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Specialised Treatment Units
- Brian D Hore (22 May 2008)
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Brian D Hore, Consultant Psychiatrist Priory Hospital Altrincham Cheshire
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briandhore{at}aol.com Brian D Hore
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I was interested in the paper Specialised Alcoholism Units are a luxury that the NHS cannot afford, as I have spent many years working in such units. It seems to me that the assessment and treatment for patients who have alcohol dependence is different to other conditions, in that the majority of patients who, for example suffer from depression or diabetes, have made the decision to take treatment and would comply with that treatment. Indivuals who have a problems with dependence on alcohol, may have not, although they are undertaking treatmrent, reached the stage of action, but remain in contemplation (stages of change model). One is therefore treating a group of patients with whatever treatment, where it is not clear that these patients have made a definite comittment to stop drinking, if that is the treatment goal, which it usually is. We know little as to how to assess whether an idividual has made the decision or the mechanisms of the process of moving from contemplation to the stage of action and it is difficult to know how this can be assessed. The penalties and gains for having treatment of stopping drinking that many people do not seem to be able to clarify on their own is best shown in groups where a very clear choice is the only option. Thus doctors who are under the GMC Fitness to Practice Comittee have a choice as do pilots and nurses that they will undertake treatment which is specified. In the case of pilots they actually specify the type of treatment. If these individuals do not accept treatment then they are liable to go to Diciplinary Action. My anecdotal experience is that the majority of doctors, not only undertake treatment but succesfuly give up drinking. For the vast majority of indivduals however the penalties and rewards of abstinence are much less clear. One frequently comes across patients who have had multiple relapses but then enter a stage of contious life long abstinence which fits in with my model of alcohol dependence as a life long condition with a tendency to relapse. What we don't know is the process by which those who come into treatment take several years before they actually stop. We do not know what has happened in their minds to stop. In many ways the article is irrelevant as certainly in England, although not in Scotland, the majority of Units have been closed, and I do not know anyone suggesting that they reopen. In any treatment service for any condition, it would be expected that there are certain indivduals who will need more intensive treatment than others. It was shown that not until five years of sustained sobriety occurred (Vaillant 1966) is relapse, unlikely to return and this does question the value of short term trials under five years. The demise of the Alcohol Treatment Units in the NHS has of course allowed this field to be occupied by the private ssctor which provides this in a vigorous manner.The question is in the present NHS system if patients fail with whatever treatment given and this is repeated where else do they go, and a considerable number go into the private system because they have no other choice. My own view is that if you are developing an alcoholism treatment service, as has been done in Manchester since the 1970's, you have a range of intensity of treatment, including a treatment service for those indivuals who have significantly failed on non intensive treatment. At present they often now have to look outside the NHS. Yours sincerely B D HORE Medical Director Addiction Treatment Programme Altrincham Priory Hospital Ref: Vaillant G E 1996 -Long term follow-up of male alcohol abuse Arch of General Psychiatry 53 243-249 |
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