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" the total estimated cost of alcohol problems in Scotland is £2.25 billion: These resources could be used more effectively to build a healthier society and ... achieve our potential."

Social and community influences can help or hinder the development of recovery in dependent drinkers. The process of recovery is subject to ongoing research, but there is emerging evidence that mutual aid plays a significant role for many people. Helping people access mutual aid groups, therapeutic communities and recovery-focused community organisations should be one of our goals in Lothian. Such an approach helps recovery from exclusion, reduces inequalities and, can provide a way for many to re-engage and contribute more fully to society.

Alcohol and society

Harmful drinking, is not a new phenomenon. Problem drinking has been recorded throughout British history1. The degree to which alcohol excess and problem drinking are tolerated, however, depends on the particular social/community context. In the second half of the 19th century, public reaction to drunkenness and the acknowledged social consequences of excess alcohol consumption led to increasing social disapproval and the development of social reform movements, including the temperance movement2.

Regardless of the direct harm which can occur through alcohol misuse, excess alcohol use at population level has adverse social consequences, affecting the levels of crime and reducing personal safety. The Scottish Government estimates the total cost of alcohol problems in Scotland to be £2.25 billion3: These resources could be used more effectively to build a healthier society and help more of us to achieve our potential.

We live in an addicted society. Social capital can moderate the level of harm experienced and there is evidence that alcohol dependent individuals with good social networks present much later than those with poorer psychosocial support5. Perhaps this is because individuals with good networks are more able to follow less habitual drinking patterns. Alternatively it may be that support helps individuals ignore harmful drinking patterns and so the consequences of dependent drinking are hidden. Al-anon, a support group for family or friends of those with problem drinking advocates that members 'detach' in a caring fashion from harmful behaviours and cease acting in a way that might enable the behaviour to continue6.

There is evidence that this helps families, but there is currently no research that shows such behaviour helps dependent drinkers to seek aid sooner or change their drinking patterns7.

[ Box 1 ]

It has been argued that the culture of addiction "is an informal social network in which group norms (prescribed patterns of perceiving, thinking, feeling and behaving) promote excessive drug use. Thus mutuality can encourage and maintain harmful patterns of addiction in a culture of heavy/dependent drinking... the culture of addiction is a way of life, a means of organising one's daily existence, and a way of viewing people and events in the outside world. It is a way of talking, walking, dressing, gesturing, believing, playing, thinking and seeing that separates people who are 'in the life' from those who are not. The culture of addiction encompasses values, artefacts, places, rituals, relationships, symbols, music and art, all of which reinforce one's involvement in excessive drug consumption"4.

People do recover

Natural recovery is well documented and it can happen without professional intervention, though not without some process of change8, 9. This can come out of self-reflection, maturing out of adolescent behaviours or significant changes in life circumstances10. Research looking at lifetime trajectories gives great cause for hope, although the duration of problem use can be long11.

Most of those with alcohol problems seeking treatment are looking for a structured intervention of some type. Project MATCH, a large scale randomised trial of alcohol treatments, helped determine that treatment type is less important than treatment style12. Clients allocated to empathetic, non-confrontational counselling staff did better.

Therapeutic communities emphasising peer support, developed in late 1950s. and have been found to be an effective intervention. By providing support from multiple sources, they can begin to manage and change addictive behaviours and improve the individuals interpersonal relationships13. They draw on the benefits of mutual support and experience, reducing reliance on professionals and utilising the strength and values that one recovering person can share with others.

Communities of recovery

There is now a growing evidence base relating to what types of programme are best suited to helping people with alcohol dependence. For example, the NTORS (National Treatment Outcome Research Study) study in England showed that a significant percentage of those with substance misuse problems entering residential treatment achieve and sustain abstinence14. This finding has been confirmed in the DORIS (Drug Outcome Research in Scotland) study in Scotland15. However there is little research on the most effective ways to improve the long term outcomes for substance users and their families.

Recovery can be achieved not only for those few who participate in residential rehabilitation programmes but also through the development of 'recovery communities'. This approach challenges the use of acute treatment models in the management of chronic problems related to alcohol and drugs16. Effective co-operation between specialist treatment providers and local community resources can help develop communities that enable individuals to sustain recovery beyond the immediate treatment episode.

Recovery involves the move from a 'culture of addiction' to a 'culture of recovery'. The ability to do this depends on recovery capital: the internal and external resources people can draw on to help them move forward. The quality of support and therapeutic relationship with professionals is important, as is good family support, employer support, community support; volunteering, education and training.

The role of mutual aid

Mutual aid groups as we currently know them started 70 years ago with the birth of Alcoholics Anonymous (AA) in the USA. AA estimates a membership of 40,000 in the UK in 4,000 groups. Scotland has around 1,200 mutual-aid groups meeting weekly. The evidence base has grown, though the key components which are important in their effectiveness are not so well understood. Of over 2,000 veterans who had gone through treatment for substance misuse17, most engaged in mutual aid on discharge. Group involvement predicted reduced substance use at one year follow up. Enhanced friendship networks appeared to mediate this response.

Mutual support, sponsorship (mentorship); altruism; self-awareness; structure and social connectedness; identification and shared experiences; self-forgiveness; spiritual growth; parting with an old identity and forming a new identity have all been suggested as mechanisms of recovery. Evidence for the benefits of mutual aid groups exists18, however, challenges also persist. Few studies of AA and '12 Step Programme' have been undertaken using methods that enable the benefits to be assessed rigorously19. As a consequence, although 75% of clients find such interventions acceptable, in one study only a third of treatment professionals thought their clients would benefit20.

Therapeutic communities with aftercare show promising results: patients in one programme were just over a third more likely to stay out of prison at 12 months than those who received usual care via the waiting list. There is evidence that therapeutic community treatment for patients with personality disorder and mentally disordered offenders can improve mental health and functioning with the odds of adverse outcomes across a range of measures reduced by a third to a half 21. Similarly, preliminary studies indicate that psychoanalytically oriented day hospital care can improve outcomes for patients with borderline personality disorder22. For these reasons, there is optimism about the development of communities of recovery in Lothian.

[ Box 2 ] Service case study

NHS Lothian saw the development of a therapeutic community within the health service recently in the Lothians & Edinburgh Abstinence Programme (LEAP), aimed at helping alcohol and drug dependent patients to achieve recovery23. One of the strengths of this service is that the staff who cared for clients during their most chaotic and vulnerable times remain involved. This removes the potential for competition for resources or policy space that is seen in other health systems between low threshold services focussed on harm reduction and those for clients ready to move on from stable supportive treatment to abstinence. This model recognises both are essential. The LEAP programme, which provides a treatment centre with flexible accommodation, is delivered in partnership with the City of Edinburgh Council and 'Transition', a vocational training organisation from the voluntary sector.

LEAP was launched in autumn 2007 as a Scottish Government pilot to help clients seeking a substance-free recovery to achieve their goal. It takes the form of a three month 'quasiresidential' programme, operating a day service and supported accommodation on different sites. LEAP addresses unmet mental and physical health needs; offers intensive psychotherapy in a therapeutic community setting; assists patients with housing, training and employment needs; and offers assertive linkage to recovery communities and a comprehensive aftercare support package for its clients. It is currently being externally evaluated using the European Addiction Severity Index. Since LEAP started, five new mutual aid groups have opened locally and a solid support network has developed, initially through formal aftercare but now extending well beyond that and there is growing support (and action) for the development of a 'recovery café'; a 'safe' space for recovering people to meet for social support.

This potential development is something not directly related to LEAP, but as a result of mutuality will be more likely to happen as communities of recovery develop in the area. Importantly, the programme also provides a means by which the wider community is supported through the re-integration of its clients into employment, housing and a sustainable lifestyle. Such support goes some way towards building a stronger community, with a greater degree of social capital.

Key messages

  • Recovery from alcohol dependence is possible and is assisted by mutual help.
  • Treatment involving groups and therapeutic communities can be effective.
  • Assertive linkage of patients to mutual aid groups gets better results than passive referral.
  • Policy-makers and service providers should adapt service structure and delivery to improve uptake and actively support and promote recovery-focused groups and services.
  • All agencies within the Lothian and Borders Community Justice Authority should consider how best to develop new approaches to dealing with alcohol-related behaviour and its consequences, especially in younger people.