their sons might turn out like them in the future, losing respect in front of their children, and emotional neglect by their daughters, made them stay away from alcohol use. Additionally, witnessing others’ health issues due to heavy alcohol consumption and personalized feedback from physicians about their health-related problems made them stop consuming alcohol and maintain abstinence in the past.

“My son did not obey my words, he uses tobacco, did not go to school, and I fear that he might turn out like me” (P 15). “My daughter stopped talking to me, did not even see my face, and neglected me because of my drinking habits, so I stopped drinking alcohol” (P 17). “My elder brother died suddenly due to excessive use of alcohol. I feared that I might also die if I continued to drink alcohol, so I stopped” (P4). “The doctor told me that I had serious liver problems due to alcohol use” (P21).

Theme 4: Social Support

Spousal emotional support, recognition of positive changes, and support from friends were identified as key components under the central theme of social support. Emotional support from the wife, continued supervision of medication by family members, encouragement, and support from non-drinking friends helped in sustained abstinence. Getting respect from the wife and workplace, recognizing positive changes, and believing in them, especially from the wife, reinforced them to maintain an alcohol-free life.

“I stopped using alcohol because of my wife; she supported me, took me to the temple regularly, showed lots of love (he cried), and cared for me most” (P 20). “My wife used to give me medication regularly, and she reminds me to take medication and food on time” (P6). “My wife has started respecting and trusting in me. So, I decided I should not destroy her faith in me. So, I stopped drinking alcohol” (P24). “My non-drinking friends supported me, and they used to advise me. I wore a mala, and they took me to Sabarimala temple; because of them, I stopped using alcohol” (P9). “My co-workers and employer started to respect me, and neighbors who disrespected me before started respecting me” (P14).

Theme 5: Responsibility

Two subordinate themes, such as children’s future and family commitment, emerged under the superordinate theme of responsibility. Concerns about the future of their daughter and commitment to creating a secure future for her, taking on family responsibilities, such as children’s education, caring for elderly parents, and building a house were related to abstinence.

“I stopped drinking because of my younger daughter’s marriage” (P1). “My elder son is taking some substance (Ganja); I felt that I was one of the reasons for it (he cried), then I stopped” (P13). “My relatives did not come forward to marry my daughter because of my drinking habits, so I decided to create a promising future for her, and I stopped drinking alcohol. My daughter cared for me the most; she is a rebirth of my mother (he cried)” (P 23). “I cared for my aged and sick parents. Also, I admitted my children to a good college and constructed a house; all these responsibilities helped me stay away from alcohol for more than one and a half years” (P6).

Discussion

Our study describes the perspectives of individuals with AUDs on factors that contributed to abstinence in the past. We found that regular employment promoted abstinence and minimized thoughts of alcohol use. This is likely because being regularly employed leads to improved self-esteem and self-efficacy, respect from others, personal income, and community integration, which in turn reduces the risk of relapse.^33,34 Stable employment also facilitates completing AUD treatment, thus functioning as an effective relapse prevention measure.^35–37 We found that individuals stayed away from alcohol out of fear of losing a job and dignity in the workplace. This was in contrast to a recent Indian study where the fear of losing a job prevented people from seeking AUD treatment.³⁸ Individuals with AUD are often fired or laid off from their jobs, experience sustained unemployment, and often have conflicts with supervisors or co-workers.³⁹ They may also be deterred from searching for jobs due to perceived self-stigma, which can diminish their chances of being employed.⁴⁰ Further, employers are reluctant to hire a person with AUD, even if the person has recovered, due to stigma and concerns related to potential poor job performance, absenteeism, and low productivity.⁴¹ These findings provide support for occupational interventions to facilitate abstinence and recovery of individuals with AUD.

We found that continued therapeutic support provided by social workers post-discharge, such as frequent telephonic contact, facilitating free medicine for those who are unable to afford medication, and a therapist being available for patients’ calls during crisis, promotes abstinence. Additionally, the patient’s treatment adherence, connection with the therapist, and regular follow-ups all contributed to maintaining abstinence. A recent randomized clinical multicenter study supported the notion that a high frequency of telephone contact by the therapist after residential treatment helps clients stay connected to healthcare services, which in turn helps maintain abstinence, reduces the risk of relapse, and facilitates faster recovery.⁴² Further, evidence shows that consistent contact with the therapist, availability and accessibility of treatment, after-care services, and follow-up reminders facilitate abstinence.^19,43 Family intervention reduces the severity of AUD and relapse, improves family functioning and intimacy, and directly supports abstinence.⁴⁴ A recent narrative review reported that digital, mobile-based interventions for Substance Use Disorder significantly reduce the frequency of substance use and improve mental health. Addiction medicine specialists can use technology-based interventions for after-care services, especially for people who need continued care but are unable to meet a therapist in person due to various reasons.⁴⁵

We also found that disulfiram was associated with abstinence in the past and that the fear of adverse effects promoted abstinence. Disulfiram can be used to motivate individuals to maintain abstinence.⁴⁶ Particularly in the Indian context, where family support is available for monitoring medicine intake, disulfiram helped individuals to attain abstinence.^47,48 We found that the fear of losing a job, responsibilities, and roles in the family, a concern that children might resort to substance use in the future, or that children have already started using substances, facilitated abstinence from alcohol. We also found that witnessing others’ health complications due to alcohol and receiving personalized feedback from a physician, from investigation reports, helped individuals to deter their alcohol use. A recent study reported that patients who viewed a recorded video of their delirium tremens were motivated to maintain abstinence.⁴⁹ Presenting personalized feedback with evidence during the therapy session might bring positive changes and help the frequently relapsing individuals to understand the consequences of alcohol use in a better way.

We found that family support, especially from the spouse, family members’ recognition of positive changes, and support from non-drinking friends promoted abstinence. Families play a crucial role in motivating individuals to consider change, monitoring medication compliance, and facilitating positive treatment outcomes and long-term recovery.^50,51 Previous studies have reported that recognizing positive changes by family members, supporting and caring relationships with siblings, and service providers promote abstinence.^52,53 A recent qualitative study found that support from a spouse, trusting relationships, romantic relationships, and healthy family interactions facilitated recovery.¹⁹ A Korean study found that satisfied lifestyles, new life values, and respect from family and others support abstinence.⁵⁴ Inversely, perceiving criticism, lack of emotional support, irritability, and intrusiveness from family members is strongly associated with frequent relapse.¹⁵ Family communication patterns are also a determinant of relapses and remission.⁵⁵ Several studies emphasize that social support is crucial for promoting abstinence.^11,13,56,57 We found that connection with non-drinking friends who encouraged involvement in spiritual activities and provided crisis support promoted abstinence in the past. This is in line with studies that demonstrate that social support from non-drinking friends, a supportive environment, and peers’ recognition of positive changes promoted abstinence.^19,52,58

The concerns about children’s education and future, commitment to arranging marriage, settling financially, and caring for elderly parents promoted abstinence. It has been observed that individuals who are recovery-oriented are highly motivated to care for their children and spouse, and are responsible for work to repay their previous debts and assume family responsibilities.¹⁹ Studies have also reported that purchasing land or a house and arranging a marriage for a daughter or sister is significantly associated with abstinence.⁵⁹ However, debt may also increase psychological stress and contribute to relapses.⁶⁰ From a theoretical standpoint, our findings align with social control theory, which posits that strong bonds with family and friends, and employment, motivate and reward individuals for exhibiting responsible behavior, such as abstaining from alcohol, and prevent them from engaging in deviant behaviors.^51,61 In India, AUD has a high treatment gap and treatment cost compared to other psychiatric conditions.⁶² Despite significant initiatives made by the Government of India to scale up addiction treatment services,⁶³ less emphasis has been placed on community-based recovery programs, such as Oxford Houses, Recovery Homes, and sober homes, where people can live together and support each other, maintain abstinence, and stay in a drug and alcohol-free environment. Community-based recovery programs increase social capital and may support long-term abstinence.^64,65

Strengths

We employed a robust qualitative methodology in which two native language speakers verified transcripts, two independent coders coded the data, and experts reviewed the themes to avoid confirmation bias. Reflexive exercises were conducted by the research team at each stage of the study to minimize the impact of the researchers’ biases and experiences on the findings. We followed Bergen and Labonté’s approaches in the study to detect and limit the social desirability bias.⁶⁶ Despite this, there is a possibility of social desirability bias as we used FGD for data collection.

Limitations

These include the potential for participants’ recall bias, the absence of family members’ perspectives, and the exclusion of women’s perspectives, which may somewhat limit the generalizability of the study findings. Although the consecutive sampling technique ensured that all individuals admitted to the inpatient had an equal chance to participate, it limits demographic diversity; most participants were from similar geographical locations and socio-economic backgrounds. To address these limitations, future research should include gender-balanced samples, employ purposive sampling, and incorporate mixed methods and prospective studies to validate qualitative findings. Additionally, research should focus on socio-ecological contexts that support recovery or abstinence, advancing the understanding of multiple pathways to abstinence and holistic approaches in AUD.

Conclusions

This study highlights the role of employment, regular contact with treatment services, family social support, and family responsibilities in promoting abstinence and recovery. These findings underscore the need to incorporate community-based interventions in the long-term management of AUD. These include occupational interventions to enhance workplace support, technology-based after-care services to facilitate consistent therapeutic engagement, and family-focused interventions to promote abstinence.

Supplemental Material

Supplemental material for this article available online.

Footnotes

Acknowledgements

The authors would like to thank all the participants in this study, peer scholars who coded the data, and subject experts who validated the FGD guideline and reviewed themes and sub-themes.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Declaration Regarding the Use of Generative AI

None used.

Ethical Consideration

This study received ethical clearance from the Institutional Ethics Committee (IEC) (Ref no. NIMH/DO/BEH.Sc.Div/2021-22 dated 15/07/2022). Written informed consent was obtained from all the participants, and the voluntary nature of participation, the right to withdraw from the study at any time, and the objectives and procedures of the study were detailed before conducting the study.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is part of the first author’s PhD work, and the study has been funded by the University Grants Commission, Govt of India (Ref no: 200510162135); However, the authors have not received any grant/financial support for publication of this article.

Appendix A

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