Alcohol dependence is as much a social challenge as it is a clinical one. Clinicians have faced several challenges in helping subjects with alcohol dependence stay in treatment and maintain abstinence. In substance abuse treatment, clients’ motivation to change has often been the focus of both clinical interest and frustration. Motivation has been described as a prerequisite for treatment, without which the clinician can do little. Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment. Treatment modalities have focused on various aspects of motivation enhancement – such as locus of control, social support, and networking. Recent literature is focusing on the role empathy plays in pathogenesis and treatment seeking in alcohol dependence. However, the way in which empathy is perceived has recently undergone drastic changes, specifically its role in both emotion processing and social interactions.
Broadly speaking, empathy is believed to be constituted of two components – cognitive and affective (or emotional). Affective empathy (AE) deals with the ability of detecting and experiencing the others’ emotional states, whereas cognitive empathy (CE) relates to perspective-taking ability allowing to understand and predict the other's various mental states (sometimes used synonymously with theory of mind). Empathy constitutes an essential emotional competence for interpersonal relations and has been shown to be highly impaired in various psychiatric disorders including alcohol dependence. Empathy is crucial for maintaining interpersonal relations, which are frequently impaired in alcoholics and prove to be a source of frequent relapses. However, research pertaining to empathy in alcohol has generated varied results. Factors such as lapses, retaining in treatment, and abstinence have also been linked to subjects’ empathy. However, few of these have assessed CE and AE separately. Previous literature has demonstrated that empathy correlates with the motivation to help others. No study however addresses the role empathy may play in self-help, a crucial step in the management of alcohol dependence. A link between an alcoholic's empathy and motivation is lacking. It is imperative to highlight changes in empathy with changes in motivation, over and above the dichotomy of abstinence and dependence.
Detailed understanding of empathy, or a lack thereof, and its fate during the natural course of the illness, particularly with each step of the motivation cycle, will prove fruitful in planning better strategies for alcohol dependence. This will, in turn, lead to better handling of its social consequences and reduction in its burden on society and healthcare. The present study was thus formulated, which aimed at comparing CE, AE, and total empathy (TE) between subjects of alcohol dependence and normal controls. Differences in CE, AE and TE with abstinence and stage of motivation were also assessed. We also correlated CE, AE, and TE with disease-specific variables.
MATERIALS AND METHODS
The present study is a cross-sectional observational study done in the outpatient psychiatric department of a tertiary care center. Ethical clearance was obtained from the institutional ethics committee (IEC/Pharm/RP/102/Feb/2019). The study was conducted over a period of 6 months (March 2019–August 2019) and purposive sampling method was used. Sixty subjects, between the ages of 18–65 years, diagnosed with alcohol dependence as per the International Classification of Diseases-10 criteria were included in the study as cases. Subjects with comorbid psychiatric and medical disorders (four subjects) and those dependent on more than one substance (six subjects) were excluded. As all the available cases were male, the study was restricted to males. Sixty normal healthy male controls who were not suffering from any medical or psychiatric illness (five subjects excluded) were recruited from the normal population (these were healthy relatives of patients attending our outpatient department). Subjects were explained about the nature of the study and written informed consent was obtained from them. A semi-structured pro forma was devised to include sociodemographic variables, such as age, marital status, family structure, education, and employment status and disease-specific variables in the cases, such as total duration of illness, number of relapses, number of hospital admissions, and family history of psychiatric illness/substance dependence. Empathy was assessed using the Basic Empathy Scale for Adults for both cases and controls and motivation was assessed in the cases using the University of Rhode Island Change Assessment Scale (URICA). The scales were translated into the vernacular languages (Hindi and Marathi) and the translated versions were used. The scales were administered by a single rater in one sitting. The entire interview was completed in 20–30 min.
The Basic Empathy Scale for Adults
It is a 20-item scale which was developed by Jolliffe and Farrington. Each question is rated on a five point Likert type scale. We used the two-factor model where nine items assess CE (Items 3, 6, 9, 10, 12, 14, 16, 19, and 20) and 11 items assess AE (Items 1, 2, 4, 5, 7, 8, 11, 13, 15, 17, and 18). The total score gives TE, which can range from 20 (deficit in empathy) to 100 (high level of empathy).
The University of Rhode Island Change Assessment Scale (URICA)
This scale is based on the transtheoretical model of motivation given by Prochaska and DiClemente, which divides the readiness to change temporally into four stages: Precontemplation (PC), contemplation (C), action (A), and maintenance (M). The URICA is a 32-item self-report measure that grades responses on a 5-point Likert scale ranging from one (strong disagreement) to five (strong agreement). The subscales can be combined arithmetically (C + A + M − PC) to yield a second-order continuous readiness to change score that is used to assess readiness to change at entrance to treatment. Based on this score, the individual is classified into the stage of motivation (precontemplation, contemplation, action, and maintenance)
SPSS 20.0 software was used for carrying out the statistical analysis. (IBM SPSS Statistics for Windows, Version 20.0, released 2011, Armonk, NY: IBM Corp.). Data were expressed as mean (standard deviation) for continuous variables and frequencies and percentages for categorical variables. Comparative analyses were done using unpaired Student's t-test and one-way ANOVA with post hoc Bonferroni's test wherever appropriate. The correlation was done using Pearson's correlation test and point biserial correlation test for continuous and dichotomous categorical variables, respectively. The effect size was determined by calculating Cohen's d (d) for t-test, partial eta square (ηp2) for ANOVA, and correlation coefficient (r) for Pearson's correlation/point biserial correlation test. P <0.05 was considered statistically significant.
A total of 120 subjects consisting of 60 cases and 60 controls who satisfied the inclusion and exclusion criteria were considered for the analysis. The mean age of cases was 40.80 (8.69) years, whereas that of controls was 39.02 (10.12) years. About 80% of the cases and 88% of the controls were married. Only 58% of the cases and 57% of the controls were educated. Almost 80% of the cases versus 95% of the controls were employed at the time of assessment. Majority of the cases (75%) and controls (83%) belonged to nuclear families. None of the sociodemographic variables varied significantly across cases and controls. Comparison of empathy between cases and controls using unpaired t-test showed cognitive (t(118)=2.59, P = 0.01), affective (t(118)=2.19, P = 0.03), and total empathy (t(118)=2.39, P = 0.02) to be significantly lower in cases Table 1. The analysis showed the difference to be most significant for CE (d = 0.48), followed by TE (d = 0.44), and then AE (d = 0.40), implying that it is CE that is most significantly lowered in men with alcohol dependence. Table 2 shows the correlation between empathy and disease-related variables amng the cases using Pearson's correlation/point biserial correlation tests. Number of relapses negatively correlated with all three measures of empathy, most with CE (r = −0.42, P = 0.001), followed by TE (r = −0.39, P = 0.002) and least with AE (r = −0.31, P = 0.016). This means that men with alcohol dependence who are more empathic tend to have lesser relapses. Having a family history of mental illness/substance use was seen to have a positive correlation with CE (r = 0.43, P = 0.001) and TE (r = 0.30, P = 0.02) but not AE (P = 0.17). As the coefficients of correlation for all the relations were <0.5, the strength of correlations in our sample was mild–moderate.
Motivation and readiness to change was assessed in the cases using the URICA scale, which had a mean score of 8.78 (4.09). About 50% of the subjects were currently consuming alcohol (30 out of 60) and the remaining were completely abstinent. Comparing empathy scores among those subjects still consuming and those subjects completely abstinent using unpaired t-test [Figure 1] showed that abstinent patients had significantly higher AE (t(58)=2.72, mean difference = 5.10 [95% confidence interval [CI]: 1.34–8.86], P = 0.009) and TE (t(58)=2.88, mean difference = 8.60 [95% CI: 2.63–14.57], P = 0.006) as compared to those still consuming but not CE (t(58)=1.93, mean difference = 2.83 [95% CI: 0.09–5.77], P = 0.058). This difference was most marked in TE (d = 0.77), followed by AE (d = 0.71). Dividing the cases into their respective stages of motivation showed that 20 out of 60 (33%) subjects were in precontemplation stage, 10 out of 60 (17%) in contemplation stage and 30 out of 60 (50%) in action stage. None were seen to be in maintenance phase. Using one-way ANOVA to assess the difference in empathy across the various stages of motivation [Table 3], it was found that AE (F (2,57) = 5.03, P = 0.01) and TE (F (2, 57) = 4.25, P = 0.02) varied across the motivation cycle but not CE (F (2,57) = 2.26, P = 0.11). Difference was more significant for affective empathy (ηp2 = 0.15) as compared to total empathy (ηp2 = 0.13), although a small one. In both cases of affective and total empathy, it can be seen that empathy increases gradually with each stage in motivation cycle [Figure 2]. However, using the post hoc Bonferroni test [Table 4] revealed that significant difference in both cases was seen between precontemplation and action stages only (P < 0.05).
Role of empathy in addictive behaviors is a pivotal one. The present analysis shows that subjects dependent on alcohol lack empathic abilities as compared to healthy controls. This translates to both cognitive and affective components of empathy. Earlier research appears divided in this aspect. Massey et al. elucidated reduction in both CE and AE by behavioral, neuroanatomical, and self-report methods. Impairment in affect processing system in alcohol dependence was cited as the reason behind the so-called “cognitive-affective dissociation of empathy” in alcoholics, which resulted in a changed AE, with relatively intact CE. However, there is enough evidence to suggest the lack of social cognition, emotional cognition, and related cognitive deficits in alcohol-dependent subjects. Cognitive deficits responsible for dampening of CE seen in addictions have been attributed to frontal deficits. In fact, it is a combined deficit which leads to impaired social and interpersonal functioning in alcoholics. Hence, our primary finding is in keeping with this hypothesis.
Empathy may relate to various aspects of the psychopathological process. Disorders have also been classified based on which aspect of empathy is deficient – cognitive, affective, or general. On such a spectrum, alcohol dependence should definitely be classified as a general empathic deficit disorder. It is also known that within a disorder, the two components of empathy may show variation, depending upon various factors. Addiction processes may have impulsivity, antisocial personality traits, externalizing behaviors, and internalizing behaviors as a part of their presentations, all factors which effect empathy. Hence, it is likely that difference in empathy could be attributable to these factors, even though it has been shown that empathy operates independent of them to impact the disease process.
Abstinence period is associated with several physiological and psychological changes and is a key experience in the life of patients with alcohol use disorder. The present analysis shows that abstinence period is associated with higher empathy than the active phase of illness. It has been demonstrated that empathy correlates significantly with abstinence and retention in treatment. A study has described improvement in empathy, attributable to personality changes with abstinence, in subjects following up for treatment in self-help groups. A causative effect of improvement in empathy due to the 12-step program and abstinence has been hypothesized, and our findings support this. Empathy is a key factor in motivation to help others and oneself when in distress. This suggests a role for it in motivation to quit and treatment seeking. Yet still, few studies have made this assessment. Across the motivation cycle, we found that TE and AE were significantly higher for subjects in action phase than for precontemplation and contemplation phases. CE showed no significant changes. Thus, it appears that AE is more amenable to change and instrumental in motivation enhancement. Treatment modalities for dependence should inculcate methods addressing empathy, especially AE as this would be more beneficial. It is also possible that these patients may innately have higher empathy and hence are motivated to quit alcohol, as has been previously demonstrated.
It is clear that in adults who have developed alcohol dependence, deficits in empathic processing remit in recovery and this finding is crucial to optimize long-term outcomes and minimize the likelihood of relapse. Altered empathic abilities have been shown to impair future problem solving in social situations, thus impacting the prognosis of the illness. Similarly, it also hampers treatment seeking in alcoholics. CE played a greater role in our sample as compared to AE, contrary to what most literature states. This is furthered by the fact that CE and TE correlated with number of relapses and having a family history of mental illness in our subjects, whereas AE correlated with only number of relapses. Subjects with higher empathy had significantly lesser relapses, suggesting a role for empathy, particularly CE in maintaining abstinence, even though it is least likely to change. This relation has been demonstrated by other researchers also. Having a positive family history of mental illness/addictions was associated with higher CE and TE. Genes have shown to influence development and dynamicity of empathy in healthy individuals and as genetics play a major role in heredity of addictions, levels of empathy may also vary accordingly. As AE did not show this relation, it appears CE and AE may not be “equally heritable.” However, more research in this area is needed.
Our study was not without limitations. Factors such as premorbid personality and baseline empathy were not considered. As all cases and controls were males, gender differences could not be assessed. We did not have any patients in the maintenance phase of motivation and hence this difference could not be assessed. It also might be more prudent to have a prospective study design wherein patients are followed throughout their motivation cycle to derive a more robust relation between empathy and motivation. As our study was a cross-sectional study, it was not possible.
To mention a few strengths, our analysis adds to the need for studying CE and AE separately, as they may impact different aspects of the illness and show varied dynamicity over the natural course of alcohol dependence owing to their difference in neural substrates. While many risk factors for alcohol dependence are difficult if not impossible to change, some components of empathy may be modifiable, particularly AE. Abstinence is associated with an increase in AE and TE and thus empathy may be crucial in propelling an individual along the motivation cycle. Our analysis stands out in being one of the few to establish a relation between stages of motivation and components of empathy in alcohol dependence, which will definitely have further research and therapeutic implications.
Empathic deficits in alcohol dependence are well established, being more for CE than AE although both being affected. Even though psychotherapeutic approaches have hitherto targeted therapist's empathy, we suggest that a detailed understanding of patient's empathy is equally crucial in the management. Increment in AE and TE is seen with abstinence and improvement in subject's motivation. Relapses are lesser in individuals with higher empathy and it is possible that those who relapse develop low empathy. The present analysis is associational and causality inference should be done with caution. Modalities of treatment which focus on empathy and its subsequent advancement, such as brief intervention and self-help groups, have met with ample success in clinical practice. Adding to existing factors that have proved successful for abstinence, focusing on improving empathy at specific points in the motivation cycle (contemplation to action) may motivate individuals better to stay in treatment and reduce further relapses.
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Conflicts of interest
There are no conflicts of interest.
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