About alcohol services
Details of the range of services available
About alcohol services
This section describes the range of services that exist for people with alcohol problems, the treatment approaches used and how these are adapting to changes in the health and social care field. It will be of help to all professional groups as well as people concerned about their own or another’s drinking who need an overview of the help available.
IntroductionSpecialist alcohol services are provided by the statutory, non-statutory (also described as the voluntary, not for profit and the independent sector) and private sectors. There are currently over 500 services throughout England and Wales providing specialist alcohol services. About 100 of these are residential services. Until recently, few day programmes existed but more of these are now emerging, both as separate new services and as additional components of existing ones. Residential services also exist for those with chronic alcohol problems who continue to drink. These may be provided by non-specialist agencies, often dealing with the homeless and rootless, as well as by agencies working specifically with street drinkers. Many alcohol services, especially residential services, also offer help for people with drug problems.
The provision of alcohol services throughout England and Wales is patchy. Some areas are well provided for, while others offer very little specialist help. Local services for people with special needs can be quite scarce. For example, although the majority of services are open to all, only a small number provide services specifically for people from Black and minority ethnic groups, though more can arrange access to interpreters if required.
Alcohol Concern’s website provides a comprehensive list of alcohol services at www.alcoholconcern.org.uk.
Advice, information and counselling services
Traditionally provided by the voluntary sector, these services are often the point of first contact for anyone concerned about their own or someone else’s drinking. Members of the public can ring for information or advice. If the agency operates a drop-in service they can simply walk in without an appointment, otherwise they can arrange an appointment to see someone about alcohol issues. Some services may be small agencies where mainly trained volunteers provide the counselling, although most are larger agencies with paid workers as well as, or instead of, volunteers.
As well as seeing clients with alcohol problems whose goal needs to be abstinence, these services do also encourage people to seek advice and help at an earlier point. They will work with clients towards reducing the problems caused by drinking where abstinence is either undesired or unnecessary, or simply unrealistic at that point in time.
These services are also keen to support people affected by someone else’s drinking with the aim of reducing the harm caused to partners and families and to teach appropriate strategies for dealing with a problem drinker.
Counselling can be available weekly for as long as is required by the client but increasingly, following assessment, an agreement is made about the length and nature of the support on offer and this is periodically reviewed. Counselling may take place at the agency, or out-post (such as premises of other agencies or perhaps a GP surgery), and even in the client’s home if there are difficulties of access - for disabled people or people with children for example. Counselling services are increasingly available within primary care services.
Treatment approaches
Many advice and counselling agencies describe their treatment approach as eclectic, meaning they do not adhere to any one treatment philosophy but borrow from a range of approaches appropriate to the needs of the client. Most adopt a client-centred approach, which means there is a focus on helping the client to define their own problems and treatment goals. Cognitive and behavioural models are often referred to together with a client-centred approach. The cognitive model recognises that problem drinking is a learnt activity and therefore people can learn alternative ways of responding to problems and drinking cues. Behavioural models recognise the individual as being able to take responsibility for their own actions rather than being controlled by alcohol. This is in contrast to the disease model where drinking problems are seen as inevitable in those with a predisposition for alcohol problems or addiction.
Outreach services
Many services also employ outreach workers who provide information, advice and counselling for people who do not contact the agency directly. These workers focus on contacting groups of clients who traditionally under use services or who are reluctant to come forward for help. Workers also help to educate other community groups about alcohol-related problems as a means of prevention and encouraging early intervention.
Specifically targeted services
Some agencies offer specifically targeted services for distinct groups eg women, young people or Black people. The service is designed to meet the particular needs of the target group. Some agencies are wholly dedicated to serving a distinct community.
Some agencies offer drink-drive rehabilitation schemes, which are alternatives to custody or may lead to reduced penalties for people convicted of drink driving. These are often 6 to 8 week alcohol education and prevention programmes and are provided in partnership between the alcohol agency, the probation service and the courts. Many services accept clients on court orders.
Workplace services
Many alcohol agencies provide advice, information and training for employers on alcohol related issues and workplace alcohol policies. Several also offer counselling for employees referred by companies.
Community Alcohol Teams and hospital based alcohol teams
CATs (Community Alcohol Teams) provide a wide range of support services including home-based and community detoxification programmes, access to in-patient detoxification, counselling and group work. Most teams are managed by the health service and often have a multi-disciplinary staff team including health-care workers and social workers. The counselling provided is most often as described under treatment approaches above. Some take self-referrals although others only deal with clients referred by GPs or other professionals.
The term residential rehabilitation is commonly used to describe residential services for people with alcohol dependency problems. Residential rehabilitation services may be provided in hospital, within nursing homes, registered care homes or in hostel accommodation, but the term is most commonly used for non-NHS based facilities. Except for the latter, a number of private treatment centres and a smaller number of other residential projects, people most often use residential rehabilitation after detoxification from alcohol. Access to these facilities, other than those who are fee paying, will require a Community Care Assessment undertaken by social services.
The most common types of residential rehabilitation are categorised below. Services can fall into more than one category.
Dry houses
Dry houses represent the largest type of residential care for alcohol misusers although this term is less in use today with services simply describing themselves as ‘residential’. They normally accommodate between four and sixteen people and are usually large houses in residential areas. The aim is to maintain an alcohol-free environment whilst offering a combination of individual counselling (through a key worker system), group work, social skills training and practical help to encourage the use of local community resources such as health, education, employment and recreational facilities. The approach is eclectic using the cognitive/behavioural and client-centred methods as described above. The houses are not always staffed at night but there is usually an on-call system for out-of-hours emergencies. The length of stay may vary between 3 and 18 months but most offer 3-6 months in the first instance. Many offer halfway houses, where people live semi-independently, as a means of helping them re-integrate into the community.
Christian philosophy houses
These houses provide rehabilitation within a Christian ethos of care. Treatment usually involves key worker counselling. Residents are required to participate in the daily routine of the community, which is the focus of therapeutic activity. Care is taken not to pressure any resident to adopt Christian beliefs. Other than this, the style is similar to the dry houses mentioned above.
Therapeutic communities
Therapeutic communities have a hierarchical structure and residents, in working through the programme, progress their way through the hierarchy. The structure is operated in conjunction with intensive group therapy sessions in which all members of the community are involved and there is less focus on individual one to one counselling. The length of stay is similar to dry houses and halfway houses are sometimes available. These models of residential rehabilitation were, in the past, mostly for drug users. Nowadays most therapeutic communities have opened their services to offer help to people with alcohol problems as well. They normally accommodate 12-18 people although a number are much larger with up to 40 or 50 places.
Minnesota method units
This treatment method is based on the 12 Step model of the fellowship of Alcoholics Anonymous (AA). AA views alcohol dependency as a disease where total abstinence is required. There is a belief in a power greater than the individual through which, along with the support of other alcoholics who share with each other their experience, common problems can be resolved and individuals can recover. Residential services which use the Minnesota method usually offer a 4 to 6 week stay in a treatment centre followed by a 4 to 6 month stay in an extended care programme. The treatment centre often provides detoxification and many agencies offering the Minnesota method take private patients, although most will accept clients funded under Community Care or by health authorities. Many residential services based on the Minnesota method offer help for alcohol and drug users and people with other sorts of addictions such as eating disorders or gambling.
Heavy drinkers’ houses
Also known as ‘wet hostels’ these provide support and care for long-term alcohol misusers who are unable or unwilling to use other forms of supported rehabilitation. There is neither a formal programme nor an expectation that residents will work towards rehabilitation or an alcohol free life-style. The goal for most is a gradual improvement in their health and quality of life. Some people stay for many years, seeing the house as their long-term home.
Alternatives to custody
Some, but by no means all, residential services will accept clients on a court order as an alternative to custody, as part of a probation order or as a condition of bail.
Day centres
These may be provided by specialist agencies within and outside the alcohol field. These centres rarely have structured programmes and place the emphasis on social interaction and low-key activities. They are used by people needing support and for those who need shelter and sustenance because they are sleeping rough or are on low incomes.
Many counselling agencies have now extended their services to provide day programmes for people with alcohol problems. Some residential services take clients on a non-residential basis.
As well as offering an alternative option for people with alcohol problems who need a high level of support and a structured programme, day programmes will also provide access for groups of people who are unable to enter residential care. These might include people with children and people in employment. However, for homeless people, those in unsuitable accommodation or those needing to move away from their local area or away from a difficult family situation, residential care will still be required.
Day programmes provide a structured, full time programme for clients for between 6 weeks to 9 months. Most will offer a combination of group work and individual counselling as well as skills training and relapse prevention work. Clients are required to be alcohol free and remain abstinent during the course of the programme.
Detoxification services
Some people may require detoxification (withdrawal from physical dependence) from alcohol as part of their treatment programme or before entering either day or residential rehabilitation. Detoxification can be provided in a number of settings:
Hospital ward-based detoxification beds on a general or psychiatric ward
Medical attention may be required when a person has a long history of alcohol misuse or where there is a risk of medical complications. The detoxification programme may be of variable length but is usually quite short (5-12 days). Little support is available other than that required for medical needs. Access to detoxification beds may be through a GP, CAT or hospital based alcohol team or through mental health services. However as only a few, if any, hospital beds are designated for in-patient alcohol detoxification they can be very difficult to obtain.
NHS alcohol treatment units
Alcohol Treatment Units provide medically supervised detoxification on an in-patient basis and are equipped to deal with any underlying medical conditions. In most cases detoxification tends to be complemented by a support, counselling and group work programme. Programmes vary between 3 weeks to 6 months. Increasingly these services are combined for people with alcohol or drug problems. Because of their limited availability and relatively high staff levels, they are often seen as back up for clients referred from community-based services. They can usually only be accessed by referral from other professionals.
Residential programmes providing detoxification
A number of residential rehabilitation projects provide a medically supervised detoxification programme as the first stage of rehabilitation. Most of these tend to be private alcohol treatment centres, many of which use the Minnesota method as described above. There are also a small number of crisis services providing short-term detoxification leading to support in second stage programmes or support in the community.
Community and home detoxification services
Alcohol detoxification is available in many areas on an out-patient basis from CATs, voluntary organisations or hospital based alcohol teams which are increasingly using community psychiatric nurses to provide alcohol detoxification in community settings and at home. These teams may also support GPs in the provision of alcohol detoxification.
General practitioners
GPs may prescribe drugs to assist the process of withdrawal. Some however are reluctant to do so, having few resources to provide the additional support and counselling that is often required to avoid relapse. There has been an increase in the number of alcohol advice and counselling centres working with GPs providing support for patients on detoxification schedules or taking referrals directly from GPs. CATs also provide support for GPs willing to undertake detoxification in some areas.
Self help groups
AA is the best-known network of self-help groups with over 3,000 local groups in the United Kingdom. The philosophy of AA is described above under Minnesota method units, which are based upon the ethos of AA. AA is open to all who want to stop drinking and is a fellowship of people with the primary purpose of staying sober and helping other alcoholics to achieve sobriety. Each group is autonomous and so the culture or style of the groups may vary, but all follow the philosophy of AA and offer peer support and regular access to out of hours support and befriending, which can be vital for some people who are attempting to remain alcohol free.
Al-Anon is a similar network for relatives and friends of problem drinkers.
SOS (Secular Organisations for Sobriety) is a self-help movement recently present in this country (from the USA). It offers a similar model to AA but with considerably less emphasis on the existence of a higher power.
Most other self-help groups are attached to either residential or non-residential services and provide a means of clients providing support for each other and sharing problems and experiences either during, or after, treatment.
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