PRIMARY CARE & LONG-TERM RECOVERY
For GPs and their colleagues, guiding a patient towards recovery is challenged by questions. Is abstinence a goal of treatment or an imperative? Should alcohol addiction be treated as a disease or a lifestyle choice? What is recovery? Howard Marsden-Hughes discusses a study he led to give them answers.
Download AddictionToday146 – Priory & GP answers
The self-determination needed by someone seeking sobriety is a significant accomplishment. But this is only one component of a complex process to achieve long-term recovery from alcohol addiction. For the general practitioner and wider primary-care team responsible for managing the health and wellbeing of a patient, this task is made more challenging by the fact that academic debate in the field of alcohol addiction is fraught with inconsistency.
Extensive empirical evidence has analysed the effectiveness of various therapeutic modalities, although the goals of treatment often vary. Is abstinence a goal of treatment or an imperative of it? Should alcohol addiction be treated as a disease, an obsessive-compulsive disorder or a lifestyle choice? Most fundamentally of all, perhaps, is the question “what defines recovery?”.
UNDERTAKING THE STUDY
In seeking a suitable answer to these questions, my colleague Professor Gubi at the University of Central Lancashire and I undertook a detailed study into a cohort of stakeholders who have been subject to minimal research to date: recovered addicts themselves. To implement the study, I adopted the qualitative method of Interpretative Phenomenological Analysis, an interview-based approach which engages with the individual and attempts to understand their experiences to gain greater insight into the subject matter itself.
At the heart of this research was a need to understand why some people can achieve long-term recovery, while others cannot. My approach was to explore how the participants could transition from alcohol dependence to recovery, and how this state of recovery was maintained.
I delineated “recovery” as a period in excess of five years – the accepted remission period in oncology (a terminal illness, like addiction, which could thus serve as a workable comparator). Each of the participants of the research had achieved long-term sobriety and fulfilled all categories of DSM-IV and ICD-10 diagnostic criteria.
IMPLICATIONS FOR THE PRIMARY HEALTHCARE PROFESSIONAL
The catalyst to make the first step towards sobriety varies and is idiosyncratic to each individual. The progression to alcohol addiction, however, is an area that is well documented and was reflected by the life experience of each interviewee. Physical and emotional dependence on alcohol – caused by dissatisfaction with the self, the need to conform and the demulsifying effect that the consumption of alcohol was able to prescribe – eventually led to a feeling of having hit rock bottom.
At some point, each of the interviewees established an awareness of the causal link between alcohol and their current situation – their “rock bottom”. To a greater or lesser extent, the interviewees described their transition as a tripartite process comprised of: being sober, achieving sobriety and eventually, recovery.
The study highlighted that not only was total abstinence regarded as a predicate of any treatment model but that, more significantly perhaps, a life-long philosophy of recovery management was required to achieve this goal.
For the GP, relapse should be understood in this life-long context. Abstinence was agreed to form a central component of treatment for each interviewee, but relapse can form an emotional and psychological burden which can heighten an existing sense of shame. So it is important to impress on the individual that acclimatising oneself to a state of full sobriety takes several years and that the process of achieving long-term recovery is comprised of daily, ongoing management of the addiction. Recovery is a state that cannot be hurried, but grows organically.
Whether or not intervention from the patient’s general practitioner played a direct part in the individual’s “spiritual awakening” (as described by one interviewee), it is evident that the role the GP plays in assisting the transition from addiction to recovery is critical.
Of course, as part of this role, it might be incumbent on the GP to signpost appropriately to positive supportive networks such as Alcoholics Anonymous, which offer the opportunity for patients to observe and hear the success narratives of others. Such networks promote feelings of empathy and congruence within and among members, while also addressing underlying feelings of self-contempt manifested by the addiction. The GP can also advise on appropriate therapeutic interventions to address the causes and nature of addictions, to help prevent relapse, such as psycho-educational classes and cognitive behaviour therapy programmes.
This approach also requires the GP to assist the patient to establish a positive wider social network which considers their emotional, social and psychological wellbeing in order to support this fundamental shift in dynamic. In short, a holistic approach is needed, one which will promote personal development beyond the myopic focus on the need to resist temptation.
Howard Marsden-Hughes is co-author of Exploring the processes involved in long-term recovery from chronic alcohol addiction (Routledge; also Journal of Counselling and Psychotherapy Research Sept,13:3). He is lead therapist in addictions at the Priory Hospital Preston (www.priorygroup.com).