By Laura Williamson
Early in 2011 the National Institute for Health and Clinical Excellence (NICE) published guidance intended to improve treatment for alcohol dependence and harmful use in England, Wales, and Northern Ireland. The guideline focuses on identifying the clinical interventions best suited to supporting recovery. However, given the influence social factors have on drinking behaviours, NICE also emphasises the need to cultivate environments and attitudes which help to ensure those with alcohol problems feel no “apprehension” about seeking treatment and discussing their alcohol misuse. It does this by identifying principles that should form the basis of treatment: a trusting, respectful relationship between healthcare providers and patients, which acknowledges and seeks to overcome “stigma and discrimination” is crucial, as is the need to support families and carers.
It is vital that individuals can expect to be treated with respect when seeking treatment because only around 5.6% of people in England and 8.2% of people in Scotland who need specialist treatment for dependence actually receive it. Part of the reason for this is that stigma acts as an obstacle for individuals in admitting their alcohol problem and opting to receive therapy. As Schomerus and colleagues stated in their systematic review of stigma and dependence published in the March-April (2011) edition of Alcohol and Alcoholism:
“People suffering from alcohol dependence (and from other addictions) are particularly severely stigmatized. They are less frequently regarded as mentally ill, they are held much more responsible for their condition, they provoke more social rejection and more negative emotions and they are at a particular risk of being structurally discriminated against.”
In the United Kingdom, and internationally, public policy on alcohol has done little to improve attitudes towards dependence. In England, for example, alcohol policy under the New Labour government prioritised the need to persuade people to drink ‘sensibly’. A key aim of the 2004 Alcohol Harm Reduction Strategy for England was to secure “long term change in attitudes to irresponsible drinking”. In his ‘Foreword to the Strategy’, then Prime Minister Tony Blair stated that individuals are expected to make “informed and responsible decisions about their own levels of alcohol consumption.” This focus on “sensible” drinking makes no allowance for the “difficulties in controlling substance-taking” or the “strong desire or sense of compulsion” that are used to diagnose dependence. As a result, it risks implicitly stigmatising the dependent by promoting in the public consciousness the notion that all heavy drinkers, even the alcohol-dependent, are simply “irresponsible.”
Under the coalition government, the stigmatisation of alcohol dependence has worsened and become increasingly explicit in England. In 2010 the government published its new Drug Strategy. The strategy enforces “sanctions” on benefit claimants who are dependent on alcohol (and drugs) if they do not engage with treatment services. This policy sits uncomfortably with the emphasis of the NICE Guidance on the importance of “supportive, empathic and non-judgemental” treatment provision. Comments made by the current Prime Minister, David Cameron, exacerbate these concerns: he has spoken in connection with the publication of data by the Department for Work and Pensions about the number of people with dependence problems claiming incapacity benefit exacerbate these concerns. Speaking on the BBC, the Prime Minister asserted:
“A lot of people who pay their taxes and work hard will think ‘that’s not what I pay my taxes for, I pay my taxes for people who are incapacitated through no fault of their own.’”
Dependent drinkers do have responsibilities for managing their condition, but they require support to deliver on these. Coercing already socially marginalised drinkers into treatment by removing their benefits – while continuing to provide inadequate treatment – is unlikely to generate trust in treatment services. Furthermore, the anxiety of the dependent with regards to acknowledging their alcohol problem may be exacerbated by the Prime Minister’s comments, which imply the dependent is not worthy of state assistance. Unfortunately, the prime time broadcast of such comments could cause more of an impact on public attitudes towards dependence than the efforts of NICE to cultivate supportive clinical and familial environments.
Competent, compassionate clinical care is an important aspect of promoting recovery from alcohol dependence. But NICE’s strategies require social support if they are to be a success. Without backing from public policy, which acknowledges and allows for the neurobiological and environmental barriers that can make it difficult for some to control their alcohol consumption, many with dependence problems may continue to find it difficult placing trust in treatment services.
Dr Laura Williamson is Wellcome Trust Research Fellow in Health Ethics at the Institute for Applied Health Research at Glasgow Caledonian University. Her paper, ‘NICE but needy: English guidance on managing alcohol dependence is not backed up by government alcohol policy’ has been made publicly available by the journal Alcohol and Alcoholism. You can read it in full and for free here.