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In 2011, a man was murdered by his former wife in the UK. For decades he had subjected her to abuse and the homicide was the tragic result. The subsequent inquiry into the case described the man as having a “chronic addiction to alcohol” and went on to say: “Appropriate referrals were made to addiction and medical services. He had a stubborn resistance to engaging with them, preferring, it seems, to continue his drinking unabated whilst deliberately avoiding medication. On occasions, he refused permission for referrals. Services cannot be effective unless the client wants to change… ”
The perception exists that if a problem drinker does not want to change, nothing can be done to help until the person discovers some motivation. It is often argued that if people do not want to change, we should ‘let them get on with it’. Indeed, it is sometimes perceived that if we intervene before the person wants to change, we are slowing their progress towards their real ‘rock bottom’ moment: the point at which things become so bad that the drinker decides to stop. Evidence exists that positive strategies and alternative approaches can be used with this patient group. More importantly, using them will target some of the most risky, vulnerable and costly individuals in society. By perpetuating the notion that ‘nothing can be done’, we will fail this patient group, extend the suffering of their victims and continue the burden on public services.
For the majority of this patient group, the best option would be recovery — giving up drinking completely and working to build a constructive life that is not disrupted by alcohol. This should almost always be the ultimate aspiration. However, this will be rejected by many patients in either words or actions. It is at this point that services have often said, ‘there is nothing that can be done; the person does not want to change’. That is untrue; essentially, two things can be done: One, work to build motivation; and, two, work to reduce harm or manage risk.
By perpetuating the notion that ‘nothing can be done’, we will fail this patient group, extend the suffering of their victims and continue the burden on public services
Statements that drinkers do not want to change are often accompanied by comments about the patients being ‘in denial’. The common perception is that this patient group does not understand the need to change. This needs to be challenged.
Miller and Rollnick’s work on motivational interventions is built on the recognition that denial is simply a façade. Behind that veneer of denial is a person who is in a state of ambivalence. They may be uncertain about whether they can change; they may believe that family history destines them to be a drinker; they may be scared of what change entails. Other evidence has shown that 40 per cent of apparently non-changing, higher-risk and dependent drinkers try and change each year. Like the rest of us, they are more complex people with fluctuating and conflicting hopes, beliefs and aspirations. The aim is to reach that more nuanced person behind the façade of denial.
The one thing you can do more than any other is to demonstrate that you believe the person can change. Promoting self-belief is crucial. You will help them believe they can change if you demonstrate that belief yourself. At times this will be tough — some patients seem set on a course that will destroy their lives or the lives of others. However, people do change. Even people who seem to have abandoned all hope of a different life can turn themselves around. If we do not demonstrate a belief in the possibility of change, we will reinforce a sense of hopelessness in clients.
The first step is to screen all clients with the AUDIT questionnaire tool, identifying those who are at risk of alcohol-related harm and offering ‘brief advice’. Regardless of AUDIT score, all patients can be offered information about standard drinks, safe limits and the risks associated with excessive drinking. This can be achieved by handing the client an alcohol leaflet and briefly going through the main points with them.
Promoting self-belief is crucial. You will help them believe they can change if you demonstrate that belief yourself
Research has proven the benefits of identification and brief advice (IBA), demonstrating that individuals have reduced their drinking by up to 15 per cent. While this may not be enough to bring the individual’s drinking down to lower-risk levels, it will reduce their alcohol-related hospital admissions by 20 per cent and ‘absolute risk of lifetime alcohol-related death’ by some 20 per cent, as well as having a significant impact on alcohol-related morbidity.
Change-resistant drinkers are unlikely to benefit from this approach. Nonetheless, this remains a good starting point. It allows workers to: one, begin a conversation on the basis of a validated screening tool; and two, make a few simple statements about the need to change and the potential benefits. If no-one talks about the drinking, opportunities to change will be missed and the pressure on the person to change will be minimised. Indeed, if workers say nothing, it may be seen as a statement that nothing is wrong with the drinking.
If someone is continuing to drink but there is a low risk of harm to self or others associated with the drinking, staff may be justified in doing no more than IBA and perhaps returning to the issue from time to time. At intervals, it would be helpful to, one, remind patients of the risk they run with their drinking in a non-judgemental manner; two, offer leaflets or new insights about the impact of drinking and services available; and, three, encourage a belief that change is possible.
However, if the continued drinking poses significant risk, then further action should be considered in order to, one, encourage change; and/or, two, reduce harm.
It is easy to dismiss the person as simply ‘unmotivated’ or ‘in denial’. Yet if a person is placing a significant burden on public services, their family or community, the least that can be done is to try and understand why they do not change or engage with services.
It is important to understand that the things that pushed someone to drink are not necessarily the same as those that prevent change. For example, evidence is beginning to suggest that alcohol-related brain injury is present in a far greater proportion of drinkers (35 per cent of dependent drinkers post-mortem) than previously considered and that other patterns of head injury may contribute to this.
Risk assessment should include alcohol problems, as well as reflecting broader risks to the individual, to others and to the wider society
Both will make it difficult for clients to motivate themselves. Poor nutrition not only contributes to brain injury but also reduces energy levels, while conditions like liver disease can reduce energy and encourage a pattern of sleep problems. In addition, a large proportion of drinkers will be in depressed states as a result of alcohol’s effects on the central nervous system. Other barriers could include low self-esteem, mental health problems, a history of severe trauma or peers who sabotage change.
Putting these factors together, we can see that the problems of engagement are not simply ‘denial’ but the fact that the person is at the centre of a ‘perfect storm’ of conditions, which make it harder and harder for them to organise and motivate themselves. Explaining this to patients will also help them to understand why they are finding it hard to change. It is not simply that they are ‘weak people’ — they have real barriers that impede change.
This assessment could also usefully look at what strengths and motivations the patient possesses. These will be useful, not only in understanding the patient’s support needs, but also in giving positive feedback, eg, reminders of past achievements. Assets could include a supportive family member, a previous successful career or achievement or current good health.
At all times we must be mindful to focus on the positives as well as the negatives.
In order to build motivation and to promote self-belief, we should ensure that any interventions have a positive tone and attempt to build self-efficacy — developing the person’s belief that change is possible. This is a powerful and evidence-based intervention. At the very least we should ensure that the patient understands that the door is always open for change. Again, this approach offers us the chance to make simple statements that the patient will take away.
Motivational interviewing is a clinical method for helping people to resolve ambivalence about change by helping them find their own reasons for motivation and commitment to change.
Family involvement should be considered wherever possible. The UK National Institute for Health and Care Excellence (NICE) clinical guideline 115 recommends encouraging families and carers to be involved in the treatment and care of people who misuse alcohol to help support and maintain positive change.
Family members will also find it useful to understand the barriers and challenges that the drinker experiences.
A common factor in many change-resistant drinkers is mental health problems (dual diagnosis). This combination is a real barrier to change and help will be required from mental health services.
UK guidelines provide the framework in that jurisdiction within which that care should be provided:
- Psychosis with co-existing substance misuse — NICE Clinical Guideline 2011.
- Dual Diagnosis Good Practice Guide (UK Department of Health Policy Implementation Guide, 2002).
- A Guide for the Management of Dual Diagnosis for Prisons (UK Department of Health, 2009).
These documents make it clear that mental health services in the UK have the lead responsibility for, at least, some of this patient group. In particular, the documents make clear that requiring someone to be free of alcohol before entering mental health services is not a clinically-validated response and will place a real barrier in the way of clients accessing vital help.
In the US, the Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the US Department of Health and Human Services that leads public health efforts to advance the behavioural health of the nation. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.
In Ireland, A Vision for Change (Department of Health 2006) sets out a comprehensive policy framework for mental health services in Ireland. Recommendations state that specialist adult teams should be developed to manage complex, severe substance abuse and mental disorders and that these specialist teams should establish clear linkages with local community mental health services and clarify pathways in and out of their services to service users and referring adult community mental health teams.
This has been interpreted as an effective uncoupling of general adult psychiatric services from addiction psychiatric services. This is widely perceived by addiction service providers as having negatively impacted on the delivery of care to their client group and not in line with international practice.
Problem drinkers with additional and co-existing problems, including people with learning disabilities, some older people, and some with social and housing problems, may be particularly vulnerable.
They may have complex needs that require more intensive or prolonged interventions, even at lower levels of alcohol use and dependence. Complex problems may also include difficulties that have a significant impact on others, such as domestic abuse, whether as victim or perpetrator.
Alcohol treatment interventions should always be designed to meet needs and reduce risk, both to the individual drinker and to others affected by their drinking, including partners, children, family and the wider community.
Assessing risk is an integral element in screening, triage assessment and comprehensive assessment. It provides information that will inform the care planning process. Risk assessment should include alcohol problems, as well as reflecting broader risks to the individual, to others and to the wider society.
Risk assessment aims to identify whether the individual has, or has had at some point in the past, certain experiences or displayed certain behaviours that might lead to harm for themselves or others.
The main areas of risk requiring assessment include:
- Risks associated with alcohol use or other substance use (such as physical damage, alcohol poisoning).
- Risk of self-harm or suicide.
- Risk of harm to others (including risks of harm to children and other domestic violence, harm to treatment staff and risks of driving while intoxicated).
- Risk of harm from others (including being a victim of domestic abuse).
- Risk of self-neglect.
Issues of risk highlight the need for appropriate information-sharing and for clarity with patients about the limits of confidentiality. If there are concerns about risk of significant harm to the children of alcohol misusers, social services would normally be involved in further assessment of the risk.
References available on request