Few interventions support the affected other on their own: A systematic review of individual level psychosocial interventions to support those harmed by others’ alcohol drinking

doi:10.21203/rs.3.rs-2250961/v1

Introduction: Over 100 million individuals worldwide experience negative outcomes as a function of a family member's substance use. Other reviews have summarized evidence on interventions; however, success often depends on the behavior of the individual causing harm, and they may not be ready or able to change. Aim: To identify and describe evaluations of psychosocial interventions which can support those affected by alcohol harm to others independent of their drinking relative or friend.

Methods: A systematic review/narrative synthesis of articles from 11 databases pre-registered on PROSPERO (CRD42021203204).

Results: Those experiencing the harm were spouses/partners, or adult children/students who have parents with alcohol problems. Studies (n=7) are from the UK, USA, Korea, Sweden, Mexico, and India. Most participants were female (71-100%). Interventions varied from guided imagery, cognitive-behavioral therapy, motivational interviewing, and anger management. Independent interventions may support those affected by another's alcohol use, although there was considerable variation in outcomes targeted by the intervention design.

Conclusions: Small-scale studies suggest brief interventions ease suffering from alcohol's harm to others, independent of the drinking family member. Understanding affected others’ experience and need is important given the impact of alcohol’s harm to others; however, there is a lack of quality evidence informing strategies to support these individuals.

affected other

alcohol

psychosocial intervention

systematic review

family

Over 100 million individuals worldwide experience negative health and social outcomes as a function of a family member's substance use (Orford et al., 2013). The cost of this harm to others is both substantial and underestimated (Navarro et al., 2011) – we will refer to those affected by harms as “affected others”. Other reviews have summarized evidence on interventions to support affected others; however, the intervention success often is affected by the change in the behavior of the individual causing the harm. This is the first paper to isolate those interventions which are independent of the drinker’s behavior who is causing the harm to the affected other. As the drinkers may not be willing or able to change, it is important to summarize evidence which can support affected others independent of their drinking relative or loved one. This independence is important so the individual affected is empowered to heal without requiring their loved one to change (Copello et al., 2000).

The impact of alcohol use on an affected other can be wide ranging (Laslett et al., 2010; Robin Room et al., 2016), occurring at the individual, group, or at societal level (Karriker-Jaffe et al., 2018; Wilkinson et al., 2014). For this review, the focus is the individual level. For individuals who are affected others, worry is common (Orford et al., 2013) and can lead to long-term impacts on physical and mental health, e.g. (Ray et al., 2009; Timko et al., 2019). Other negative consequences, include physical harms (e.g, injuries; traffic accidents; harm from interpersonal violence, aggression and crime; harm to families, including domestic violence and harm to a developing foetus), psychological harms (e.g., psychological distress, marital disharmony), and changes in other aspects of life (e.g., separation and divorce, child or household neglect; finance, work, parenting, and the meeting of other obligations) (Navarro et al., 2011; R Room et al., 2016). The harm can result from a single event or multiple occasions (McClatchley et al., 2014; R Room et al., 2016).

Several high-quality reviews exist which summarize the nature and effectiveness of interventions for family members affected by an adult relative’s substance use. For example McGovern et al. (2021) summarized the findings in a systematic narrative review of sixty-five trials which aggregated both those which include family members in the intervention and those that do not, and with those who use alcohol, and those who use drugs. Overall, they summarized behavioral interventions delivered with the substance user and the affected other could improve outcomes, but the complex ‘multidimensional adversities’ experienced by the drinker and their affected other are rarely covered effectively. It is not clear if or how affected others’ experience might differ depending on whether alcohol or drugs were used. Similarly, they concluded interventions which are solely designed for the affected other but contain some component of behavioral modification directed at the person who is experiencing alcohol harm rarely served the needs of the affected other (McGovern et al., 2021). In another recent systematic review with meta-analysis, Merkouris et al. (2022) explored affected other interventions across different addictions, demonstrating some effectiveness in improving some characteristics of the experience of harm to others such as depression, life satisfaction, and coping. Although the aim was to understand affected other interventions, there was some focus on the drinker causing the harm in some of the synthesized work and this expansion facilitated meta-analysis across addictions. The authors highlighted limitations in the evidence base in terms of capacity and methodological issues.

In acknowledgement that harm to others differs internationally (Wilsnack et al., 2018), and that low and middle-income countries (LMIC) are often under-represented in reviews, Rane et al. (2017), in their systematic narrative review, focused on interventions for affected others in the LMIC setting. They summarized four articles; some evidence of positive benefit for affected others from alcohol and drugs, but only one reflected an intervention which was independently targeting the affected other (de los Angeles Cruz-Almanza et al., 2006).

The evidence base for interventions which can support an affected other individual without another individual having to change is unclear. Other high-quality reviews have provided evidence for affected other interventions; however, some include interventions which have some role in changing the drinker causing the harm, or combine their findings with other substances/addictive behaviors beyond just alcohol. For those who wish to change on their own, independent of the drinker causing harm, there is a need for a clear evidence base. This evidence base, with a focus only on alcohol can help us understand if existing interventions are effective, and assess the gaps that inform the development of novel psychosocial interventions to address the harm (England et al., 2015). There are no current systematic reviews of this nature. The following questions are considered: (1) What is the nature of psychosocial interventions to support adults harmed by others’ drinking? (2) What evidence is given of their efficacy or effectiveness? and (3) What are the outcome measures (primary, secondary, or undefined outcomes) used to show efficacy or effectiveness and how are these measured?

We registered the review protocol in advance on PROSPERO (CRD42021203204). Materials relating to the interim steps of the systematic review are available on the open science framework https://osf.io/jx4cz/. OVID (Medline, EMBASE, PsycINFO, PsycARTICLES, HMIC), EBSCO (CINAHL, ERIC), Cochrane Library, Scopus, Web of Science[1], and Scielo were the databases searched. Other sources were ongoing and registered trials at Clinicaltrials.gov, WHO International Clinical Trials Registry Platform (ICTRP), and the Open Science Framework[2].We identified grey literature through CADTH Grey Matters tool, Open-SIGLE (http://www.opengrey.eu), Mednar, Citation and reference searches of included papers. There were no date restrictions. Searches were run in May 2021. Included papers evaluated an intervention which targets the person(s) affected by the alcohol use (affected others) only and did not target the drinker who is perceived to be causing the harm. Core search concepts related to three domains: alcohol use, brief interventions, and longitudinal quantitative design. The PICO (population, intervention, comparator, outcomes) framework informed the eligibility criteria as outlined below. Terms were coupled with relevant Medical Subject Headings (MeSH)/thesaurus terms, truncated and variant spellings were used to identify useful records. All search terms and results are available on the open science framework. Eligible studies were randomized controlled trials, controlled trials, randomized trials, quasi-experimental trials, pre-post evaluations of interventions where individuals are evaluated at baseline before intervention and followed up after intervention. For this review, all included studies will report on quantitative outcomes.

Population

The population are adults who are experiencing or have experienced (when a child but is now an adult), harm as a function of another adult’s unhealthy alcohol use.

Intervention

At least one psychosocial intervention targeting the affected other. A psychosocial intervention is broadly defined as non-pharmacological in nature and which aims to improve health and wellbeing. Interventions which include the drinker or include the affected other adult in the drinker’s treatment will not be included. Interventions which target groups (including families or couples) or at a societal level will be excluded.

Comparator

Comparators could be any active or control intervention, or a pre-post design using baseline measures as the comparator.

Outcomes

Description of the interventions according to the elements of the TIDiER framework (Hoffmann et al., 2014)

Improvement in the affected person’s physical, psychological, or social wellbeing however defined by the outcomes of the project and the target of the intervention. Where possible we will code interventions for behavior change techniques (Michie et al., 2014; Michie et al., 2011).

Search results were downloaded to EndNote Version X7 (Clarivate, Philadelphia, PA) and de-duplicated. All titles and abstracts were entered in Rayyan software with xxx, screening all titles and abstracts, and one of xxx, xxx, xxx, xxx, xxx, xxx blind second screening results. Discrepancies were resolved by discussion. All full-text versions of potentially eligible articles were reviewed by xxx, and all double-screened by one of xxx, xxx, xxx, xxx, xxx, xxx; discussion resolved discrepancies. Extraction forms were piloted by xxxx and xxx. All data were extracted by xxx, and blind double extracted by xxx. Two reviewers (xxx/xxx) independently assessed the quality of the eligible studies using the Mixed Methods Appraisal Tool (MMAT) (Hong et al., 2018). A PRISMA checklist is in Supplementary Material B. Each intervention was coded for Behavior Change Techniques (BCT) by two reviewers (xxx/xxx). Where there was a discrepancy in BCT or MMAT coding, these were resolved by discussion amongst both coders.

[1] Includes Science Citation Index Expanded, Social Sciences Citation Index, Arts & Humanities Citation Index, Conference Proceedings Citation Index and Emerging Sources Citation Index

[2] Note two protocol amendments: 1) remove Google Scholar as a database as records cannot be downloaded for processing and 2) AMED was not searched as the lead institution no longer has access to this database.

Searches identified 6230 articles (after de-duplication) for eligibility screening by title and abstract. Exclusion at title and abstract stage reflected unambiguous violation of the above PICO criteria based on topic area (i.e., not alcohol), not a quantitative intervention evaluation (e.g., interviews), nor an individual level intervention targeting the affected other (e.g., family or dyadic therapies). Any unclear matches were referred to full text assessment for closer inspection; 26 articles were retrieved for full text evaluation against PICO criteria, and 7 were eligible (Figure 1). The seven included articles contained data on 421 participants, from India, Korea, USA, UK, Sweden, and Mexico. Three studies were randomized trials, two were pre-post designs, and the rest were quasi-experimental group designs. Two papers were the same population reporting on 12- and 24- month follow up (H Hansson et al., 2006; Hansson et al., 2007), and one paper analyzed their sample in two ways, a pre-post case study design and with a quasi-experimental study with a convenience control group. Most papers focused on partners or spouses of people experiencing drinking problems (n=4); two were adult children of those with alcohol problems and one was a family member of patients with AUD.

Outcomes measured were diverse, the most common were stress, coping, and anger outcomes, although there was little use of similar questionnaires to measure these or other concepts. Other outcomes included affected other’s alcohol use, relational factors with the person drinking, and mental health. Regarding the findings, all but two reported a significant difference in outcomes in a pre-post (Son & Choi, 2010) and quasi-experimental design (de los Angeles Cruz-Almanza et al., 2006). Several reported within-group differences but not between-group differences (de los Angeles Cruz-Almanza et al., 2006; H Hansson et al., 2006; Hansson et al., 2007). There was some evidence that affected other interventions reduced stress (Aarti et al., 2020; Helena Hansson et al., 2006; Hansson et al., 2007; Howells & Orford, 2006), alcohol problems (H Hansson et al., 2006; Hansson et al., 2007; Howells & Orford, 2006), alcohol use (H Hansson et al., 2006; Hansson et al., 2007), life being affected (Howells & Orford, 2006), depression (Rychtarik et al., 2015) and anger (Rychtarik et al., 2015); and increased coping (Aarti et al., 2020; Howells & Orford, 2006), self-esteem (Howells & Orford, 2006), and independence (Howells & Orford, 2006).

The nature of the interventions varied. Some interventions (number in brackets) used guided imagery (1), rational emotive behavioral therapy (1), motivational interviewing (2), cognitive-behavioral models (3), anxiety management (1), coping skills (3), anger management (1), cultural care theories (1), or social control theory (1) as the underpinning mechanism. Those studies with control groups or waiting list controls did not detail the nature of what occurred during the wait, or in the control group. As some researchers have outlined previously, there can be active ingredients for change in the control group and this may contribute to effects arising from research participation, including that enrolling in a study is a precursor to change for all enrolled (Bendtsen & McCambridge, 2021; Jecks, 2021; Shorter et al., 2019).

Interventions were mostly face to face; all had multiple sessions ranging from 3-24 sessions, Where time periods were specified, interventions varied from an intensive week of six daily sessions, up to a session a week for 18 weeks. All sessions had some element of tailoring, which included participants choosing activities on their own, automatic tailoring based on responses to questionnaires, and tailoring of intervention content by therapists. The behaviors targeted by the intervention were alcohol use behavior of the affected other (H Hansson et al., 2006; Hansson et al., 2007), behaviors arising from anger (Son & Choi, 2010), assertive interpersonal or other communication behaviors (de los Angeles Cruz-Almanza et al., 2006), adaptive coping strategies (H Hansson et al., 2006; Hansson et al., 2007; Howells & Orford, 2006; Rychtarik et al., 2015), and meditation practice (Aarti et al., 2020). Regarding behavior change techniques (BCT), in the seven papers with 11 interventions, two control groups did not describe the details to determine these BCTs (de los Angeles Cruz-Almanza et al., 2006; Son & Choi, 2010). Of the nine with details of interventions, there were 48 BCTs identified, ranging from two in Son and Choi’s anger management program intervention (Son & Choi, 2010) to nine in the Hansson and colleagues’ alcohol intervention and combined interventions (H Hansson et al., 2006; Hansson et al., 2007). All interventions except Hanssons’ coping intervention program (H Hansson et al., 2006; Hansson et al., 2007) contained 4.1 instruction on how to perform the behaviour. Other popular BCTs included 1.2 problem solving (six times), and 6.1 Demonstration of the behavior, 8.1 Behavioral practice/rehearsal and, 4.2 Information about antecedents which appeared four times each.

This review aimed to identify psychosocial interventions for affected others in their own right; the evidence base is limited, although, a more liberal inclusion criteria would have broadened the findings when we include papers which support affected others’ with their drug use such as (Carpenter et al., 2020; Copello et al., 2000; Copello et al., 2009; Velleman et al., 2011). These were deliberately excluded here given the additional complication of substance use and legal matters; although undoubtably the harm associated with both alcohol and drugs is substantial (Orford et al., 2013) and there is some overlap in harms. Only seven studies worldwide were identified, and these were mostly exploratory studies with small sample sizes, and of varying quality with risk of bias ranging from 40%-100%..

The studies included in this review showed a positive effect of interventions on affected others, however, the use of a diverse range of outcomes limited quantitative synthesis. The summary of the findings showed a reduction of psychological and physical distress, reduced anger, and better coping and more assertive behavior. Only 16/93 BCTs were represented here, and there was variability in the detail provided of the intervention. Many of the interventions evaluated here were modeled on intervention modalities designed for general population mental health (e.g., cognitive-behavioral therapy) or used in treatment services (e.g., motivational interviewing) rather than being designed for affected others directly. We also found a predominance of female affected others (Rane et al., 2017; Templeton et al., 2010), which may reflect the excessive burden carried by females. However, males also experience harm from others’ drinking (Sundin et al., 2021) and are too deserving of intervention. Those from white ethnic origin, where ethnicity was available, also predominated the landscape (Templeton et al., 2010).

There were of course notable omissions from this review that are commonly considered to be interventions independent of the drinker; however they did not meet the inclusion criteria of this review. For example, the ‘pressure to change’ model by Barber and colleagues (Barber & Crisp, 1995; Barber & Gilbertson, 1996, 1998) provides assessment and feedback to the affected other but works with them to develop skills to improve the consumption behaviors of the drinker. Notable other exceptions such as Sainz and Rey (2003) or Osilla et al., (2018) also focus on coping independent of the drinker, but the intervention is designed with added outcomes/activiies related to the behavior of the drinker. These and other interventions were excluded here as even if the drinker is not directly involved, the intervention changes their behavior specifically. Group interventions directly working with individuals such as Al Anon, were also excluded, as they rely other people for the therapeutic benefit. We also excluded interventions which have a family orientation; others have noted family being particularly important in certain cultures when it comes to health change and behavioral interventions (Rane et al., 2017). Whilst there has been criticism levelled at the alcohol treatment field and its commissioners for not adequately including family members in service delivery (Orford et al., 2013), the health and wellbeing of the affected individual cannot depend on the change of behavior of another and it has been shown that increasing the treatment engagement of the drinker may not benefit the affected other (McGovern et al., 2021).

Despite an increase in attention on alcohol’s harm to others, there has been little attention on interventions which support affected others, regardless of what the drinker who may be causing harm is doing. There are several implications for this in practice. First, there is some evidence supporting individuals who are experiencing harm can improve their stress, quality of life, mental health, coping, self-esteem, social support and independence. Anger was also reduced in some interventions. Second, we must support individuals who wish to improve their psychological wellbeing, so that their chances to improve their health do not depend on another person to change. Third, more research in this area is required, and the field should integrate to allow for comparable interventions and outcomes to create a high-quality body of evidence. Larger scale trials with due attention to risk of bias are also required to improve the quality of the evidence. Fourth, the diversity of outcomes and behavioral targets in interventions is of concern; international and synthesized qualitative work may help to prioritize targets for intervention; however, it must be cautious to cultural diversity in international works. Co-designed approaches to interventions may support the acceptability and uptake in future trials (Giebel et al., 2022). Finally, the target population may also need to be diversified, non-white, and non-female populations are under-represented, yet still experience harm from others’ alcohol. This is not to say we should not survey white or female identifying populations, but that we should expand our samples to represent the populations who may also experience this kind of harm.

A substantial burden is carried by individuals, and society, due to alcohol’s harms to others. Despite this, interventions which could reduce this burden are severely under researched. More work is required to improve the evidence base and intervention development (Public health England, 2019), particularly to help and support those who experience the harm from others’ alcohol use without the drinker having to change. The field is in its infancy and needs urgent attention of researchers and policy makers, including developing a consensus on which outcomes are important such as for other ABI interventions (Shorter et al., 2021; Tiburcio et al., 2022) and should be studied in the context of these types of interventions, as well as plans for dissemination. In addition, while cost-effectiveness of interventions was not established for any of the interventions in this review, understanding the cost of alcohol’s harm to others alleviated by a well-designed intervention in addition to the effectiveness is important, and was also emphasized by Navarro (2011). It would make the case for investment in interventions to support others and tackle the costs associated with other people’s alcohol use. In summary, whilst there is some early evidence that interventions can be successful in supporting the affected other independent of the drinker, new interventions are warranted, which are carefully designed, and appropriately evaluated including effectiveness and cost-effectiveness.

Registration: PROSPERO review registration (CRD42021203204) on April 2021 before review start.

Conflicts of interest: MB owns a private company (Alexit AB) which develops and distributes digital lifestyle interventions to the general public and for health care settings. Alexit AB had no part in funding, planning, or execution of this study. All others have no conflict of interest.

Grant funding: None

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Table 1: Characteristics of the seven studies included in the review of individual level psychological intervention designed to reduce alcohol’s harm to others in the affected drinker.

Study	Country	N	Study design	Affected other	Demographic characteristics	Active Intervention(s)	Control	Summary of outcomes	Reported Outcomes	Reported Measures	Follow up
Aarti et al. (2020)	India	33	One group pre-post design	Wives of alcoholics	100% F Age 18-60 years	Guided imagery intervention	N/A	Significantly reduced stress and maladaptive coping Significantly increased adaptive coping	Stress	Modified perceived stress scale*	Baseline 8 days
									Adaptive coping	Brief COPE scale*
									Maladaptive coping	Brief COPE scale*
de los Angeles Cruz-Almanza et al. (2006)	Mexico	35	Quasi-experimental design	Wife of person who is a problem drinker	100% F Age 25-50 years	Rational emotive behavioral therapy	Those who dropped out	No comparison between control/REBT groups [Self-esteem, assertiveness, coping significantly increased in pre-post intervention group; no change in control except assertiveness likelihood]	Self-esteem	Self-esteem Inventory (Coopersmith, 1984)	Baseline Post test 3, 6, 18 months 2 years
									Coping	Birmingham Coping Inventory (Orford et al., 1998)
									Likelihood of being assertive	Assertion inventory (Gambrill & Richey, 1975)
									Degree of discomfort differences	Assertion inventory (Gambrill & Richey, 1975)
Hansson et al. (2006)	Sweden	78	Randomised trial	Adult children of parents with alcohol problems	71.8% F 28.2% M Mean Age =25.6 (4.9) years	Alcohol intervention program; Coping Intervention Program; Combination of both	None	SIP, AUDIT, and eBAC were significantly better in the two alcohol intervention groups compared to the coping group.	Social interaction	Interview schedule for social interaction (Unden & Orth-Gomer, 1989)	Baseline 1 year
									Mental health	SCL-90 (Derogatis, 1977)
									Standardized difference score alcohol	Mean standardized differences of AUDIT/eBAC/SIP. Mean divided by standard deviation baseline to follow up
									Alcohol problems	SIP (Feinn et al., 2003)
									Alcohol use/related problems	AUDIT (Saunders et al., 1993)
									Blood alcohol concentration	eBAC (US Department of Transportation, 1994)
									Coping parental abuse	Coping behaviour scale (Orford et al., 1975)
Hansson et al.(2007)	Sweden	77	Randomised trial	Adult children of parents with alcohol problems	71.8% F 28.2% M Mean Age 25.6 (4.9) years	Alcohol intervention program; Coping Intervention Program; Combination of both	None	AUDIT and eBAC significantly lower in combination compared to coping or alcohol intervention; many interactions are change within-groups rather than between-groups	Social interaction	Interview schedule for social interaction (Unden & Orth-Gomer, 1989)	Baseline 2 years
									Psychological symptoms	SCL-90 (Derogatis, 1977)
									Standardized difference score alcohol	Mean standardized differences of AUDIT/eBAC/SIP. Mean divided by standard deviation baseline to follow up
									Alcohol problems	SIP (Feinn et al., 2003)
									Alcohol use/related problems	AUDIT (Saunders et al., 1993)
									Blood alcohol concentration	eBAC (US Department of Transportation, 1994)
									Coping parental abuse	Coping behaviour scale (Orford et al., 1975)
Howells & Orford (2006)	UK	20	Quasi-experimental design	Partners of problem drinkers	NS	Intervention for the partners of problem drinkers, in their own right	Waiting list control	Stress, sacrificing coping, and self-esteem significant at 6 months but not at 1 year between groups Independence significantly different at 6 months and 1 year between groups	Stress	Symptom Rating Test (Kellner et al., 1968)	Baseline 6 weeks 3 months
									Engaged coping	Amended Short Coping Questionnaire (Orford et al., 1992)
									Sacrificing coping	Amended Short Coping Questionnaire (Orford et al., 1992)
									Life affected	Self-generated*
									Self-esteem	Self-esteem and independence questionnaire (self generated)
									Independence
									Drinking related behavior	Adapted from Perceptions of Alcohol Problems Questionnaire (Velleman & Orford, 1990)
	UK	37	Case study design	Partners of problem drinkers	NS	Intervention for the partners of problem drinkers in their own right	None	Stress, sacrificing coping, life affected significantly different between baseline and 3 months, and 3 months and 6 months. Self-esteem and independence between baseline and 3 months significant only and drinking related behavior and engaged coping significantly different between 3 and 6 months.	Stress	Symptom Rating Test (Kellner et al., 1968)	Baseline 3 months 6 months 12 months
									Engaged coping	Amended Short Coping Questionnaire (Orford et al., 1992)
									Sacrificing coping	Amended Short Coping Questionnaire (Orford et al., 1992)
									Life affected	Self-generated*
									Self-esteem	Self-esteem and independence questionnaire (self generated)
									Independence
									Drinking related behavior	Adapted from Perceptions of Alcohol Problems Questionnaire (Velleman & Orford, 1990)
Rychtarik et al (2015)	USA	88	Randomised trial	Spouse	100% F Age NS	Coping skills training	8-week delayed treatment control	Depression, state anger significantly lower in CST vs DTC; participants in CST had greater post access skill acquisition. Anger, anxiety were non-significant, and the prevalence of partner treatment, self-help, or IPV was too low for data analysis	Depression	Beck Depression Inventory II	Baseline 8 weeks
									Anxiety	Depression, Anxiety, Stress Scales (Lovibond & Lovibond, 1995)
									Stress	Depression, Anxiety, Stress Scales (Lovibond & Lovibond, 1995)
									Anger expression index	State-Trait Anger Expression Inventory (STAXI-2; Spielberger, 1999)
									State anger	State-Trait Anger Expression Inventory (STAXI-2; Spielberger, 1999)
									% of days abstinent past week	TLFB (Sobell & Sobell, 1996)
									# standard drinks per drinking day/past week	TLFB (Sobell & Sobell, 1996)
									Skill acquisition	Spouse situation inventory A&B; Rychtarik & McGillicuddy, 1997)
Son & Choi (2010)	Korea	53	Quasi-experimental design	Family of patients with AUD	92.5% F 7.5% M Mean age 49.47 (SD=NS)	Anger management program	Control group not specified	No comparison between experimental and control groups [significant decrease in anger in experimental group pre-post]	Anger	Korean Anger Expression Inventory (Chon, 1996)	Baseline 1 months

* Scale author/origin not clear; AUD=Alcohol Use Disorder; SD=Standard deviation; M=Male; F=Female; NS=Not specified; outcomes in bold are primary outcomes

Table 2: Nature of the interventions included in the review of interventions targeting the affected other using TiDiER (n=7)

Study	Brief name	Why, rationale	What, materials and procedures	Who, provided	How, modes of delivery	Where, locations of intervention	When, how much, time period	Tailoring to individual patient	Modifications	a) How well, planned b) How well, actual
Aarti et al. (2020)	Guided imagery intervention	Guided imagery for stress management	Sessions (1) Natural guiding for individual; (2) Natural guiding with loved ones; (3) Spiritual guiding; (4) Deep relaxation guiding; (5) Meditation guiding (on negative thoughts); (6) Individual choice Each session was 30 minutes including 5 minutes deep breathing as a warm up, 20 minutes of guiding, 5 minutes deep breathing at the end.	Researcher provided guided imagery	Face to face	In a de-addiction centre in India	Daily delivery for 6 days on days 2-7; each session 30 minutes long	Individuals can choose the sixth day focus	Unclear	No assessment planned or reported
de los Angeles Cruz-Almanza et al. (2006)	Rational-Emotive Behavioral Therapy (REBT)	Exploring cognitive biases in personal interaction and assertiveness	Aims (1) Identify & correct cognitive biases/ defective information; (2) establish emotional regulation strategies; (3) acquire assertive interpersonal skills. Discuss effects of emotions on human function. Take turns to identify/give examples of own emotional reactions /analyze emotions. Therapist prompt other participants’ comments on similarities/differences with personal cases. Practice deep diaphragmatic breathing and progressive muscle relaxation	Trained therapist provided	Face to face in groups	Community center office	18 150-minute weekly sessions	Sessions tailored by therapist to individual's experience in confines of the model	Therapist was trained and expected to use manual	Deviations from manual were to be noted; none reported
de los Angeles Cruz-Almanza et al. (2006)	Refused	Unclear	Unclear	Unclear	Unclear	Unclear	Unclear	Unclear	Unclear	Unclear
Hansson et al. (2006; 2007)	Alcohol intervention program	Motivational interviewing	Aims (1) Identify high-risk drinking situations; (2) provide accurate information on alcohol; (3) identify personal risk factors; (4) challenge myths/ positive expectations; (5) establish appropriate and safer drinking goals; (6) manage high-risk drinking situations; (7) learn from mistakes Discuss AUDIT scores/alcohol expectations with feedback. Discuss Swedish facts, myths, drinking patterns. Learn to calculate blood alcohol level (BAC). Plan use including drinks, moderation strategy, drink refusal, peer influence, assertive behavior, high-risk situations identification, manage negative emotional states. Consumption diary/BAC between intervention sessions. 2nd session, topics repeated. Homework (diary) discussed in detail.	Manualized individually presented discussion by one therapist a few years older than the respondents	Face to face and self-complete	University setting	An individual 1 h baseline assessment, two individual 2-hour sessions	Feedback on AUDIT scores and alcohol use expectations; Plan party alcohol consumption; discuss drinking diary/BAC	Follow manual strictly, flexible in approach, aware of empathy, warmth, acceptance, or support of risk taking, single therapist for all data points	No assessment planned or reported;
	Coping intervention program	Cognitive behavioral coping intervention	Aims (1) Feedback from coping assessment on student’s experience of living with person, relations with non-alcoholic family members/social network; (2) information on common coping patterns/strategies in families. Focus on relationship, emotion, problem coping. Discuss ability to express emotions, handle discord, or not use avoidance; (3) Discuss better coping strategies. Diary of coping strategies used in trying situations during the month between the sessions, rating situation severity on an analogue visual scale (1–100). Read/reflect on books in Swedish, ‘Become my mother again’ and ‘If you really loved me’. Second intervention session repeats first session topics. Homework (diary) also discussed in detail					Diary of coping strategies used in trying situations in daily life during the intervention
	Combination of both	Combination of both	Both above. All individual parts remained; BAC/coping strategies discussed at less detailed level					Less BAC/ coping strategies than 1&2
Howells & Orford (2006)	Intervention for partners of problem drinkers, in their own right	Anxiety management techniques, problem solving, role playing	Sessions explored, expectations of change, areas of power, independence of finances, non-confrontational communication, how other family members were affected, and the role of the drinker. Portfolio of 15 items with a 2-page rationale and 4-page protocol. Listening sympathetically to the family member. discussion of development of own interests, and role playing of assertive and clear communication. Appointment with a counsellor	Trained Counselors	Face to face counseling service	In non-hospital based National Health Service addiction team	Mean number of appointments was 4 (range 1-12) lasting approximately one hour	Tailoring includes client experience, intervention after violence/contingency plans re. violence if appropriate	Unclear	Supervised by author, structured record sheets and tape recorded sessions; none reported
Rychtarik et al (2015)	Internet administered coping skills training program	Coping Skills Training -	StopSpinningMyWheels.org, online skill training website, and (b) randomization to one of two site coaches (professional counselors) who could, at the participant’s discretion, be consulted either by phone, secure email, or chat. Participants were phoned at the outset with contact at weeks 1, 3, and 6 to trouble shoot any problems. Participants had 8 weeks to access the program - sequentially presented sessions averaged 17 mins (range 4-32 minutes)	Online program + support on site coaches who were professional counsellors	Online intervention of individual sequential sessions. Coach was by telephone one on one	Online and on phone	24 sessions; mean=20.38 completed in 7.04 weeks. Coach contacts administrative mean (SD) =4.73 (2.96), technical 2.58 (2.58), clinical 1.18 (2.16)	Self-paced via instructional narration, animated presentations, quizzes, personal journaling, Fidelity assessed by competence scale	Not applicable	Inter-rater reliability of coach content/ type notes (20%), coach competence Kappa .82 content, .87 type/competence median 3-4 (good-v.good)
Son & Choi (2010)	Anger Management Program	Hwa-Byung or Korean Anger Syndrome Cultural care theory; Social control theory Cognitive Behavioral Therapy	Eight sessions (1) sharing experience of anger, (2) purposes of anger management, (3) causes and strategies of anger, (4) appeasing and changing anger, (5) expressing anger positively, (6) coping with anger, (7) anger and family, (8) program completion ceremony. Program based on the anger management manual for patients with substance dependence and/or mental health problems. Relaxation therapy began each session, and worksheets were used to support session activity. Goal to express, ventilate, cope with anger using CBT	Psychiatric–mental health nurse practitioners trained for 3+ years	Face to face delivery by group	Nurse led, but location unclear	8 sessions once a week for 2 hours; 3 experimental groups over 2 months	Individual experiences feed into content delivered	Unclear	Program reflection/ field notes were used to monitor; none reported
Son & Choi (2010)	Control	Unclear	Unclear	Unclear	Unclear	Unclear	Unclear	Unclear	Unclear	Unclear

Table 3: Behavior Change Techniques used in all seven studies with 11 interventions

Study	Brief name of intervention	Aim or behavior	Behavior change techniques
Aarti et al., (2020)	Guided imagery intervention	Meditation Practice	4.1 Instruction on how to perform the behavior 6.1 Demonstration of the behavior 8.1 Behavioral practice/rehearsal 11.2 Reduce negative emotions
de los Angeles Cruz-Almanza, et al., (2006)	Rational-Emotive Behavioral Therapy (REBT)	Increase assertive interpersonal behavior	4.1 Instruction on how to perform the behavior 6.1 Demonstration of the behavior 8.1 Behavioral practice/rehearsal 11.2 Reduce negative emotions
de los Angeles Cruz-Almanza, et al., (2006)	Refused the intervention but were followed up at 2 years	Unclear	Unclear
Hansson et al., (2006) (2007)	The alcohol intervention program	Reduce alcohol consumption	1.2 Problem solving 2.2 Feedback on behavior 2.3 Self-monitoring of behavior 2.4 Self-monitoring of outcomes of behavior 2.7 Feedback on outcome(s) of behavior 4.1 Instruction on how to perform the behavior 4.2 Information about antecedents 6.2 Social comparison 15.3 Focus on past success
	The coping intervention program	Increase adaptive coping strategy behaviors	1.2 Problem solving 2.2 Feedback on behavior 2.3 Self-monitoring of behavior 2.4 Self-monitoring of outcomes of behavior 2.7 Feedback on outcome(s) of behavior 4.2 Information about antecedents
	Combination of the alcohol and coping intervention programs	Reduce alcohol consumption and Increase adaptive coping strategy behaviors	1.2 Problem solving 2.2 Feedback on behavior 2.3 Self-monitoring of behavior 2.4 Self-monitoring of outcomes of behavior 2.7 Feedback on outcome(s) of behavior 4.1 Instruction on how to perform the behavior 4.2 Information about antecedents 6.2 Social comparison 15.3 Focus on past success
Howells & Orford (2006)	Intervention for the partners of problem drinkers, in their own right & then waiting list control six weeks after enrollment	Increase adaptive coping strategy behaviours	1.2 Problem solving 3.2 Social support (practical) 4.1 Instruction on how to perform the behavior 8.1 Behavioral practice/rehearsal 11.2 Reduce negative emotions 12.1 Restructure physical environment
Rychtarik et al,. (2015)	Internet administered coping skills training program	Increase adaptive coping behaviors	1.2 Problem solving 4.1 Instruction on how to perform the behavior 6.1 Demonstration of the behavior
Rychtarik et al,. (2015)	Internet administered coping skills training program 8 weeks delayed	Increase adaptive coping behaviors	1.2 Problem solving 4.1 Instruction on how to perform the behavior 6.1 Demonstration of the behavior
Son & Choi (2010)	Anger Management Program	Manage behaviors arising from feeling angry	4.2 Information about antecedents 8.1 Behavioral practice/rehearsal
Son & Choi (2010)	Control	Unclear	Unclear

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Few interventions support the affected other on their own: A systematic review of individual level psychosocial interventions to support those harmed by others’ alcohol drinking

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