4.2. REVIEW OF THE QUALITATIVE LITERATURE
4.2.1. Introduction
A systematic search for published reviews of relevant qualitative studies of people who misuse alcohol was undertaken. The aim of the review was to explore the experience of care for people who misuse alcohol and their families and carers in terms of the broad topics of receiving a diagnosis, accessing services and having treatment.
4.2.2. Review questions
For people who misuse alcohol, what are their experiences of having problems with alcohol, of access to services and of treatment?
For families and carers of people who misuse alcohol, what are their experiences of caring for people with an alcohol problem and what support is available for families and carers?
4.2.3. Evidence search
Reviews were sought of qualitative studies that used relevant first-hand experiences of people who misuse alcohol and their families/carers. For more information about the databases searched, see .
Databases searched and inclusion/exclusion criteria for clinical evidence.
4.2.4. Studies considered
Based on the advice of the GDG, this review was focused on qualitative research only because it was felt to be most appropriate to answer questions about the experience of care of those with alcohol dependence or alcohol misuse. Because good quality qualitative research exists within the literature, quantitative and survey studies were excluded.
The search found 32 qualitative studies which met the inclusion criteria (Aira et al., 2003; Allen et al., 2005; Bacchus, 1999; Beich et al., 2002; Burman, 1997; Copeland, 1997; Dyson, 2007; Gance-Cleveland, 2004; Hartney et al., 2003; Hyams et al., 1996; Jethwa, 2009
10; Kaner et al., 2006; Lock, 2004; Lock et al., 2002; Mohatt et al., 2007; Morjaria & Orford, 2002; Murray, 1998; Nelson-Zlupko et al., 1996; Nielsen, 2003; Orford et al., 1998a and 1998b; Orford et al., 2002; Orford et al., 2006a and 2006b; Rolfe et al., 2005; Rolfe et al., 2009; Smith, 2004; Vandermause, 2007; Vandermause & Wood, 2009; Vandevelde et al., 2003; Vargas & Luis, 2008; Yeh et al., 2009).
Thirty-four studies considered for the review did not meet the inclusion criteria. The most common reasons for exclusion were: alcohol was not the primary substance used; or there was not a high enough percentage of people who were alcohol dependent or reaching harmful levels of alcohol consumption; or the studies were quantitative or surveys.
Further information about both included and excluded studies can be found in Appendix 16a. The included studies have been categorised under six main headings: experience of alcohol misuse, access and engagement, experience of assessment and treatment for alcohol misuse, experience of recovery, and carer experiences and staff experiences.
4.2.5. Experience of alcohol misuse
One of the main themes that emerged under the heading of ‘experience of alcohol misuse’ was reasons for discontinuation of drinking. There were seven studies (Burman, 1997; Hartney et al., 2003; Jethwa, 2009; Mohatt et al., 2007; Nielsen, 2003; Rolfe et al., 2005; Yeh et al., 2009) that looked at people's motivation for stopping drinking in populations of people who drank heavily and were untreated. All studies mentioned that a significant motivation to discontinue drinking stemmed from external factors such as relationships, employment and education. Responsibility for others was a particular catalyst in maintaining motivation to stop drinking (for example, having a child, loss of a family member, or divorce/separation from a partner).
Rolfe and colleagues (2005) found that participants specified three key reasons for decreasing alcohol consumption. The first was ‘needing to’ decrease their alcohol consumption to minimise harm, once there was a realisation that alcohol was having a direct negative impact on their emotional and physical well-being. Both Rolfe and colleagues (2005) and Burman (1997) reported that the onset of physical problems was a significant motivation to stop drinking: ‘You need that scare to do it … you don't pack it in until you've had that scare and reached rock bottom’. The second reason was ‘having to’ decrease alcohol consumption due to work or relationship factors. The third was ‘being able to cut down’, which referred to no longer feeling the need or desire to consume alcohol and was typically inspired by a positive or negative change in a specific area of their life (for example, medical treatment or change in employment).
In the qualitative component of their study, Hartney and colleagues (2003) found that most participants did not have a sense of being unable to stop drinking alcohol, and issues such as relationships or driving a car would be prioritised over continuing to drink. This furthers the idea that, for untreated heavy drinkers, triggers and cues for alcohol consumption are largely socially determined. Another interesting finding was the conscious process that many participants went through in order to find moderation strategies to apply to their alcohol consumption. This was largely based around an observation of their own drinking in relation to other people's drinking levels, and disconnecting themselves from a drinking ‘taboo’ or what they considered to be ‘dependence’, including concealing evidence of alcohol consumption or the effects of physical withdrawal.
Nielsen (2003) found that participants in Denmark used different ways to narratively describe and contextualise their drinking behaviour. Several participants categorised their alcohol consumption as ‘cultural drinking’, where alcohol was used in a social and cultural context. Cultural drinking is a way of normalising alcohol consumption within a social environment (such as drinking at a party). Moreover, participants in this study distinguished their own heavy alcohol consumption from what they perceived as ‘real alcoholics’, who appeared to be more out of control: ‘Real alcoholics are drinking in the streets’.
Other patterns of drinking included symptomatic drinking, where patients drink as a reaction to external influences (for example, workload or relationship difficulties) or internal influences (for example, mental health problems). Cultural drinkers were found to use therapy and treatment more for information and feedback, rather than for the helpfulness of their therapists. Cultural drinkers tended to rely on their own willpower to cut back on their drinking. Conversely, those who were symptomatic drinkers used alcohol more as a way to solve problems and were more reliant and engaged in their treatment sessions with their therapists. Lastly, the Nielsen (2003) study highlights the process of heavy drinking and the ‘turning point’ that many harmful and dependent drinkers experience once the realisation is made that their alcohol consumption needs to change and treatment is needed. This turning point is in line with what Burman (1997) and Mohatt and colleagues (2007) found as well, in that participants typically experience an accumulation of negative alcohol-related events, and this prompts the decision to give up drinking. A period of reflection regarding their alcohol misuse may follow, and a key event often precipitates the motivation to stop drinking, and leads to a turning point.
Recently, Jethwa (2009) interviewed people who were alcohol dependent and found that six of the ten participants interviewed started drinking in response to a stressful life event (for example, depression, bereavement, or breakdown of a relationship). Other common reasons included familial history of drinking, being lured in by social networks, or just liking the taste of alcohol. Interestingly, once the decision was made to quit drinking, nearly all of the participants did not find it difficult once this ‘turning point’ was reached.
Yeh and colleagues (2009) conducted a study to look into the process of abstinence for alcohol-dependent people in Taiwan and discuss their challenges in abstaining from alcohol. Based on previous theories and the interviews, Yeh and colleagues (2009) identified a cycle of dependence, comprising the stages of indulgence, ambivalence and attempt (the IAA cycle). In the first stage of indulgence, alcohol-dependent people feel a loss of control over their alcohol consumption and to overcome unpleasant physical or mental states they consume more alcohol, exacerbating their dependence:
When I had physical problems and saw the doctor, they never got better. But I felt good when I had a drink. I started relying on alcohol and started wanting to drink all the time. Drinking would help me feel better.
In the ambivalent stage, people want to seek help but the will to drink is stronger than to remain abstinent. In the attempt phase, people try to remain abstinent but, due to a lack of coping strategies in situations that trigger alcohol consumption, many relapse.
Dyson (2007) found that recovery from alcohol dependence arose from a culmination or combination of consequences, coupled with the realisation that life was unbearable as it was:
My real recovery began when I admitted that my life had become unmanageable and that I could not control the drink. I experienced a deep change in thinking – sobriety had to be the most important thing in my life.
Several participants pointed out that their decision to pursue recovery and abstinence had to be made on their own and could not be made or influenced much by others: ‘It was something I had to do on my own and I had to do it for me, not for anyone else’. Evidently this personal decision has important implications for the carers around them. The key to begin recovery appears to be the individual's willingness and readiness to stop drinking (Dyson, 2007).
An earlier study by Orford and colleagues (1998) looked at social support in coping with alcohol and drug problems at home, using a cross-cultural comparison between Mexican and English families. The main cross-cultural differences were that positive social support for Mexican relatives stemmed mostly from family, whereas English relatives mentioned self-help sources, professionals and friends in addition to family. The accounts from the participants mentioned family and friend support as more unsupportive or more negative for the English families. Conversely, the Mexican families often mentioned their family and neighbours as significant contributors of support. The researchers explored the participant's perceptions of the positive and negative drawbacks to their heavy drinking. The negative aspects included increased vulnerability to arguments and fights, and the unpleasant physical effects of drinking (such as waking up tired, stomach upsets and headaches). Many participants mentioned the adverse effects alcohol had had on their physical and mental health. Interestingly, several participants mentioned drinking in order to cope with difficult life events, but masked this association between coping and alcohol by terming it as being ‘relaxed’. Many submerged the notion of coping by using the fact that alcohol helped them relax in distressing situations. Thus, the long-term psychological and short-term physical consequences were noted as the principle drawbacks of harmful alcohol consumption, whereas coping, and feelings of being carefree and relaxed, seem to constitute the positive aspects of drinking.
4.2.6. Access and engagement
In the review of the qualitative literature, several themes emerged under the broad heading of ‘access and engagement’ to services for alcohol misuse, including factors that may act as barriers to accessing treatment services such as external and internal stigma, ethnicity and gender. This review also identified ‘reasons for seeking help’ as a theme emerging from the included studies. There were eight studies from which themes of access and engagement emerged (Copeland, 1997; Dyson, 2007; Lock, 2004; Nelson-Zlupko et al., 1996; Orford et al., 2006; Rolfe et al., 2009; Vandermause & Wood, 2009; Vandevelde et al., 2003; Vargas & Luis, 2008).
Stigma
Dyson (2007) found that all participants used strategies to hide their alcohol dependence, including covering up the extent of their alcohol consumption. This was primarily due to the fear of being judged or stigmatised: ‘I knew that I was ill but was too worried about how other people would react. I felt I would be judged’. All participants in the study had some contact with healthcare professionals in an attempt to control or reduce their drinking. GPs were described as being particularly helpful and supportive, and nurses and other healthcare workers as less understanding and more dismissive, especially those in accident and emergency departments; this contrasts with another study (Lock, 2004), where people who misuse alcohol found primary care nurses to be helpful. Social stigma can also occur from groups in the community. For example, Morjaria and Orford (2002) highlight in their study that South Asian men in the UK often perceive that members of their religious community could influence their desire to consume alcohol, and furthermore, once religious leaders in the community expressed disapproval of alcohol consumption, there was more encouragement towards being abstinent from alcohol.
Ethnicity
Vandevelde and colleagues' (2003) study of treatment for substance misuse looked at cultural responsiveness from professionals and clients' perspectives in Belgium. People from minority groups found it difficult to openly discuss their emotional problems due to cultural factors, such as cultural honour and respect. Participants stressed the absence of ethno-cultural peers in substance misuse treatment facilities, and how this made it hard to maintain the motivation to complete treatment. Although this study had a focus on substance misuse (that is, both drugs and alcohol), it is important to note its generalisability to alcohol services and treatment.
Gender
Vandermause and Wood (2009) and Nelson-Zlupko and colleagues (1996) both looked at experiences and interactions of women with healthcare practitioners in the US. Many women described waiting until their symptoms were severe before they would seek out healthcare services:
… it's hard for me to go in … and it's not someplace that I want to be, especially when I know that I have to be there. I know that I'm ill, I don't want to admit it… I have to get my temperature taken and my blood pressure and they gotta look at my eyes and my ears … find out what it is that I've got from somebody else sharing a bottle you know.
Once the women sought help from a healthcare professional, several felt angry and frustrated after repeated clinic visits resulted in being turned away, treated poorly, or silenced by comments from healthcare professionals. Some women would go in needing to be treated for a physical health problem and the practitioner would address the alcohol problem while ignoring the primary physical complaint.
Conversely, other women were satisfied about how they were treated in interactions with their practitioners, which influenced perceptions of the healthcare services, seeking out treatment and feeling comfortable about disclosing their alcohol use:
I was confused and angry, and the doctor made me feel comfortable, even though I was very very ill … he let me know that I was an individual person but I had a problem that could be arrested. He was very compassionate very empathetic with me and told me the medical facts about what was happening to me, why I was the way I was and he told me a little bit about treatment, what it would do … so I was able to relax enough and stop and listen rather than become defensive …
When women specifically sought treatment for their alcohol use, the authors suggested that there was a crucial need for healthcare practitioners to make the patient feel comfortable and acknowledge their alcohol problem in addition to addressing any other physical health problems.
Nelson-Zlupko and colleagues (1996) found that individual counselling might be important in determining whether a woman is retained or drops out of treatment. Many women felt that what they wanted from treatment was someone to ‘be there for them’ and lend support. A therapist's ability to treat their patients with dignity, respect and genuine concern was evaluated as more important than individual therapist characteristics (such as ethnicity or age). Some women mentioned that good counsellors were those who:
… view you as a person and a woman, not just an addict. They see you have a lot of needs and they try to come up with some kind of a plan.
Both Nelson-Zlupko and colleagues (1996), and Copeland (1997), highlighted that childcare was a particular need for women because it was not widely available in treatment. When childcare was available, this was perceived to be among one of the most helpful services in improving attendance and use of treatment and drug/alcohol services. In addition, women felt strongly about the availability and structure of outpatient services offered and felt there should be more flexible outpatient programmes taking place, for example, in the evenings or at weekends.
Copeland's (1997) Australian study was of women who self-managed change in their alcohol dependence and the barriers that they faced in accessing treatment. One of the central themes of the study was the social stigma that women felt as being drug or alcohol dependent. Seventy-eight per cent of participants felt that women were more ‘looked down upon’ as a result of their drinking and the additional burden of an alcohol or drug problem only increased the stigma. Some women reported that the feeling of being stigmatised impacted on their willingness to seek treatment:
There is the whole societal thing that women shouldn't show themselves to be so out of control … that stigma thing was part of the reason for not seeking treatment.
In line with this, Rolfe and colleagues (2009) interviewed women in the UK about their own perceptions of their heavy alcohol consumption and its relation to a wider social perspective. Many women claimed that stigma was a major obstacle to accessing treatment services and that, while men did carry stigma as heavy drinkers, there was an additional stigma for women due to the way a ‘heavy drinking woman’ was perceived within society. The interviews emphasised that women need to perform a ‘balancing act’ to avoid being stigmatised as a ‘manly’ woman or as someone with alcohol dependence. These discourses are important in understanding the perception of gender differences in heavy alcohol consumption and ways in which stigma can affect women, and their ability and willingness to seek treatment for their alcohol use.
Reasons for seeking help
A study conducted by Orford and colleagues (2006b) investigated the reasons for entering alcohol treatment in the UK. The study was based on pre-treatment interviews from participants who were about to commence the UK Alcohol Treatment Trial (UKATT) and receive either MET or social network behavioural therapy (SNBT) for alcohol dependence or harmful alcohol use. Reasons for entering alcohol treatment included the realisation of worsening problems and accumulating multiple problems relating to alcohol use, which had a negative impact on both family members and the participants' health. Participants were also interviewed about reasons for seeking professional treatment as opposed to unaided or mutual self-help. Common reasons for seeking formal help included such help being suggested by primary care workers, a strong belief in the medical model and in counselling or psychological therapy, or feelings of helplessness.
Accessing help: reasons and preferences
Lock (2004) conducted a focus group study with patients registered with general practices in England. Participants were classified as ‘sensible’ or ‘heavy/binge drinkers’. Participants responded positively to advice delivered in an appropriate context and by a healthcare professional with whom they had developed a rapport. Overall, the GP was deemed to be the preferred healthcare professional with whom to discuss alcohol issues and deliver brief alcohol interventions. Practice nurses were also preferred due to the perception that they were more understanding and more approachable than other healthcare workers. Most said they would rather go straight to their GP with any concern about alcohol, either because the GP had a sense of the patient's history, had known them for a long time or because they were traditionally whom the person would go to see. It was assumed that the GP would have the training and experience to deal with the problem, and refer to a specialist if necessary. Alcohol workers were perceived by many as the person to go to with more severe alcohol misuse because they were experts, but this also carried the stigma of being perceived to have a severe alcohol problem. Seeing a counsellor was also perceived as negative in some ways, as there would be a stigma surrounding mental health problems and going to therapy.
4.2.7. Experience of assessment and treatment for alcohol misuse
In the review of the qualitative literature, several themes emerged under the broad heading of ‘experience of treatment for alcohol misuse’, including experience of assessment (pre-treatment), assisted withdrawal, other treatments (such as psychological interventions) and treatment setting (inpatient). In this review of assessment and treatment, there were six studies included (Allen et al., 2005; Bacchus, 1999; Dyson, 2007; Hyams et al., 1996; Orford et al., 2006a; Smith, 2004).
Experience of assessment (pre-treatment)
Hyams and colleagues (1996) interviewed service users about their experience and satisfaction with the assessment interview prior to engagement in alcohol treatment. The study had both a quantitative and qualitative aspect to it. The qualitative component assessed the best and worst aspects of the assessment interview. Thirty-three of the 131 participants said that the therapeutic relationship with the interviewer was most beneficial (as assessed by ‘The interviewer's understanding of the real me’, ‘Friendliness of the interviewer’ and ‘A feeling of genuine care about my problems’). Twenty participants appreciated the ability to talk generally and therapeutically to the interviewer about their problems. Eight participants reported that the assessment interview provided them with a sense of increased awareness about their alcohol use and its impact on their lives: ‘I found insight into why I drink …’ Others found that the assessment interview was crucial in taking the first step into treatment: ‘Glad that I did attend the interview’ and ‘Given me some hope’.
Although participants identified few drawbacks regarding the interview, they did cite general nervousness particularly about starting the interview. Some criticised the interviewer for not giving enough feedback or not having enough time to talk. Several participants felt that it was distressing to have to reveal so much information about their drinking problems and to come to a state of painful awareness about their problem. This study is noteworthy because it highlights the importance of a thorough assessment prior to entering alcohol treatment that allows participants to speak freely to an accepting, empathetic interviewer and that, if a positive experience for the service user, will increase engagement and motivation to change in subsequent alcohol treatment programmes.
In line with these findings, Orford and colleagues (2006a) found that a comprehensive pre-treatment assessment was perceived by participants to have motivational and self-realising aspects to it. Many participants expressed that this assessment was influential in increasing motivation to undergo their alcohol treatment.
Experience of assisted withdrawal
Two studies, Allen and colleagues (2005) and Smith (2004), captured the patient experience of medically-assisted withdrawal programmes for alcohol misuse in both the UK and Australia. Both studies found that participants expressed fears about the future and a hesitation about coping with life events that had previously been associated with alcohol consumption:
I feel safe in the environment but I don't feel safe with my thoughts at the moment because I can't use alcohol or any drug to cope with it …
The most common themes emerged around fears regarding social environment, the physical effects of withdrawal and medication prescribed during detoxification. Participants discussed fears about returning to their homes after detoxification and how to lead a life without alcohol:
When you've done the first few days [of detoxification], you get your head back together and start to think, How am I going to be able to cope outside? You know you've got to leave here sometime, so how am I going to cope?
Participants also expressed significant concerns about the effects of medication, although there were also a number of positive experiences of medication which were referred to but were not described in detail. Some participants feared that their medication would be addictive:
I didn't want another problem of having to get off something as well as the booze. I was worried that I could get addicted to the tablets as well and then start craving for those.
Nearly all participants were apprehensive about the transmission of information about medication between the staff and themselves; they felt they had inadequate information about what medication they were taking, why they were taking it and the effects it may have on them:
I didn't know what they were, what they were going to do to me … they didn't tell me why I was taking them.
It is clear from this study that providing adequate information about assisted withdrawal and medication procedures needs to be ensured in alcohol services.
A significant proportion of participants also expressed fears about the physical effects of withdrawal, and any pain and/or distress that may be a side effect of the detoxification programme. Those who had had previous medically-assisted withdrawals prior to this study seemed to have the greatest fears. Lastly, participants discussed fears about their future and were concerned about their ability to cope once completing the detoxification programme. These fears mostly stemmed from difficult interpersonal situations and coping strategies:
I'm worried about having too much time on my hands; the day goes so much quicker with a few drinks inside you.
In both studies, participants expressed a lack of confidence and an inability to resist temptation; they also felt that they were not being accepted back into their original social networks where heavy drinking was perceived as the norm. Additionally, fears about the future were related to a feeling that the hospital setting was too far removed from real life:
It's nice and safe in here. You are secure in here. But it's not real life is it? And it tells you nothing about how you are going to cope when you are back in the same old situations with the same old problems.
Participants in the Smith (2004) study also articulated feelings of being out of control during their admission to treatment. These feelings of distress revolved around the difficulty to alter their alcohol consumption, and stick to a reduced consumption level or abstinence:
You get well physically and you start thinking clearly … you start telling yourself you're over it … you might maintain some kind of normal drinking activity for a short period of time. I just believe that I can't keep doing it. I don't want to.
With each medically-assisted withdrawal, the goal of abstinence seemed more distant – the thought of this was anxiety-provoking for many participants because they felt they would be unable to maintain abstinence in the future. After medically-assisted withdrawal, they would have to return to a life where all their personal, professional and relationship difficulties still existed but were previously associated with alcohol.
Conversely, there were positive feelings about treatment because most felt they had taken steps to bring about positive changes in their lives by seeking treatment. The facility enabled participants to have respite from their lives as well as social and emotional support from other participants in the programme. The authors suggested that nurses could assist participants in reducing negative feelings (such as shame) by closely observing behaviour and being more sensitive and empathetic to service users' feelings, thereby strengthening therapeutic communication between staff and patients.
Experience of psychological treatment
Orford and colleagues (2005 and 2008) carried out a content analysis of service users' perspectives on change during a psychological intervention for their alcohol dependence in UKATT. Participants highlighted that psychological treatment had helped them to think differently, for example about fearing the future and focusing on the downside of drinking. Others talked of adopting a more positive outlook or more alcohol-focused thinking (for example, paying attention to the physical consequences such as liver disease or brain damage). Several participants mentioned that, ‘the questions, the talking, being honest, being open – that was positive [of treatment]’. Other factors to which change was attributed to were awareness of the consequences of drinking and feeling comfortable talking about their alcohol consumption.
Experience of support from family and voluntary organisations
Orford and colleagues (2005) also found that the influence of family and friends helped in promoting change in alcohol consumption. Treatment seemed to assist participants in finding non-drinking-related activities and friends, and seeking out more support from their social networks to deal with problematic situations involving alcohol. Supportive networks provided by AA and the 12-step programme facilitated recovery for participants in the Dyson (2007) study as well, because they were able to be with others who genuinely understood their experiences and fostered a sense of acceptance: ‘Here was a bunch of people who really understood where I was coming from’.
Experience of treatment setting – inpatient
Bacchus (1999) carried out a study about opinions on inpatient treatment for drug and alcohol dependence. Over one third of participants reported that they would have preferred to enter treatment sooner because there was an urgent need to maintain treatment motivation and receive acute medical care:
When you make that decision to ask for help, you need it straight away. If you have to wait a long time to get in you just lose your motivation and you might just give up.
Participants also felt frustrated about the lack of communication and liaison from the referring agency during the waiting period. The structured individual and group counselling treatment programme was seen as a generally effective way of improving self-confidence and self-esteem. Educational group discussions about substance use and risks were particularly positively regarded. Recreational groups (for example, art therapy, exercise and cookery) also proved to be beneficial in terms of engaging in other non-drinking-related activities. One of the most positive aspects of treatment noted by participants was the quality of the therapeutic relationships. Staff attitudes, support, and being non-judgemental and empathetic were all mentioned as crucial components of a positive experience in treatment. Sixty-two per cent of patients had made prior arrangements with staff for aftercare treatment and expressed satisfaction with the arrangements. The only exception was that patients wished for more detailed information about the next phase of their treatment.
4.2.8. Experience of recovery
Four studies (Burman, 1997; Mohatt et al., 2007; Morjaria & Orford, 2002; Yeh et al., 2009) looked at the experience and process of recovery for people who misuse alcohol. All studies with the exception of Yeh and colleagues (2009) looked at recovery from the standpoint of drinkers who were untreated. Nearly all the studies highlighted the importance of utilising active coping and moderation strategies in order to stop consuming alcohol, and a number of the studies touch on the importance of positive social support networks, faith and self-help groups.
Morjaria and Orford (2002) examined the role of religion and spirituality in promoting recovery from drinking problems, specifically in AA programmes and in South Asian men. Both South Asian men and men in AA began recovery once there was a feeling of hitting ‘rock bottom’ or of reaching a turning point where they felt their drinking must stop. Both groups drew on faith to help promote recovery, but the South Asian men already had a developed faith from which to draw upon, whereas the men in AA had to come to accept a set of beliefs or value system and develop religious faith to help promote abstinence.
In terms of self-recovery strategies, participants in Burman (1997), Mohatt and colleagues (2007) and Yeh and colleagues (2009) often utilised recovery strategies that mirrored those in formal treatment, consisting of drawing on social support networks and avoiding alcohol and alcohol-related situations. Seeing another person giving up alcohol also helped to promote abstinence and motivation, again highlighting the necessity of positive support networks. Another stage of sobriety for participants in Mohatt's study (2007) involved a more gradual acceptance of their vulnerability towards consuming alcohol and continuing to strategise and resist the urge to drink. Additional coping strategies outlined by Burman (1997) were: setting a time limit for recovery; discussing their goals and plans with others to help keep them on track; and keeping reminders of negative experiences to help prevent further relapse.
Similar to those in formal treatment programmes, once in the midst of self-recovery, participants reported a number of positive changes since abstaining (for example, increased energy and memory, self-awareness and empowerment), and more external benefits including regaining trust from their social networks and reintegrating into society. Negative consequences of abstinence included edginess and physical side effects, family problems, struggles with craving and a loss of a specific social circle or group previously related to alcohol.
Taken together, the self-recovery studies highlight the process of abstinence for alcoholics, stressing that the path is not straightforward, and assistance from self-help groups and social support networks are crucial to help ensure a better recovery.
4.2.9. Carer experiences
Four studies (Gance-Cleveland, 2004; Murray, 1998; Orford et al., 1998a; Orford et al., 2002) were found that could be categorised under the heading ‘carer experiences’.
Orford and colleagues (1998) conducted cross-sectional interview and questionnaire studies with a series of family members in two sociocultural groups, in Mexico City and in the west of England. They found that there were three approaches to interacting with their family members who misuse alcohol: (1) tolerating; (2) engaging; and (3) withdrawing. In the first approach, the carer would tolerate inaction and support the person in a passive way. Some carers mentioned taking the ‘engaging’ position with their family members in an attempt to change unacceptable and excessive substance use. Some forms of engagement were more controlling and emotional in nature; others more assertive and supportive. Lastly, some carers mentioned emotionally and physically withdrawing from their family members with an alcohol problem (for example, asking their alcohol-using family member to leave the house). This was seen as a way to detach oneself from the alcohol problem of their family member. One form of coping that carers also mentioned was that one needs to enforce supportive and assertive coping:
You need to be very strong, to be there and talk to him but still stick to your own values and beliefs in life.
There was significant overlap between the coping strategies outlined by both families from England and from Mexico. Families in both countries used assertive and supportive ways of coping with their family member's alcohol problem, either through direct confrontation, financial or emotional sacrifice. Thus, even given a different sociocultural context, there are several common ways for carers to cope and interact with a family member with an alcohol problem.
Orford and colleagues (2002) interviewed the close relatives of untreated heavy drinkers. Most relatives recognised the positive aspects of their family member consuming alcohol (for example, social benefits) and reported a few drawbacks to drinking. Many family members contrasted their family member's current problem with how their problem used to be. Other family members used controlling tactics (for example, checking bottles) as a way to monitor their family members, while others tried to be tolerant and accepting of their family member's drinking behaviour.
There are two qualitative studies that have looked at the perspectives and experiences of people whose parents misuse alcohol. Murray (1998) conducted a qualitative analysis of five in-depth accounts of adolescents with parents who misuse alcohol and found four main themes: (1) ‘The nightmare’, which includes betrayal (abuse/abandonment), over-responsibility, shame, fear, anger, lack of trust and the need to escape; (2) ‘The lost dream’, which consists of loss of identity and childhood (lack of parenting, comparing oneself with others, unrealistic expectations); (3) ‘The dichotomies’, which is the struggle between dichotomies, for example, love and hate (towards parents), fear and hope (towards the future) and denial and reality; (4) ‘The awakening’, which is gaining an understanding of the problem, realising alcohol is not an answer (possibly through their own experiences), realising they were not to blame and regaining a sense of self.
Another qualitative study (Gance-Cleveland, 2004) investigated the benefit of a school-based support group for children with parents who misuse alcohol and found that the group helped them to identify commonalities with each other, feel that they were understood, support and challenge each other, and share coping strategies. The children who took part also felt that the group was a trusted and safe place in which they could reveal secrets and feel less isolated and lonely, that it enabled them to be more aware of the impact of addiction on family dynamics and helped them increase resilience and do better at school (Gance-Cleveland, 2004). In conclusion, talking to others (especially with those who have had similar experiences) was found to be helpful in terms of coping, making friendships and understanding more about alcohol misuse.
4.2.10. Staff experiences
There were six studies (Aira et al., 2003; Beich et al., 2002; Kaner et al., 2006; Lock et al., 2002; Vandermause, 2007; Vandevelde et al., 2003, Vargas & Luis, 2008) looking at the experience of staff who work with people who misuse alcohol. There were several themes emerging from staff experiences, the first being hesitancy in delivering brief interventions to people who misuse alcohol. Staff implementing the WHO screening and brief intervention programme in Denmark found that it was difficult to establish a rapport with patients who screened positive for alcohol misuse and ensure adherence with the intervention (Beich et al., 2002). In England, primary care practitioners had little confidence in their ability to deliver brief interventions and override negative reactions from patients (Lock et al., 2002). Furthermore, because alcohol misuse can be a sensitive and emotional topic, a significant proportion of the staff in the studies expressed a lack of confidence about their ability to counsel patients effectively on lifestyle issues (Aira et al., 2003; Beich et al., 2002; Lock et al., 2002):
The patient does not bring it up and obviously is hiding it … [Alcohol] is a more awkward issue; which of course must be brought up…
Approaching emotional problems related to substance misuse through the medical dimension might facilitate the treatment of minority groups, because it was perceived that emotional problems were more often expressed somatically (Vandevelde et al., 2003).
A positive experience with a service user involved an assessment using effective diagnostic tools where staff were able to employ an indirect, non-confrontational approach and service users were able to discuss their problems and tell their story at their own pace (Vandermause, 2007).
Both Beich and colleagues (2002) and Lock and colleagues (2002) highlighted that brief interventions and confronting service users regarding their alcohol consumption was important; there were, however, a number of significant barriers to delivering these interventions effectively (for example, the fear of eliciting negative reactions from their patients). Staff interviewed in the Vandermause (2007) qualitative study also found that staff had concerns about defining alcohol as problematic for their patients.
Aira and colleagues (2003) found that staff were not ready to routinely inquire about alcohol consumption in their consultations, unless an alcohol problem was specifically indicated (for example, the service user was experiencing sleeplessness, high blood pressure or dyspepsia). Even when they were aware of alcohol misuse in advance, staff still had significant difficulty in finding the ideal opportunity to raise the issue with their patients. If they did not know in advance about a drinking problem, they did not raise the issue.
Kaner and colleagues (2006) looked at GPs' own drinking behaviour in relation to recognising alcohol-related risks and problems in their patients. The interviews indicated that GPs' perceived their own drinking behaviour in two ways. Some GPs drew on their own drinking behaviour when talking to patients because it could be seen as an opportunity to enable patients to gain insight into alcohol issues, facilitate discussion and incorporate empathy into the interaction. Other GPs separated their own drinking behaviour from that of ‘others’, thereby only recognising at-risk behaviours in patients who were least like them.
Vargas and Luis (2008) interviewed nurses from public district health units in Brazil and discovered that despite alcoholism being perceived as a disease by most of the nurses, the patients who misuse alcohol who seek treatment are still stigmatised:
We generally think the alcohol addict is a bum, an irresponsible person, we give them all of these attributes and it doesn't occur to you that [he/she] is sick.
Furthermore, the nurses interviewed seemed to express little hope and optimism for their patients because they believed that after being assisted and detoxified, they would relapse and continue drinking:
… he comes here looking for care, takes some glucose and some medications, and as soon as he is discharged he goes back to the … drink.
This study highlights the extent of external stigma that those who misuse alcohol can face within the healthcare setting, and how it could prevent positive change due to an apprehension about continually accessing services or seeking help.
All six studies made recommendations for improving staff experience when engaging with people who misuse alcohol, with an emphasis on training, communication skills and engaging patients about alcohol consumption, combined with a flexible approach to enhance dialogue and interaction. However, although many healthcare professionals received training about delivering brief interventions, many lacked the confidence to do so and questioned their ability to motivate their patients to reduce their alcohol consumption. Staff also frequently cited a lack of guidance concerning alcohol consumption and health. Clear health messages, better preparation and training, and more support were cited as recommendations for future programmes. As many healthcare professionals found screening for excessive alcohol use created more problems than it solved, perhaps improving screening procedures could improve the experience of staff delivering these interventions.
4.2.11. Summary of the literature
The evidence from the qualitative literature provides some important insights into the experience of people who misuse alcohol, their carers and staff. Problematic alcohol consumption appears to stem from a range of environmental and social factors, including using alcohol to cope with stressful life events, having family members with alcohol or drug problems and/or social situations that encourage the consumption of alcohol. A cycle of dependence then begins wherein the person goes through stages of indulgence in, ambivalence towards and attempts to abstain from alcohol (Yeh et al., 2009), resulting in a loss of control over their alcohol consumption. This leads to the consumption of more alcohol to counteract unpleasant physical or mental states. As the alcohol consumption becomes harmful, there seems to be an accumulation of negative alcohol-related events. These can become the catalyst for change in the person's life, when the person realises that their alcohol problem requires further assistance and/or treatment. This readiness or willingness to change needs to be determined by the person who misuses alcohol, sometimes with support and insight from their social networks – readiness to change cannot be imposed externally. These differing patterns of alcohol consumption and reasons for deciding to engage in treatment or change one's behaviour mean that treatment services need to understand an individual's reasons for drinking and how this may influence treatment.
With regard to access and engagement in treatment, once people who misuse alcohol had made the conscious decision to abstain from or reduce their drinking, they were more willing to access treatment, although external factors and the motivational skills of healthcare professional may also play a part. Barriers to treatment included internal and external stigma, an apprehension towards discussing alcohol-related issues with healthcare professionals, and a fear of treatment and the unpleasant effects of stopping drinking. As a group, women felt that they faced additional barriers to treatment in the form of more social stigma, and the need for childcare while seeking and undergoing treatment. In addition, women felt that they received less support from treatment providers, and would benefit from a more empathetic and therapeutic approach. The studies focusing on women and alcohol problems emphasise that a non-judgemental atmosphere in primary care is necessary in order to foster openness and willingness to change with regard to their alcohol problems.
In one study looking at the impact of ethnicity and culture on access to treatment, participants from an ethnic minority report having mostly positive experiences with healthcare practitioners, but improvements could be made to the system in the form of more ethno-cultural peers and increased awareness of culture and how it shapes alcohol consumption and misuse.
The literature strongly suggests that assessments that incorporate motivational cues are crucial in ensuring and promoting readiness to change early on in the treatment process. Having open and friendly interviewers conducting the assessments also seems to have an effect on increasing disclosure of information and the person's willingness to enter into subsequent alcohol treatment.
Although there were some positive experiences of medication, the qualitative literature highlights consistent fears surrounding assisted withdrawal and the unpleasant effects one may experience while in treatment. Many participants across studies fear the future and not being able to adopt appropriate coping strategies that will assist in preventing relapse once they return to their familiar social milieu. More information from staff in alcohol services may be beneficial in alleviating patient's fears about treatment.
Psychological treatment was seen to facilitate insight into one's drinking behaviour and understand the downsides of drinking. Talking with a therapist honestly and openly about alcohol helped in alleviating fears about the future and developing coping strategies. Within a residential treatment programme setting, a therapeutic ethos and a strong therapeutic relationship were regarded as the most positive aspects of alcohol treatment.
Active coping and moderation strategies, self-help groups, rehabilitation programmes and aftercare programmes were found to be helpful in preventing relapse post-treatment, and social support networks may serve as an additional motivation to change and can help promote long-term recovery. It should be noted that these findings were from studies of untreated drinkers, so this should be interpreted with caution if generalising to a population formally in treatment. Emphasis on a therapeutic relationship between healthcare practitioners and patients and good communication seem integral to promoting recovery. Social support, empathic feedback, and adequate information provision also facilitate the recovery process.
Family and friends can have an important role in supporting a person with an alcohol problem to promote and maintain change, but to do this they require information and support from healthcare professionals. But the strain on carers can be challenging and they may require a carer's assessment.
From a staff perspective, the qualitative studies suggest that many staff in primary care have feelings of inadequacy when delivering interventions for alcohol misuse and lack the training they need to work confidently in this area. An improvement in staff training is required to facilitate access and engagement in treatment for people with alcohol problems. When interventions were successfully delivered, assessment and diagnostic tools were seen as crucial. In addition, thorough assessment and diagnostic tools may aid in the process of assessing and treating patients with alcohol-use disorders.
Even if they were aware of a problem, many healthcare professionals felt they had inadequate training, lack of resources, or were unable to carry out motivational techniques themselves. More training about harmful drinking populations and associated interventions, as well as more awareness about how to interact with these populations from a primary care perspective, should be considered.
