Abstract

Objective

Alcohol use disorder (AUD) is among the most prevalent substance use disorders in the USA. Despite availability of effective interventions, treatment initiation and engagement remain low. Existing interventions target motivation and practical barriers to accessing treatment among individuals established within treatment systems. In contrast, Cognitive Behavioral Therapy for Treatment-Seeking (CBT-TS) aims to elicit and modify treatment-seeking beliefs to increase treatment-seeking behaviors among treatment-naïve samples. We aim to understand which beliefs were endorsed by those who did/did not initiate treatment, including changes in number of drinking days.

Method

We examined treatment seeking beliefs elicited during CBT-TS among community-based adults with moderate–severe AUD with no treatment history. In this study, we discuss which beliefs were modifiable (i.e. those discussed during the intervention among individuals who subsequently attended treatment and may be associated with treatment-seeking behaviors).

Results

Of the 194 participants who received the intervention, 16 categories of beliefs were endorsed. Of the 38 participants (19.6%) who attended treatment, the most frequently endorsed belief was ‘Not wanting specific types of substance use treatment or supports’ (50%), a belief that may inhibit treatment seeking. The idea ‘Treatment is positive’ (47%) was also frequently cited, a belief that may facilitate treatment seeking.

Conclusions

This study describes the beliefs that were more frequently endorsed among adults with moderate–severe, but untreated AUD who reported attending treatment following CBT-TS. Findings point to the potential of discussing and modifying treatment-seeking beliefs among treatment-naïve adults with severe AUD to increase treatment-seeking behaviors.

Introduction

Alcohol use disorder (AUD) is among the most prevalent substance use disorders in the USA among individuals ages 12 years and older (SAMHSA 2023). Despite evidence that AUD treatment is effective (e.g. substance use disorder specialty treatment centers, general medical sources, nonmedical sources such as Alcoholics Anonymous (AA; Dawson et al. 2012; Trim et al. 2013), interventions for AUD are underused, leading to a large gap between the prevalence of illness and proportion of those receiving treatment (Kohn et al. 2004). For example, in 2022, 1 in 10 individuals 12 years and older with AUD received treatment (SAMHSA 2023), highlighting treatment seeking as one of the greatest barriers to the effective treatment of AUD. Alcohol use, even heavy drinking patterns, is largely normative, which adds to the challenge of identifying someone or oneself as having a need for treatment, with the most frequently endorsed barrier reported as not believing that the problem was serious enough for treatment, that the individual could handle the problem on their own, or that the problem would get better on its own (Rapp et al. 2006; Saunders et al. 2006). Because of the significant disease burden of untreated AUD despite effective treatment options available, failure to access treatment is a major public health concern (Carvalho et al. 2019).

Brief interventions held in primary care settings targeting alcohol problems have demonstrated support for persons with nondependent level disorders (Fleming et al. 2004). In particular, screening, brief intervention, and referral to treatment (SBIRT) interventions (Glass et al. 2017) have been used to increase the use of alcohol-related care and have demonstrated effects in reducing alcohol use patterns and problems among individuals with less severe symptoms. However, little evidence supports either electronic or in-person administrations lead to alcohol-related care or that improvement in alcohol use outcomes are attributable to SBIRTs among individuals with more severe symptoms of AUD (Glass et al. 2017; Glass et al. 2015a; Knox et al. 2019; Saitz 2010). Further, of the interventions available addressing AUD, many target practical barriers to accessing treatment, and yet the majority of individuals with alcohol use problems do not receive treatment, which suggests these interventions are not addressing other barriers or beliefs, which if modified may increase treatment-seeking behaviors (Glass et al. 2015a; Glass 2015b). Further, because many of these interventions are disseminated within existing institutions, they target individuals already established within treatment systems and frequently miss individuals in the community without similar connections (Stecker 2011).

An alternative approach to prior efforts is to focus on factors that promote treatment-seeking behaviors, given that increasing the availability and accessibility of treatment alone may not be sufficient. Even if treatment is widely available in a community, it will not benefit those in need if they do not make the decision to seek treatment. Cognitive Behavioral Therapy has demonstrated consistent effectiveness for treating a wide variety of disorders (i.e. depression, anxiety, e.g. Vittengl et al. 2005) via its focus on changing the cognitive beliefs underlying symptomology and behavioral decisions to seek treatment (e.g. Beck 2005; Butler et al. 2005). See Donato and Ray (2023) for a full review of available treatment options for AUD, including behavioral and pharmacological interventions and their current evidence base. Following this line of evidence, Stecker (2010a) developed Cognitive Behavioral Therapy for Treatment Seeking (CBT-TS) to examine the specific factors that influence an individual’s decision to seek treatment (Stecker et al. 2007).

The conceptual frameworks behind CBT-TS are (i) Cognitive Behavioral Therapy, which targets the interaction of thoughts, feelings, and behaviors to create change, and (ii) the Theory of Planned Behavior (Ajzen 1991), which explains and predicts health behaviors through three considerations: (a) behavioral beliefs (beliefs about the likely consequence of a behavior), (b) normative beliefs (beliefs about the normative expectations of others), and (c) control beliefs (beliefs about factors that facilitate or prevent the performance of a behavior). The resulting attitudes from these beliefs lead to the formation of behavioral intentions and subsequent behavioral action. Beliefs are deemed modifiable if an individual stated such a belief during the intervention and subsequently initiated AUD treatment.

CBT-TS is longer than a typical one-session SBIRT intervention, is administered exclusively by telephone, has a singular target of promoting treatment seeking, and does not require follow-up interactions, all important practical considerations that are advantageous for its dissemination and potentially increase its potency. CBT-TS has been shown to be efficacious in increasing rates of treatment initiation rates among adults with mental and/or behavioral health diagnoses (Stecker 2010b). During the intervention, participants identify and elaborate on their thoughts about initiating alcohol treatment in a three-step process, in which participants are asked about their stated beliefs, whether the belief is 100% true, whether there are any alternative beliefs, and if anything could change the accuracy of the belief (i.e. how realistic is this belief). The term “belief” is used to represent participants’ thoughts or perceptions surrounding treatment-seeking behaviors. See Stecker et al. (2012) for a complete description of how “belief” is defined in this intervention. Thus far, it has been tested among veterans, active military, and community adults presenting with a range of diagnoses including post-traumatic stress disorder, suicidal ideation, and AUD.

Given the low rates of treatment engagement among adults with moderate–severe AUD (SAMHSA 2023), it is critical to promote the detection and treatment of this disorder in this population. The purpose of this study was to test the effectiveness of CBT-TS among a sample of community-based adults with moderate–severe AUD with no treatment history to improve treatment utilization. In this secondary analysis using qualitative methodology, we assessed participant characteristics and treatment seeking beliefs elicited during the CBT-TS intervention session to understand which beliefs were endorsed by those who did and did not initiate treatment, including potential changes in the number of drinking days.

Materials and Methods

Participants and procedures

Adults who resided in a contiguous 17-county region in western and central New York State for a phase-II RCT using a two-group parallel design with a 1:1 allocation ratio were recruited to participate in the trial testing the efficacy of CBT-TS to promote the use of alcohol-related treatment and improve alcohol use outcomes. Recruitment was conducted through social media advertisements, primarily Facebook, and referred to a telephone-based study for adults who may be concerned with their alcohol use and/or may be considering treatment. See ClinicalTrials.gov (NCT03758274) for further detail on the parent study design and aims. Individuals were eligible to participate in this study if they were 18 years or older, had no history of professional alcohol-related treatment use based on the Alcohol Use Disorders Identification and Associated Disabilities Interview (AUDADIS) version 5 (Grant et al. 2011) screening item: “Have you ever gone anywhere or seen anyone for a reason that was related in any way to your drinking—a physician, counselor or any other community agency or professional?”, scored a 16 or greater on the AUDIT (Saunders et al. 1993), and reported alcohol use in the past 30 days that exceeds the limit for low-risk drinking (U.S. Department of Health and Human Services and U.S. Department of Agriculture 2015). For participants that endorsed a history of treatment on the AUDADIS screening item, we confirmed they were not referring only to mutual help (e.g. A.A.), which was not an exclusion. Individuals were excluded from the study if they were non-English speaking, resided outside of the study catchment area, had a lifetime history of AUD treatment, and alcohol withdrawal requiring immediate medical evaluation. The study protocol was reviewed and approved by all participating institutional review boards. Recruitment and assessment spanned 1 March 2019 to 31 December 2021 and included baseline (prerandomization), 1-, 3-, and 6-month follow-ups. All 6-month follow-ups were completed within 6 months plus 21 days of the baseline assessment. All measures were administered via scheduled phone calls between study coordinators and participants. Of the 1925 individuals assessed for eligibility, 447 were referred to consent, of which 411 were consented and 406 completed baselines, with a final sample of 400 randomized (n = 197 to CBT-TS). Participants included in the present analysis were randomized into the intervention arm at baseline and completed the intervention session during baseline.

Intervention content

Participants in the intervention group received one 45–60-min telephone session administered by a trained research staff. The intervention aims to modify thoughts about treatment seeking to change behavior and is divided into four structured phases: (i) a brief assessment of the participant’s history of symptoms and current functioning to establish treatment need and highlight the impact of continuing to delay treatment, (ii) a brief assessment of the participant’s coping strategies to manage their symptoms, including what has and has not worked thus far to identify potential limitations of the participant’s current coping strategies and highlight the benefits of attending treatment, (iii) identifying the participant’s beliefs about AUD treatment, and working collaboratively with the participant to modify their beliefs and problem-solve stated practical barriers to seeking treatment, and (iv) to develop a short-term action plan. The interventionist recorded all four components on a structured worksheet for each participant, using verbatim language when possible, in real time during the phone call. Author T.S., the developer of CBT-TS, provided training in the intervention before delivery and supervised interventionists through bi-weekly group sessions to ensure fidelity and competency. Study interventionists included Ph-D-level clinicians, masters-level clinicians, and graduate students.

Measures

Demographics

Participants self-reported their age, race, ethnicity, sex, marital status, and income.

Alcohol use disorders identification test and alcohol use disorders identification and associated disabilities interview version 5

The alcohol use disorders identification test (AUDIT; Saunders et al. 1993) is a 10-item measure that assess alcohol intake, potential alcohol dependence, and experiences of alcohol-related harm. Scores range from 0 to 40. A threshold of 16-plus on the AUDIT was used to identify a sample in need of AUD treatment, consistent with recommendations based on extant research of the AUDIT (Babor et al. 2016). Subsequently, the alcohol use disorders identification and associated disabilities interview (AUDADIS; Grant 2011) diagnostic interview was administered to assess AUD symptoms. In the overall sample, all but one participant (99.75%) met criteria for AUD, and 91.25% of participants met criteria for severe AUD (i.e. 6-plus AUD symptoms), leading to our characterization of it as a severe AUD sample in need of AUD treatment. See our primary outcomes paper for this information (Conner et al. 2023).

Timeline follow back interview

The timeline follow back interview (TLFB; Sobell and Sobell 1996) provided a measure of alcohol use in the prior 30 days. Extensive research of the TLFB includes validation by telephone administration (Sobell and Sobell 1996; Maisto et al. 2008). TLFB data were used to calculate three measures of alcohol use in the prior 30 days: (i) the number of drinking days, a measure of drinking frequency; (ii) average number of standard drinks per drinking day, an assessment of average intensity of alcohol use; and (iii) number of days of heavy episodes of drinking (i.e. 4-plus for women, 5-plus for men), a measure of heavy, episodic alcohol use. The current paper describes the change in number of drinking days from baseline to months 1, 3, and 6 postintervention.

Treatment utilization

To assess treatment utilization, we used the AUDADIS (Grant, 2011) to assess the presence or absence of utilization at 1-, 3-, and 6-month follow-ups. Participants were asked whether they had initiated treatment (by both scheduling and attending the appointment) and, if they had, the number of treatment sessions they had attended. Sources of professional alcohol treatment services assessed for included: (i) family or social services agency; (ii) alcohol or drug detoxification ward or clinic; (iii) inpatient ward of a general hospital, community mental health program, or inpatient psychiatric hospital; (iv) outpatient program including day or partial hospital treatment; (v) alcohol or drug rehabilitation program; (vi) emergency room or urgent care facility; (vii) halfway house or therapeutic community; (viii) crisis center; (ix) employee assistance program; (x) member of the clergy including a priest, rabbi, or any type of religious counselor; and (xi) private provider including primary care physician, psychologist, psychiatrist, social worker, nurse, or another professional counselor. We also assessed the type of treatment received (including cognitive behavioral therapy [CBT], medications, or exposure therapy). The data were combined to provide a summary measure of the presence/absence of professional alcohol-related treatment over each follow-up period, and “presence” was coded if any of the 11 sources were used.

Statistical analyses

We used standard thematic analysis of inductive/deductive coding to code the worksheets. Thematic analysis is the systematic examination of text by identifying and grouping themes, coding them, and developing categories (Pope and Mays 1995). The first step in the coding process involved three independent coders (C.T., S.S., T.S.) reading through all intervention participant worksheets to code each belief. Following this, the three coders met to discuss the initial round of beliefs coded and their definitions of terminology, the collapsing of individual beliefs under larger categories (i.e. “I don’t want AA” or “I don’t want inpatient” was collapsed into an overarching category of having treatment preferences and “stigma about being an alcoholic” or “stigma about admitting a problem and seeking help” was collapsed into an overarching category of stigma about treatment), and discussed discrepant codes until a consensus was reached.

First, we report descriptive statistics of the sample’s demographic characteristics and alcohol use at baseline. Following this, we provide a description of the frequency of categories of beliefs discussed during the intervention by (i) the overall frequency of individuals who endorsed specific categories of beliefs and (ii) the frequency of categories of beliefs organized by participants who initiated treatment to examine which beliefs were associated with behavior change that led individuals to go to treatment. Then we provide Spearman correlations between each of the beliefs for the overall sample, followed by chi-square independence tests and independent-samples t-tests to examine for differences among those who did and did not attend treatment on endorsed beliefs and demographic characteristics. Finally, we separately discuss the patterns of change in number of days drinking from baseline to months 1, 3, and 6 post-intervention by categories of beliefs endorsed for the overall sample.

Results

A total of 197 individuals were eligible, randomized to the intervention, and completed the CBT-TS session. About half of participants were male (n = 90; 46%), 80% were racially White (n = 156; 80%), 13% were African American (n = 25), and 6% identified as Latinx (n = 12). On average, participants were 4.3 years old (SD = 1.43, range = 18–60 years old) and reported an average score of 22.6 on the AUDIT (SD = 5.03) and an average score of 8.2 on the AUDADIS (SD = 2.0). See Table 1.

Table 1

Sample characteristics

Variablen (%)
Gender
 Male90 (46%)
 Female107 (54%)
Race
 White158 (80%)
 Black26 (13%)
 Asian3 (2%)
 Native American/Alaskan1 (1%)
 More than one race8 (4%)
 Other1 (1%)
Hispanic/Latinx ethnicity12 (6%)
m (SD)
Age4.3 (1.5), range 18–60
AUDIT22.5 (5.0), range 16–39, IQR 18–26
Variablen (%)
Gender
 Male90 (46%)
 Female107 (54%)
Race
 White158 (80%)
 Black26 (13%)
 Asian3 (2%)
 Native American/Alaskan1 (1%)
 More than one race8 (4%)
 Other1 (1%)
Hispanic/Latinx ethnicity12 (6%)
m (SD)
Age4.3 (1.5), range 18–60
AUDIT22.5 (5.0), range 16–39, IQR 18–26
Table 1

Sample characteristics

Variablen (%)
Gender
 Male90 (46%)
 Female107 (54%)
Race
 White158 (80%)
 Black26 (13%)
 Asian3 (2%)
 Native American/Alaskan1 (1%)
 More than one race8 (4%)
 Other1 (1%)
Hispanic/Latinx ethnicity12 (6%)
m (SD)
Age4.3 (1.5), range 18–60
AUDIT22.5 (5.0), range 16–39, IQR 18–26
Variablen (%)
Gender
 Male90 (46%)
 Female107 (54%)
Race
 White158 (80%)
 Black26 (13%)
 Asian3 (2%)
 Native American/Alaskan1 (1%)
 More than one race8 (4%)
 Other1 (1%)
Hispanic/Latinx ethnicity12 (6%)
m (SD)
Age4.3 (1.5), range 18–60
AUDIT22.5 (5.0), range 16–39, IQR 18–26

The process of inductive/deductive thematic analysis collapsed 578 individual beliefs from the 197 participants into 16 overarching categories. The three most frequently reported categories were “having treatment preferences (i.e. AA, group or inpatient therapy, or medication),” “Treatment is positive,” and “Logistical issues.” Following these categories, roughly 30% of participants each reported that they “Do not have a drinking problem,” “Can handle it on their own,” and “Do not want to stop drinking.” The final 10 categories were endorsed by 2%–20% of participants.

Spearman correlations of the 16 categories of beliefs revealed significant positive associations between “Having treatment preferences” and “Stop drinking first” (r = .146, P < .05), “Not having a problem” and “Handling it themselves” (r = .222, P < .01), “Treatment is negative” and “Wanting medication” (r = .223, P < .01), and “I can do it alone” and “I want to stop drinking first” (r = .200, P < .01). Spearman correlations of the 16 categories of beliefs revealed significant negative associations between “I don’t have a problem” and “Treatment is positive” (r = −.222, P < .01), “I don’t have a problem” and “No information” (r = −.157, P < .05), “Handling it themselves” and “Treatment is positive” (r = −.198, P < .01), “Treatment is positive” and “No abstinence” (r = −.171, P < .05), “Stigma” and “Treatment is positive” (r = −.196, P < .01), and “Treatment is positive” and “Treatment is negative” (r = −.263, P < .01). See Table 2 for further details.

Table 2

Spearman correlations of beliefs

Tx preferencesNo problemHandle it myselfNo abstinenceStigmaTX is positiveTX is negativeTX is scaryLose job kids friendsCrisisLogisticsAloneNo infoStop drinking firstPrefer friendsWant meds
Tx preferences
No problem−0.089
Handle it myself−0.0150.222**
No abstinence0.0680.046−0.011
Stigma0.022−0.089−0.0440.017
TX is positive0.022−0.222**−0.198**−0.171*−0.196**
TX is negative0.067−0.0660.011−0.089−0.059−0.263**
TX is scary−0.054−0.0160.001−0.1130.012−0.034−0.031
Lose job kids friends−0.1100.052−0.0010.012−0.004−.046−0.083−.026
Crisis0.1230.0050.0570.038−0.021−0.0930.079−0.101−0.058
Logisitics−0.031−0.114−.0890.108−.023−0.064−0.122−.0830.080−.036
Alone0.002−0.128−0.0620.012−0.0040.010−0.083−0.095−.0370.0420.023
No info−0.107−0.157*−0.0850.0360.084−0.034−0.103−0.113−0.095−.054−.137−0.026
Stop drinking first0.146*0.008−0.080−0.0740.065−0.103−0.054−.062−0.0240.114−0.0960.200**−0.062
Prefer friends0.0230.062−0.0920.080−0.0610.029−0.0620.111−0.028−0.044−.036−0.028−.072−0.018
Want meds−0.054−0.128−0.123−0.114−0.004−.0460.223**−.026−0.037−.058−0.034−.037−0.095−.024−0.028
Tx preferencesNo problemHandle it myselfNo abstinenceStigmaTX is positiveTX is negativeTX is scaryLose job kids friendsCrisisLogisticsAloneNo infoStop drinking firstPrefer friendsWant meds
Tx preferences
No problem−0.089
Handle it myself−0.0150.222**
No abstinence0.0680.046−0.011
Stigma0.022−0.089−0.0440.017
TX is positive0.022−0.222**−0.198**−0.171*−0.196**
TX is negative0.067−0.0660.011−0.089−0.059−0.263**
TX is scary−0.054−0.0160.001−0.1130.012−0.034−0.031
Lose job kids friends−0.1100.052−0.0010.012−0.004−.046−0.083−.026
Crisis0.1230.0050.0570.038−0.021−0.0930.079−0.101−0.058
Logisitics−0.031−0.114−.0890.108−.023−0.064−0.122−.0830.080−.036
Alone0.002−0.128−0.0620.012−0.0040.010−0.083−0.095−.0370.0420.023
No info−0.107−0.157*−0.0850.0360.084−0.034−0.103−0.113−0.095−.054−.137−0.026
Stop drinking first0.146*0.008−0.080−0.0740.065−0.103−0.054−.062−0.0240.114−0.0960.200**−0.062
Prefer friends0.0230.062−0.0920.080−0.0610.029−0.0620.111−0.028−0.044−.036−0.028−.072−0.018
Want meds−0.054−0.128−0.123−0.114−0.004−.0460.223**−.026−0.037−.058−0.034−.037−0.095−.024−0.028

Note. * = P < .05, ** = P < .01.

Table 2

Spearman correlations of beliefs

Tx preferencesNo problemHandle it myselfNo abstinenceStigmaTX is positiveTX is negativeTX is scaryLose job kids friendsCrisisLogisticsAloneNo infoStop drinking firstPrefer friendsWant meds
Tx preferences
No problem−0.089
Handle it myself−0.0150.222**
No abstinence0.0680.046−0.011
Stigma0.022−0.089−0.0440.017
TX is positive0.022−0.222**−0.198**−0.171*−0.196**
TX is negative0.067−0.0660.011−0.089−0.059−0.263**
TX is scary−0.054−0.0160.001−0.1130.012−0.034−0.031
Lose job kids friends−0.1100.052−0.0010.012−0.004−.046−0.083−.026
Crisis0.1230.0050.0570.038−0.021−0.0930.079−0.101−0.058
Logisitics−0.031−0.114−.0890.108−.023−0.064−0.122−.0830.080−.036
Alone0.002−0.128−0.0620.012−0.0040.010−0.083−0.095−.0370.0420.023
No info−0.107−0.157*−0.0850.0360.084−0.034−0.103−0.113−0.095−.054−.137−0.026
Stop drinking first0.146*0.008−0.080−0.0740.065−0.103−0.054−.062−0.0240.114−0.0960.200**−0.062
Prefer friends0.0230.062−0.0920.080−0.0610.029−0.0620.111−0.028−0.044−.036−0.028−.072−0.018
Want meds−0.054−0.128−0.123−0.114−0.004−.0460.223**−.026−0.037−.058−0.034−.037−0.095−.024−0.028
Tx preferencesNo problemHandle it myselfNo abstinenceStigmaTX is positiveTX is negativeTX is scaryLose job kids friendsCrisisLogisticsAloneNo infoStop drinking firstPrefer friendsWant meds
Tx preferences
No problem−0.089
Handle it myself−0.0150.222**
No abstinence0.0680.046−0.011
Stigma0.022−0.089−0.0440.017
TX is positive0.022−0.222**−0.198**−0.171*−0.196**
TX is negative0.067−0.0660.011−0.089−0.059−0.263**
TX is scary−0.054−0.0160.001−0.1130.012−0.034−0.031
Lose job kids friends−0.1100.052−0.0010.012−0.004−.046−0.083−.026
Crisis0.1230.0050.0570.038−0.021−0.0930.079−0.101−0.058
Logisitics−0.031−0.114−.0890.108−.023−0.064−0.122−.0830.080−.036
Alone0.002−0.128−0.0620.012−0.0040.010−0.083−0.095−.0370.0420.023
No info−0.107−0.157*−0.0850.0360.084−0.034−0.103−0.113−0.095−.054−.137−0.026
Stop drinking first0.146*0.008−0.080−0.0740.065−0.103−0.054−.062−0.0240.114−0.0960.200**−0.062
Prefer friends0.0230.062−0.0920.080−0.0610.029−0.0620.111−0.028−0.044−.036−0.028−.072−0.018
Want meds−0.054−0.128−0.123−0.114−0.004−.0460.223**−.026−0.037−.058−0.034−.037−0.095−.024−0.028

Note. * = P < .05, ** = P < .01.

Overall, 38 (19.6%) of participants who received the CBT-TS intervention went to treatment during the trial. The most frequently endorsed categories of beliefs were: “Having treatment preferences (i.e. AA, group or inpatient therapy, or medication),” “Treatment is positive,” and “Treatment is scary.” Following these, ~20% of participants who attended treatment each endorsed “Logistical issues,” “Not having enough information about treatment,” and “Stigma about treatment.” The final 10 categories of beliefs were endorsed by 0%–16% of participants. Table 3 presents frequencies of categories of belief endorsement among participants who received the intervention and among those who attended treatment, in addition to providing frequencies of those who attended treatment by gender and race.

Table 3

Frequency of beliefs of those who attended treatment

Belief categoriesFrequency of individuals who endorsed this belief and received the intervention (n = 194)Frequency of individuals who endorsed this belief, received the intervention, and attended treatment (n = 38)Frequency of
individuals who
endorse this
belief and
attended
treatment: gender
Frequency of
individuals who
endorse this
belief and
attended
treatment: race
Men (n = 20)Women (n = 18)White (n = 29)Black (n = 6)More than one race (n = 3)
Having treatment preferences82 (42.3%)19 (50%)12 (38%)7 (14%)17 (59%)2 (33%)0 (0%)
Treatment is positive79 (4.7%)18 (47%)8 (40%)10 (55.6%)12 (41%)5 (83%)1 (33%)
Logistical issues73 (37.6%)8 (21%)5 (25%)3 (17%)5 (17%)2 (33%)1 (33%)
I don’t have a problem59 (3.4%)6 (16%)3 (15%)3 (17%)5 (17%)0 (0%)1 (33%)
I can handle it myself56 (28.9%)5 (13%)1 (5%)4 (22%)5 (17%)0 (0%)0 (0%)
I don’t want to stop drinking50 (25.8%)5 (13%)4 (20%)1 (20%)5 (17%)0 (0%)0 (0%)
Treatment is scary38 (19.6%)9 (24%)3 (15%)6 (33%)7 (24%)1 (17%)1 (33%)
I don’t have enough info38 (19.6%)8 (21%)4 (20%)4 (22%)7 (24%)1 (17%)0 (0%)
Treatment is negative30 (15.5%)6 (16%)3 (15%)3 (17%)5 (17%)0 (0%)1 (33%)
Stigma29 (14.9%)7 (18%)3 (15%)4 (22%)7 (24%)0 (0%)0 (0%)
I will wait for a crisis16 (8.2%)2 (5%)2 (10%)0 (0%)2 (7%)2 (7%)0 (0%)
I will lose my job/kids/friends7 (3.6%)1 (3%)1 (5%)0 (0%)0 (0%)0 (0%)1 (33%)
It’s hard to do it alone7 (3.6%)0 (0%)0 (0%)0 (0%)0 (0%)0 (0%)0 (0%)
I want medications7 (3.6%)4 (11%)4 (20%)0 (0%)4 (14%)0 (0%)0 (0%)
I’d rather get help from friends4 (2.1%)1 (3%)0% (0%)1 (6%)0 (0%)1 (17%)0 (0%)
I need to stop drinking first3 (1.5%)1 (3%)1 (5%)0 (0%)1 (3%)0 (0%)0 (0%)
Belief categoriesFrequency of individuals who endorsed this belief and received the intervention (n = 194)Frequency of individuals who endorsed this belief, received the intervention, and attended treatment (n = 38)Frequency of
individuals who
endorse this
belief and
attended
treatment: gender
Frequency of
individuals who
endorse this
belief and
attended
treatment: race
Men (n = 20)Women (n = 18)White (n = 29)Black (n = 6)More than one race (n = 3)
Having treatment preferences82 (42.3%)19 (50%)12 (38%)7 (14%)17 (59%)2 (33%)0 (0%)
Treatment is positive79 (4.7%)18 (47%)8 (40%)10 (55.6%)12 (41%)5 (83%)1 (33%)
Logistical issues73 (37.6%)8 (21%)5 (25%)3 (17%)5 (17%)2 (33%)1 (33%)
I don’t have a problem59 (3.4%)6 (16%)3 (15%)3 (17%)5 (17%)0 (0%)1 (33%)
I can handle it myself56 (28.9%)5 (13%)1 (5%)4 (22%)5 (17%)0 (0%)0 (0%)
I don’t want to stop drinking50 (25.8%)5 (13%)4 (20%)1 (20%)5 (17%)0 (0%)0 (0%)
Treatment is scary38 (19.6%)9 (24%)3 (15%)6 (33%)7 (24%)1 (17%)1 (33%)
I don’t have enough info38 (19.6%)8 (21%)4 (20%)4 (22%)7 (24%)1 (17%)0 (0%)
Treatment is negative30 (15.5%)6 (16%)3 (15%)3 (17%)5 (17%)0 (0%)1 (33%)
Stigma29 (14.9%)7 (18%)3 (15%)4 (22%)7 (24%)0 (0%)0 (0%)
I will wait for a crisis16 (8.2%)2 (5%)2 (10%)0 (0%)2 (7%)2 (7%)0 (0%)
I will lose my job/kids/friends7 (3.6%)1 (3%)1 (5%)0 (0%)0 (0%)0 (0%)1 (33%)
It’s hard to do it alone7 (3.6%)0 (0%)0 (0%)0 (0%)0 (0%)0 (0%)0 (0%)
I want medications7 (3.6%)4 (11%)4 (20%)0 (0%)4 (14%)0 (0%)0 (0%)
I’d rather get help from friends4 (2.1%)1 (3%)0% (0%)1 (6%)0 (0%)1 (17%)0 (0%)
I need to stop drinking first3 (1.5%)1 (3%)1 (5%)0 (0%)1 (3%)0 (0%)0 (0%)
Table 3

Frequency of beliefs of those who attended treatment

Belief categoriesFrequency of individuals who endorsed this belief and received the intervention (n = 194)Frequency of individuals who endorsed this belief, received the intervention, and attended treatment (n = 38)Frequency of
individuals who
endorse this
belief and
attended
treatment: gender
Frequency of
individuals who
endorse this
belief and
attended
treatment: race
Men (n = 20)Women (n = 18)White (n = 29)Black (n = 6)More than one race (n = 3)
Having treatment preferences82 (42.3%)19 (50%)12 (38%)7 (14%)17 (59%)2 (33%)0 (0%)
Treatment is positive79 (4.7%)18 (47%)8 (40%)10 (55.6%)12 (41%)5 (83%)1 (33%)
Logistical issues73 (37.6%)8 (21%)5 (25%)3 (17%)5 (17%)2 (33%)1 (33%)
I don’t have a problem59 (3.4%)6 (16%)3 (15%)3 (17%)5 (17%)0 (0%)1 (33%)
I can handle it myself56 (28.9%)5 (13%)1 (5%)4 (22%)5 (17%)0 (0%)0 (0%)
I don’t want to stop drinking50 (25.8%)5 (13%)4 (20%)1 (20%)5 (17%)0 (0%)0 (0%)
Treatment is scary38 (19.6%)9 (24%)3 (15%)6 (33%)7 (24%)1 (17%)1 (33%)
I don’t have enough info38 (19.6%)8 (21%)4 (20%)4 (22%)7 (24%)1 (17%)0 (0%)
Treatment is negative30 (15.5%)6 (16%)3 (15%)3 (17%)5 (17%)0 (0%)1 (33%)
Stigma29 (14.9%)7 (18%)3 (15%)4 (22%)7 (24%)0 (0%)0 (0%)
I will wait for a crisis16 (8.2%)2 (5%)2 (10%)0 (0%)2 (7%)2 (7%)0 (0%)
I will lose my job/kids/friends7 (3.6%)1 (3%)1 (5%)0 (0%)0 (0%)0 (0%)1 (33%)
It’s hard to do it alone7 (3.6%)0 (0%)0 (0%)0 (0%)0 (0%)0 (0%)0 (0%)
I want medications7 (3.6%)4 (11%)4 (20%)0 (0%)4 (14%)0 (0%)0 (0%)
I’d rather get help from friends4 (2.1%)1 (3%)0% (0%)1 (6%)0 (0%)1 (17%)0 (0%)
I need to stop drinking first3 (1.5%)1 (3%)1 (5%)0 (0%)1 (3%)0 (0%)0 (0%)
Belief categoriesFrequency of individuals who endorsed this belief and received the intervention (n = 194)Frequency of individuals who endorsed this belief, received the intervention, and attended treatment (n = 38)Frequency of
individuals who
endorse this
belief and
attended
treatment: gender
Frequency of
individuals who
endorse this
belief and
attended
treatment: race
Men (n = 20)Women (n = 18)White (n = 29)Black (n = 6)More than one race (n = 3)
Having treatment preferences82 (42.3%)19 (50%)12 (38%)7 (14%)17 (59%)2 (33%)0 (0%)
Treatment is positive79 (4.7%)18 (47%)8 (40%)10 (55.6%)12 (41%)5 (83%)1 (33%)
Logistical issues73 (37.6%)8 (21%)5 (25%)3 (17%)5 (17%)2 (33%)1 (33%)
I don’t have a problem59 (3.4%)6 (16%)3 (15%)3 (17%)5 (17%)0 (0%)1 (33%)
I can handle it myself56 (28.9%)5 (13%)1 (5%)4 (22%)5 (17%)0 (0%)0 (0%)
I don’t want to stop drinking50 (25.8%)5 (13%)4 (20%)1 (20%)5 (17%)0 (0%)0 (0%)
Treatment is scary38 (19.6%)9 (24%)3 (15%)6 (33%)7 (24%)1 (17%)1 (33%)
I don’t have enough info38 (19.6%)8 (21%)4 (20%)4 (22%)7 (24%)1 (17%)0 (0%)
Treatment is negative30 (15.5%)6 (16%)3 (15%)3 (17%)5 (17%)0 (0%)1 (33%)
Stigma29 (14.9%)7 (18%)3 (15%)4 (22%)7 (24%)0 (0%)0 (0%)
I will wait for a crisis16 (8.2%)2 (5%)2 (10%)0 (0%)2 (7%)2 (7%)0 (0%)
I will lose my job/kids/friends7 (3.6%)1 (3%)1 (5%)0 (0%)0 (0%)0 (0%)1 (33%)
It’s hard to do it alone7 (3.6%)0 (0%)0 (0%)0 (0%)0 (0%)0 (0%)0 (0%)
I want medications7 (3.6%)4 (11%)4 (20%)0 (0%)4 (14%)0 (0%)0 (0%)
I’d rather get help from friends4 (2.1%)1 (3%)0% (0%)1 (6%)0 (0%)1 (17%)0 (0%)
I need to stop drinking first3 (1.5%)1 (3%)1 (5%)0 (0%)1 (3%)0 (0%)0 (0%)

Overall, 156 (8.4%) of participants who received the CBT-TS intervention did not attend treatment during the trial. The most frequently endorsed categories of beliefs were: “Logistical issues,” “Having treatment preferences (i.e. AA, group or inpatient therapy, or medication),” and “Treatment is positive.” Following these, ~30% of participants who did not attend treatment each endorsed “Not having a problem,” “Handling it themselves,” and “Not wanting to stop drinking.” The final 10 categories of beliefs were endorsed by 1%–19% of participants. Table 4 presents frequencies of categories of belief endorsement among participants who received the intervention and did not attend treatment, in addition to providing frequencies of those who did not attend treatment by gender and race.

Table 4

Frequency of beliefs of those who did not attend treatment

Belief categoriesFrequency of individuals who endorsed this belief and received the intervention (n = 194)Frequency of individuals who endorsed this belief, received the intervention and did not attend treatment (n = 156)Frequency of
individuals who
endorse this
belief and
did not attend
treatment: gender
Frequency of
individuals who
endorse this
belief and
did not attend
treatment: race
Men (n = 70)Women (n = 86)White (n = 127)Black (n = 19)More than one race (n = 10)
Having treatment preferences82 (42.3%)63 (40%)20 (27%)43 (50%)54 (43%)6 (32%)3 (30%)
Treatment is positive79 (4.7%)60 (38%)24 (34%)36 (42%)48 (38%)10 (53%)2 (20%)
Logistical issues73 (37.6%)64 (41%)24 (34%)40 (47%)51 (40%)10 (53%)3 (30%)
I don’t have a problem59 (3.4%)53 (34%)28 (40%)25 (29%)44 (35%)4 (21%)5 (50%)
I can handle it myself56 (28.9%)51 (33%)25 (36%)26 (30%)44 (35%)5 (26%)2 (20%)
I don’t want to stop drinking50 (25.8%)45 (29%)20 (29%)25 (29%)36 (30%)3 (16%)4 (40%)
Treatment is scary38 (19.6%)29 (19%)15 (21%)14 (16%)25 (20%)3 (16%)1 (10%)
I don’t have enough info38 (19.6%)30 (19%)15 (21%)15 (17%)23 (18%)4 (21%)3 (30%)
Treatment is negative30 (15.5%)24 (15%)12 (17%)12 (14%)22 (17%)1 (5%)1 (10%)
Stigma29 (14.9%)22 (14%)7 (10%)15 (17%)20 (16%)0 (0%)2 (20%)
I will wait for a crisis16 (8.2%)14 (9%)5 (7%)9 (11%)9 (7%)3 (16%)2 (20%)
I will lose my job/kids/friends7 (3.6%)6 (4%)1 (1%)5 (6%)5 (4%)2 (11%)0 (0%)
It’s hard to do it alone7 (3.6%)7 (5%)4 (6%)3 (4%)5 (4%)0 (0%)0 (0%)
I want medications7 (3.6%)3 (2%)3 (4%)0 (0%)2 (2%)1 (5%)0 (0%)
I’d rather get help from friends4 (2.1%)1 (1%)1 (1%)2 (2%)2 (2%)0 (0%)1 (10%)
I need to stop drinking first3 (1.5%)1 (1%)1 (1%)1 (1%)1 (1%)1 (5%)0 (0%)
Belief categoriesFrequency of individuals who endorsed this belief and received the intervention (n = 194)Frequency of individuals who endorsed this belief, received the intervention and did not attend treatment (n = 156)Frequency of
individuals who
endorse this
belief and
did not attend
treatment: gender
Frequency of
individuals who
endorse this
belief and
did not attend
treatment: race
Men (n = 70)Women (n = 86)White (n = 127)Black (n = 19)More than one race (n = 10)
Having treatment preferences82 (42.3%)63 (40%)20 (27%)43 (50%)54 (43%)6 (32%)3 (30%)
Treatment is positive79 (4.7%)60 (38%)24 (34%)36 (42%)48 (38%)10 (53%)2 (20%)
Logistical issues73 (37.6%)64 (41%)24 (34%)40 (47%)51 (40%)10 (53%)3 (30%)
I don’t have a problem59 (3.4%)53 (34%)28 (40%)25 (29%)44 (35%)4 (21%)5 (50%)
I can handle it myself56 (28.9%)51 (33%)25 (36%)26 (30%)44 (35%)5 (26%)2 (20%)
I don’t want to stop drinking50 (25.8%)45 (29%)20 (29%)25 (29%)36 (30%)3 (16%)4 (40%)
Treatment is scary38 (19.6%)29 (19%)15 (21%)14 (16%)25 (20%)3 (16%)1 (10%)
I don’t have enough info38 (19.6%)30 (19%)15 (21%)15 (17%)23 (18%)4 (21%)3 (30%)
Treatment is negative30 (15.5%)24 (15%)12 (17%)12 (14%)22 (17%)1 (5%)1 (10%)
Stigma29 (14.9%)22 (14%)7 (10%)15 (17%)20 (16%)0 (0%)2 (20%)
I will wait for a crisis16 (8.2%)14 (9%)5 (7%)9 (11%)9 (7%)3 (16%)2 (20%)
I will lose my job/kids/friends7 (3.6%)6 (4%)1 (1%)5 (6%)5 (4%)2 (11%)0 (0%)
It’s hard to do it alone7 (3.6%)7 (5%)4 (6%)3 (4%)5 (4%)0 (0%)0 (0%)
I want medications7 (3.6%)3 (2%)3 (4%)0 (0%)2 (2%)1 (5%)0 (0%)
I’d rather get help from friends4 (2.1%)1 (1%)1 (1%)2 (2%)2 (2%)0 (0%)1 (10%)
I need to stop drinking first3 (1.5%)1 (1%)1 (1%)1 (1%)1 (1%)1 (5%)0 (0%)
Table 4

Frequency of beliefs of those who did not attend treatment

Belief categoriesFrequency of individuals who endorsed this belief and received the intervention (n = 194)Frequency of individuals who endorsed this belief, received the intervention and did not attend treatment (n = 156)Frequency of
individuals who
endorse this
belief and
did not attend
treatment: gender
Frequency of
individuals who
endorse this
belief and
did not attend
treatment: race
Men (n = 70)Women (n = 86)White (n = 127)Black (n = 19)More than one race (n = 10)
Having treatment preferences82 (42.3%)63 (40%)20 (27%)43 (50%)54 (43%)6 (32%)3 (30%)
Treatment is positive79 (4.7%)60 (38%)24 (34%)36 (42%)48 (38%)10 (53%)2 (20%)
Logistical issues73 (37.6%)64 (41%)24 (34%)40 (47%)51 (40%)10 (53%)3 (30%)
I don’t have a problem59 (3.4%)53 (34%)28 (40%)25 (29%)44 (35%)4 (21%)5 (50%)
I can handle it myself56 (28.9%)51 (33%)25 (36%)26 (30%)44 (35%)5 (26%)2 (20%)
I don’t want to stop drinking50 (25.8%)45 (29%)20 (29%)25 (29%)36 (30%)3 (16%)4 (40%)
Treatment is scary38 (19.6%)29 (19%)15 (21%)14 (16%)25 (20%)3 (16%)1 (10%)
I don’t have enough info38 (19.6%)30 (19%)15 (21%)15 (17%)23 (18%)4 (21%)3 (30%)
Treatment is negative30 (15.5%)24 (15%)12 (17%)12 (14%)22 (17%)1 (5%)1 (10%)
Stigma29 (14.9%)22 (14%)7 (10%)15 (17%)20 (16%)0 (0%)2 (20%)
I will wait for a crisis16 (8.2%)14 (9%)5 (7%)9 (11%)9 (7%)3 (16%)2 (20%)
I will lose my job/kids/friends7 (3.6%)6 (4%)1 (1%)5 (6%)5 (4%)2 (11%)0 (0%)
It’s hard to do it alone7 (3.6%)7 (5%)4 (6%)3 (4%)5 (4%)0 (0%)0 (0%)
I want medications7 (3.6%)3 (2%)3 (4%)0 (0%)2 (2%)1 (5%)0 (0%)
I’d rather get help from friends4 (2.1%)1 (1%)1 (1%)2 (2%)2 (2%)0 (0%)1 (10%)
I need to stop drinking first3 (1.5%)1 (1%)1 (1%)1 (1%)1 (1%)1 (5%)0 (0%)
Belief categoriesFrequency of individuals who endorsed this belief and received the intervention (n = 194)Frequency of individuals who endorsed this belief, received the intervention and did not attend treatment (n = 156)Frequency of
individuals who
endorse this
belief and
did not attend
treatment: gender
Frequency of
individuals who
endorse this
belief and
did not attend
treatment: race
Men (n = 70)Women (n = 86)White (n = 127)Black (n = 19)More than one race (n = 10)
Having treatment preferences82 (42.3%)63 (40%)20 (27%)43 (50%)54 (43%)6 (32%)3 (30%)
Treatment is positive79 (4.7%)60 (38%)24 (34%)36 (42%)48 (38%)10 (53%)2 (20%)
Logistical issues73 (37.6%)64 (41%)24 (34%)40 (47%)51 (40%)10 (53%)3 (30%)
I don’t have a problem59 (3.4%)53 (34%)28 (40%)25 (29%)44 (35%)4 (21%)5 (50%)
I can handle it myself56 (28.9%)51 (33%)25 (36%)26 (30%)44 (35%)5 (26%)2 (20%)
I don’t want to stop drinking50 (25.8%)45 (29%)20 (29%)25 (29%)36 (30%)3 (16%)4 (40%)
Treatment is scary38 (19.6%)29 (19%)15 (21%)14 (16%)25 (20%)3 (16%)1 (10%)
I don’t have enough info38 (19.6%)30 (19%)15 (21%)15 (17%)23 (18%)4 (21%)3 (30%)
Treatment is negative30 (15.5%)24 (15%)12 (17%)12 (14%)22 (17%)1 (5%)1 (10%)
Stigma29 (14.9%)22 (14%)7 (10%)15 (17%)20 (16%)0 (0%)2 (20%)
I will wait for a crisis16 (8.2%)14 (9%)5 (7%)9 (11%)9 (7%)3 (16%)2 (20%)
I will lose my job/kids/friends7 (3.6%)6 (4%)1 (1%)5 (6%)5 (4%)2 (11%)0 (0%)
It’s hard to do it alone7 (3.6%)7 (5%)4 (6%)3 (4%)5 (4%)0 (0%)0 (0%)
I want medications7 (3.6%)3 (2%)3 (4%)0 (0%)2 (2%)1 (5%)0 (0%)
I’d rather get help from friends4 (2.1%)1 (1%)1 (1%)2 (2%)2 (2%)0 (0%)1 (10%)
I need to stop drinking first3 (1.5%)1 (1%)1 (1%)1 (1%)1 (1%)1 (5%)0 (0%)

We ran chi-square independence tests to examine group differences among participants who attended or did not attend treatment following the CBT-TS intervention in demographic characteristics and treatment-seeking beliefs. Several significant differences were noted: participants who attended treatment were more likely to be older (t = −2.007, P = .046) and endorse “Wanting meds” (χ2 = 6.503, P = .011), whereas participants who did not attend treatment were more likely to endorse “Not having a problem” (χ2 = 4.775, P = .029), “Handling it themselves” (χ2 = 5.679, P = .017), “Not wanting to stop drinking” (χ2 = 3.931, P = .047), and “Logistics” (χ2 = 5.223, P = .022). See Table 5 for more details.

Table 5

Demographic and belief categories group differences among participants who attended or did not attend treatment at 1 or 3 months

Variable% attenders who endorsed belief% did not attend who endorsed beliefChi-squareDfP-value
Treatment-seeking beliefs
Having treatment preferences50.0%4.4%1.1581.282
Not having a problem15.8%34.0%4.7751.029*
Handle it myself13.2%32.7%5.6791.017*
Not wanting to stop drinking13.2%28.8%3.9311.047*
Stigma18.4%14.1%0.4481.503
Treatment is positive47.4%38.5%1.0081.315
Treatment is negative15.8%15.4%0.0041.951
Treatment is scary23.7%18.6%0.5031.478
I will lose my job/kids/friends2.6%3.8%0.1301.719
I will wait for a crisis5.3%9.0%0.5561.456
Logistics21.1%41.0%5.2231.022**
It’s hard to do alone0.0%4.5%1.7691.184
I don’t have enough information21.1%19.2%0.0641.800
I want to stop drinking first2.6%1.3%0.3661.545
I’d rather get help from friends2.6%1.9%0.0761.783
I want medication1.5%1.9%6.5031.011*
Demographics
Ethnicity
 Hispanic
 Non-Hispanic
0%
100%
7.5%
92.5%
3.0541.081
Gender
 Male
 Female
52.6%
47.4%
44.0%
56.0%
0.9161.339
Race
 White
 Black
 NA/AN
 A/PI
 More than one race
 Other
76.3%
15.8%
.0%
.0%
7.9%
.0%
81.1%
12.6%
.6%
1.9%
3.1%
.6%
3.2275.665
M (SD) attendersM (SD) did not attendt-testDfP-value
Age43.37 (9.16)39.59 (1.70)−2.007195.046*
Education (in years)14.63 (2.02)14.52 (1.84)−0.332194.740
Income4.66 (1.74)4.80 (1.48)0.508195.612
Baseline AUDIT23.63 (4.50)22.27 (5.12)−1.506195.134
Variable% attenders who endorsed belief% did not attend who endorsed beliefChi-squareDfP-value
Treatment-seeking beliefs
Having treatment preferences50.0%4.4%1.1581.282
Not having a problem15.8%34.0%4.7751.029*
Handle it myself13.2%32.7%5.6791.017*
Not wanting to stop drinking13.2%28.8%3.9311.047*
Stigma18.4%14.1%0.4481.503
Treatment is positive47.4%38.5%1.0081.315
Treatment is negative15.8%15.4%0.0041.951
Treatment is scary23.7%18.6%0.5031.478
I will lose my job/kids/friends2.6%3.8%0.1301.719
I will wait for a crisis5.3%9.0%0.5561.456
Logistics21.1%41.0%5.2231.022**
It’s hard to do alone0.0%4.5%1.7691.184
I don’t have enough information21.1%19.2%0.0641.800
I want to stop drinking first2.6%1.3%0.3661.545
I’d rather get help from friends2.6%1.9%0.0761.783
I want medication1.5%1.9%6.5031.011*
Demographics
Ethnicity
 Hispanic
 Non-Hispanic
0%
100%
7.5%
92.5%
3.0541.081
Gender
 Male
 Female
52.6%
47.4%
44.0%
56.0%
0.9161.339
Race
 White
 Black
 NA/AN
 A/PI
 More than one race
 Other
76.3%
15.8%
.0%
.0%
7.9%
.0%
81.1%
12.6%
.6%
1.9%
3.1%
.6%
3.2275.665
M (SD) attendersM (SD) did not attendt-testDfP-value
Age43.37 (9.16)39.59 (1.70)−2.007195.046*
Education (in years)14.63 (2.02)14.52 (1.84)−0.332194.740
Income4.66 (1.74)4.80 (1.48)0.508195.612
Baseline AUDIT23.63 (4.50)22.27 (5.12)−1.506195.134

Note. P < .05*, P < .01**.

Table 5

Demographic and belief categories group differences among participants who attended or did not attend treatment at 1 or 3 months

Variable% attenders who endorsed belief% did not attend who endorsed beliefChi-squareDfP-value
Treatment-seeking beliefs
Having treatment preferences50.0%4.4%1.1581.282
Not having a problem15.8%34.0%4.7751.029*
Handle it myself13.2%32.7%5.6791.017*
Not wanting to stop drinking13.2%28.8%3.9311.047*
Stigma18.4%14.1%0.4481.503
Treatment is positive47.4%38.5%1.0081.315
Treatment is negative15.8%15.4%0.0041.951
Treatment is scary23.7%18.6%0.5031.478
I will lose my job/kids/friends2.6%3.8%0.1301.719
I will wait for a crisis5.3%9.0%0.5561.456
Logistics21.1%41.0%5.2231.022**
It’s hard to do alone0.0%4.5%1.7691.184
I don’t have enough information21.1%19.2%0.0641.800
I want to stop drinking first2.6%1.3%0.3661.545
I’d rather get help from friends2.6%1.9%0.0761.783
I want medication1.5%1.9%6.5031.011*
Demographics
Ethnicity
 Hispanic
 Non-Hispanic
0%
100%
7.5%
92.5%
3.0541.081
Gender
 Male
 Female
52.6%
47.4%
44.0%
56.0%
0.9161.339
Race
 White
 Black
 NA/AN
 A/PI
 More than one race
 Other
76.3%
15.8%
.0%
.0%
7.9%
.0%
81.1%
12.6%
.6%
1.9%
3.1%
.6%
3.2275.665
M (SD) attendersM (SD) did not attendt-testDfP-value
Age43.37 (9.16)39.59 (1.70)−2.007195.046*
Education (in years)14.63 (2.02)14.52 (1.84)−0.332194.740
Income4.66 (1.74)4.80 (1.48)0.508195.612
Baseline AUDIT23.63 (4.50)22.27 (5.12)−1.506195.134
Variable% attenders who endorsed belief% did not attend who endorsed beliefChi-squareDfP-value
Treatment-seeking beliefs
Having treatment preferences50.0%4.4%1.1581.282
Not having a problem15.8%34.0%4.7751.029*
Handle it myself13.2%32.7%5.6791.017*
Not wanting to stop drinking13.2%28.8%3.9311.047*
Stigma18.4%14.1%0.4481.503
Treatment is positive47.4%38.5%1.0081.315
Treatment is negative15.8%15.4%0.0041.951
Treatment is scary23.7%18.6%0.5031.478
I will lose my job/kids/friends2.6%3.8%0.1301.719
I will wait for a crisis5.3%9.0%0.5561.456
Logistics21.1%41.0%5.2231.022**
It’s hard to do alone0.0%4.5%1.7691.184
I don’t have enough information21.1%19.2%0.0641.800
I want to stop drinking first2.6%1.3%0.3661.545
I’d rather get help from friends2.6%1.9%0.0761.783
I want medication1.5%1.9%6.5031.011*
Demographics
Ethnicity
 Hispanic
 Non-Hispanic
0%
100%
7.5%
92.5%
3.0541.081
Gender
 Male
 Female
52.6%
47.4%
44.0%
56.0%
0.9161.339
Race
 White
 Black
 NA/AN
 A/PI
 More than one race
 Other
76.3%
15.8%
.0%
.0%
7.9%
.0%
81.1%
12.6%
.6%
1.9%
3.1%
.6%
3.2275.665
M (SD) attendersM (SD) did not attendt-testDfP-value
Age43.37 (9.16)39.59 (1.70)−2.007195.046*
Education (in years)14.63 (2.02)14.52 (1.84)−0.332194.740
Income4.66 (1.74)4.80 (1.48)0.508195.612
Baseline AUDIT23.63 (4.50)22.27 (5.12)−1.506195.134

Note. P < .05*, P < .01**.

Using the overall sample (n = 194), we conducted a general linear model, which demonstrated a significant linear reduction in the number of drinking days from baseline to 6 months postintervention (Λ = .889, F = 7.142, P < .001, ηp2 = .111). Thus, regardless of the category of belief endorsed or participants’ subsequent treatment-seeking behaviors, the majority of participants reduced their drinking behaviors following the intervention. Tests of within-subjects effects revealed a significant reduction in drinking days (Huynh–Feldt, F = 9.658 (df = 2.729), P < .001, ηp2 = .053), and one significant interaction between drinking days and “Do not have a problem” (Huynh–Feldt, F = 3.290 (df = 2.729), P = .024, ηp2 = .019). Descriptive results reveal certain categories of beliefs highlight different, nonsignificant patterns of change in drinking behaviors postintervention. Specifically, participants who endorsed that they “Do not have a problem” saw most of their reduction in days drinking in the first month, with smaller reductions at the 3- and 6-month follow-ups compared to most other endorsed categories that saw continued moderate reductions in drinking days over time. Additionally, participants who endorsed “Stigma about treatment” and that they “Would rather get help from their friends” were the only two categories of beliefs that did not see a linear trend in reduced number of days drinking from baseline to months 1, 3, and 6 post-intervention, but instead saw both reduction and subsequently increased number of drinking days across the follow-up period. See Table 6 for more details.

Table 6

Change in number of days drinking from baseline to 6 months post-intervention among subjects who endorsed the belief categories

Belief categoriesDelta days drinking: baseline–1 month
(among subjects who endorse the belief)
Delta days drinking: baseline–3 months
(among subjects who endorse the belief)
Delta days drinking: baseline–6 months
(among subjects who endorse the belief)
Has treatment preferences (n = 82)−3.30 (6.41)−6.67 (8.89)−6.56 (9.60)
Treatment is positive (n = 79)−3.62 (6.00)−7.18 (8.84)−8.52 (9.52)
Logistical issues (n = 73)−3.41 (6.00)−7.67 (9.32)−9.59 (11.16)
I don’t have a problem (n = 59)−4.07 (6.21)−6.56 (8.00)−6.69 (9.28)
I can handle it myself (n = 56)−3.71 (4.82)−6.88 (7.58)−9.09 (8.65)
I don’t want to stop drinking (n = 50)−2.32 (6.16)−5.26 (8.81)−7.44 (9.51)
Treatment is scary (n = 38)−3.58 (5.19)−7.37 (8.10)−7.54 (8.20)
I don’t have enough info (n = 38)−3.29 (7.02)−7.24 (8.77)−8.39 (8.89)
Treatment is negative (n = 30)−4.10 (8.83−6.62 (9.52)−7.48 (11.81)
Stigma (n = 29)−3.62 (6.62)−6.69 (9.66)−6.00 (1.54)
I will wait for a crisis (n = 16)−3.13 (7.10)−7.94 (6.50)−8.88 (9.13)
I will lose my job/kids/friends (n = 7)−6.00 (9.92)−4.29 (7.72)−12.43 (12.73)
It’s hard to do it alone (n = 7)−2.86 (5.43)−7.14 (12.93)−7.56 (11.13)
I want medications (n = 7)−8.56 (1.34)−5.33 (12.12)−5.33 (12.09)
I’d rather get help from friends (n = 4)0.75 (2.99)−7.00 (7.62)−3.75 (5.56)
I need to stop drinking first (n = 3)−7.67 (3.51)−5.33 (7.58)−6.67 (13.28)
Intervention group overall means and SDs (for comparison)−3.61 (6.40)−6.84 (8.65)−8.26 (9.80)
Belief categoriesDelta days drinking: baseline–1 month
(among subjects who endorse the belief)
Delta days drinking: baseline–3 months
(among subjects who endorse the belief)
Delta days drinking: baseline–6 months
(among subjects who endorse the belief)
Has treatment preferences (n = 82)−3.30 (6.41)−6.67 (8.89)−6.56 (9.60)
Treatment is positive (n = 79)−3.62 (6.00)−7.18 (8.84)−8.52 (9.52)
Logistical issues (n = 73)−3.41 (6.00)−7.67 (9.32)−9.59 (11.16)
I don’t have a problem (n = 59)−4.07 (6.21)−6.56 (8.00)−6.69 (9.28)
I can handle it myself (n = 56)−3.71 (4.82)−6.88 (7.58)−9.09 (8.65)
I don’t want to stop drinking (n = 50)−2.32 (6.16)−5.26 (8.81)−7.44 (9.51)
Treatment is scary (n = 38)−3.58 (5.19)−7.37 (8.10)−7.54 (8.20)
I don’t have enough info (n = 38)−3.29 (7.02)−7.24 (8.77)−8.39 (8.89)
Treatment is negative (n = 30)−4.10 (8.83−6.62 (9.52)−7.48 (11.81)
Stigma (n = 29)−3.62 (6.62)−6.69 (9.66)−6.00 (1.54)
I will wait for a crisis (n = 16)−3.13 (7.10)−7.94 (6.50)−8.88 (9.13)
I will lose my job/kids/friends (n = 7)−6.00 (9.92)−4.29 (7.72)−12.43 (12.73)
It’s hard to do it alone (n = 7)−2.86 (5.43)−7.14 (12.93)−7.56 (11.13)
I want medications (n = 7)−8.56 (1.34)−5.33 (12.12)−5.33 (12.09)
I’d rather get help from friends (n = 4)0.75 (2.99)−7.00 (7.62)−3.75 (5.56)
I need to stop drinking first (n = 3)−7.67 (3.51)−5.33 (7.58)−6.67 (13.28)
Intervention group overall means and SDs (for comparison)−3.61 (6.40)−6.84 (8.65)−8.26 (9.80)

Note. Negative values indicate the mean number of reduced drinking days between the two time points; positive values indicate the mean number of increased drinking days between the two time points.

Table 6

Change in number of days drinking from baseline to 6 months post-intervention among subjects who endorsed the belief categories

Belief categoriesDelta days drinking: baseline–1 month
(among subjects who endorse the belief)
Delta days drinking: baseline–3 months
(among subjects who endorse the belief)
Delta days drinking: baseline–6 months
(among subjects who endorse the belief)
Has treatment preferences (n = 82)−3.30 (6.41)−6.67 (8.89)−6.56 (9.60)
Treatment is positive (n = 79)−3.62 (6.00)−7.18 (8.84)−8.52 (9.52)
Logistical issues (n = 73)−3.41 (6.00)−7.67 (9.32)−9.59 (11.16)
I don’t have a problem (n = 59)−4.07 (6.21)−6.56 (8.00)−6.69 (9.28)
I can handle it myself (n = 56)−3.71 (4.82)−6.88 (7.58)−9.09 (8.65)
I don’t want to stop drinking (n = 50)−2.32 (6.16)−5.26 (8.81)−7.44 (9.51)
Treatment is scary (n = 38)−3.58 (5.19)−7.37 (8.10)−7.54 (8.20)
I don’t have enough info (n = 38)−3.29 (7.02)−7.24 (8.77)−8.39 (8.89)
Treatment is negative (n = 30)−4.10 (8.83−6.62 (9.52)−7.48 (11.81)
Stigma (n = 29)−3.62 (6.62)−6.69 (9.66)−6.00 (1.54)
I will wait for a crisis (n = 16)−3.13 (7.10)−7.94 (6.50)−8.88 (9.13)
I will lose my job/kids/friends (n = 7)−6.00 (9.92)−4.29 (7.72)−12.43 (12.73)
It’s hard to do it alone (n = 7)−2.86 (5.43)−7.14 (12.93)−7.56 (11.13)
I want medications (n = 7)−8.56 (1.34)−5.33 (12.12)−5.33 (12.09)
I’d rather get help from friends (n = 4)0.75 (2.99)−7.00 (7.62)−3.75 (5.56)
I need to stop drinking first (n = 3)−7.67 (3.51)−5.33 (7.58)−6.67 (13.28)
Intervention group overall means and SDs (for comparison)−3.61 (6.40)−6.84 (8.65)−8.26 (9.80)
Belief categoriesDelta days drinking: baseline–1 month
(among subjects who endorse the belief)
Delta days drinking: baseline–3 months
(among subjects who endorse the belief)
Delta days drinking: baseline–6 months
(among subjects who endorse the belief)
Has treatment preferences (n = 82)−3.30 (6.41)−6.67 (8.89)−6.56 (9.60)
Treatment is positive (n = 79)−3.62 (6.00)−7.18 (8.84)−8.52 (9.52)
Logistical issues (n = 73)−3.41 (6.00)−7.67 (9.32)−9.59 (11.16)
I don’t have a problem (n = 59)−4.07 (6.21)−6.56 (8.00)−6.69 (9.28)
I can handle it myself (n = 56)−3.71 (4.82)−6.88 (7.58)−9.09 (8.65)
I don’t want to stop drinking (n = 50)−2.32 (6.16)−5.26 (8.81)−7.44 (9.51)
Treatment is scary (n = 38)−3.58 (5.19)−7.37 (8.10)−7.54 (8.20)
I don’t have enough info (n = 38)−3.29 (7.02)−7.24 (8.77)−8.39 (8.89)
Treatment is negative (n = 30)−4.10 (8.83−6.62 (9.52)−7.48 (11.81)
Stigma (n = 29)−3.62 (6.62)−6.69 (9.66)−6.00 (1.54)
I will wait for a crisis (n = 16)−3.13 (7.10)−7.94 (6.50)−8.88 (9.13)
I will lose my job/kids/friends (n = 7)−6.00 (9.92)−4.29 (7.72)−12.43 (12.73)
It’s hard to do it alone (n = 7)−2.86 (5.43)−7.14 (12.93)−7.56 (11.13)
I want medications (n = 7)−8.56 (1.34)−5.33 (12.12)−5.33 (12.09)
I’d rather get help from friends (n = 4)0.75 (2.99)−7.00 (7.62)−3.75 (5.56)
I need to stop drinking first (n = 3)−7.67 (3.51)−5.33 (7.58)−6.67 (13.28)
Intervention group overall means and SDs (for comparison)−3.61 (6.40)−6.84 (8.65)−8.26 (9.80)

Note. Negative values indicate the mean number of reduced drinking days between the two time points; positive values indicate the mean number of increased drinking days between the two time points.

Discussion

This study provides a description of how adults with moderate–severe AUD who do not have a treatment history perceive attending treatment to address their drinking. In general, the subsample who received CBT-TS reported an average of three beliefs, each related to treatment. Following the intervention, only a small number of this sample’s categories of beliefs were reported among those who attended treatment (19.6%), whereas many individuals may have held to their beliefs or modified certain beliefs but did not report treatment-seeking behaviors during our data collection window. Further, we saw a pattern of reduced number of days drinking across the sample who received the intervention regardless of the category of beliefs endorsed or whether an individual attended treatment.

Overall, the most frequently reported category of belief among individuals who both chose to attend and did not attend treatment was “Having treatment preferences (i.e. AA, group or inpatient therapy, or medication).” During the intervention session, the interventionist worked with participants to modify their beliefs. For this particular category of beliefs, the goal was often to modify it from “I don’t want inpatient therapy” to “I don’t want inpatient therapy, but I do want (fill in the blank).” Other common categories of beliefs among those who ended up attending treatment that may have been amenable to change focused on practical barriers, such as “Logistical issues” and “Not having enough information about treatment.” Interventionists provided psychoeducation of types of treatment available, how to search for local treatment options, and strategies of how to manage concerns of logistics, such as travel and childcare. These categories of beliefs indicate a need for future research targeting adults with moderate–severe AUD to focus on providing additional information about treatment in general, with a person-centered focus to understand what types of treatment this treatment-resistant population is willing to attend to address their drinking problems.

Most of the participants who received the intervention and discussed their beliefs did not attend treatment during the trial. Frequently reported categories of beliefs among this group were “It’s hard to do it alone,” “Don’t have a drinking problem,” and “Can handle the problem on my own.” Future studies examining whether these specific beliefs hindered treatment initiation, and how their modification may increase treatment-seeking behaviors above other categories of beliefs are warranted. Additionally, many individuals who did not attend treatment reported “Not wanting to stop drinking.” Prior trials of CBT-TS have aided in the modification of this category of belief and were successful in participants initiating treatment by stating that the participant didn’t need to stop drinking, but could attend treatment to work on other things, without focusing on alcohol abstinence (Stecker et al. 2012). However, this same modification was likely unsuccessful in the current trial. Separately, prior research highlights stigma as significant in the decision to initiate treatment (i.e. Finn et al. 2023): however, while both the current and prior trials of CBT-TS indicated “Stigma about treatment” as a frequent category of belief among participants, it is not a prominently reported belief regarding their decisions to attend treatment. Further exploration of how beliefs interfere with treatment seeking among civilian versus veteran samples and among those with differing presenting problems is necessary.

Finally, we saw a general trend of reduced number of drinking days following the intervention through 6-month follow-up, regardless of the category of belief endorsed by participants. However, certain categories were more frequently reports among participants who saw less reduction in the number of drinking days (i.e. “I don’t have a problem”) or saw nonlinear change in their number of drinking days (i.e. “stigma”) over the follow-up period. Future research is necessary to further explore the relationship between endorsed beliefs about treatment for alcohol use, changes in drinking behaviors, and treatment-seeking behaviors among adults with no alcohol use treatment history.

Limitations

The current sample only includes community-based adults from upstate New York, which may limit generalizability of findings to other geographic regions. Further, the sample was limited in the number of participants identifying as racial and/or ethnic minorities; thus, only frequencies and percentages were listed, making it difficult to understand which beliefs may be different for non-White samples and how this could influence their decisions to seek treatment. Due to small cell sizes of frequency, only counts of frequency and percentages are reported, and no follow-up data of beliefs were collected, which prevents from knowing which beliefs were changed or not. Treatment-seeking beliefs were only collected among individuals who received the intervention; future studies should examine the beliefs of individuals who were randomized to the control condition to compare beliefs and subsequent treatment-seeking behaviors. Additionally, a small number of individuals referred to consent did not complete consenting procedures (n = 36), a group of interest because they may be particularly difficult to engage in treatment. The authors used worksheets filled out by intervention clinicians in real time to record stated beliefs; however, this limits the accuracy of beliefs that could be mitigated through the use of recordings that are professionally transcribed. The intervention took place during the beginning and middle of the COVID pandemic, which may have impacted the beliefs endorsed by participants and their uptake of treatment following the intervention, for example, due to restricted access to in-person groups. Information on how beliefs may have been impacted by the changing landscape of treatment options during the pandemic was not assessed. However, we examined alcohol consumption, COVID-19-related worries, and qualitative responses of alcohol use and positive changes during COVID-19 in a subset of the current sample recruited since the onset of COVID-19, and found nearly 90% reported an increase in alcohol use, with more heavy episodic drinking in the first 6 months of COVID-19, with participants reporting increased drinking noting they had “more time on their hands” (Hutchison et al. 2022). Future larger trials of beliefs are necessary to perform causal analyses of beliefs and subsequent treatment-seeking behaviors.

Conclusions

It is necessary to understand beliefs about treatment and how the modification of them may lead to increased treatment initiation among adults with moderate–severe untreated AUD. Findings from the current study point to the potential specific belief categories held by adults with moderate–severe AUD, namely, “Not having a problem,” “Handling it themselves,” “Not wanting to stop drinking,” and “Logistics,” which may hinder an individual’s decision to seek treatment for their drinking. However, participants who ultimately sought treatment were significantly more likely to report “wanting medication.” Our findings point to the potential focus of future interventions to address and reduce barriers related to self-efficacy of managing drinking behaviors (i.e. I can handle it myself) to instill associated changes in behavior that lead to treatment initiation to address their AUD.

This is among the first examinations of treatment-seeking beliefs in a community sample of untreated adults with moderate–severe AUD. Replication of these findings is necessary to understand whether the beliefs amenable to change to initiate treatment hold. Additionally, examination of modifiable beliefs in samples oversampled for ethnic and/or minority participants to understand if their beliefs are different and how this may influence the intervention session and strategies utilized to increase treatment-seeking behaviors are necessary. Finally, additional work is necessary to study which underlying beliefs are most prevalent for specific samples (i.e. community versus veteran, AUD versus mental health, and male versus female participants) to focus on modifying these beliefs and reducing barriers specific to the population to bolster treatment-seeking behaviors.

Acknowledgements

This work was supported by NIH grants R01AA026815-01, T32MH20061, K23MH096936, and 2KL2RR024136-06, and Grant No. YIG-0-10-286 from the American Foundation for Suicide Prevention.

Author contributions

Morica Hutchison (Conceptualization [equal], Writing—original draft, Writing—review & editing [lead]), Sarah Szafranski (Conceptualization, Writing—review & editing [equal], Project administration [supporting]), Caitlin Titus (Conceptualization, Writing—review & editing [equal], Project administration [supporting]), Beau Abar (Data curation, Methodology, Writing—review & editing [equal], Formal analysis [lead]), Kenneth Conner (Project administration [equal], Funding acquisition, Investigation, Methodology [lead], Conceptualization, Writing—review & editing [supporting]), S A Maisto (Investigation [equal], Conceptualization, Funding acquisition, Methodology, Project administration, Writing—review & editing [supporting]), Tracey Stecker (Conceptualization, Formal analysis [equal], Funding acquisition, Investigation, Methodology, Project administration [lead], Writing—original draft, Writing—review & editing [supporting])

Conflict of interest: None declared.

Funding

NIAAA: R01AA026815-03S1.

Data availability

Data are available upon request. Please email Morica Hutchison (morica_hutchison@urmc.rochester.edu).

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