Trajectories of help-seeking and progress or regress in the drinking problem

The help-seeking pathway of most individuals will not be straightforward but in fact rather “messy” because they will derive varying degrees of parallel support from informal, nonspecialist, and specialist sources that vary over the time course. Although multiple sources of treatment can be accessed simultaneously, the position of the treatment arrow on Figure 8.1 highlights the treatment source that is “making the running” at any one particular time. The temporary or sustained treatment goal is depicted by the star, and many treatment paths may not terminate in one. Furthermore, there are multiple permutations of these treatment trajectories that occur in various combinations, with associated gaps, pauses, and delays. Whilst the treatment arrows build into a trajectory that is unique for that individual, characteristic patterns may also be recognized.

Many will manage their drinking problem without accessing specialist or nonspecialist services, using the informal support of family and friends to achieve their goal, either rapidly as shown by trajectory 1 in Figure 8.1b or over a longer period as depicted in trajectory 2. Others will approach nonspecialist services, such as their practice nurse, who may assist by using a brief intervention (trajectory 3). An example of the stepped-care model is presented in trajectory 4, in which specialist alcohol treatment is reserved for those who do not respond to simpler approaches (Bower & Gilbody, 2005). In this example, concerned relatives advise the individual to cut down, and, when this fails for the second time, the individual consults their general practitioner who provides community detoxification. Several weeks later, the patient relapses, continuing drinking during a second attempted community detoxification. The general practitioner then refers them to the specialist services, and, following detailed assessment, in-patient detoxification is arranged followed by residential rehabilitation. The individual then successfully maintains a prolonged period of abstinence with the support of Alcoholics Anonymous.

Some see stepped care as providing specialist input to those who have “failed” at other approaches, thereby delaying access to the needed treatment. Therefore, an important aspect of stepped care is a mechanism for self-correction that monitors progress and provides for the “stepping up” of treatment as required. In addition, accurate assessment in the early stages of presentation is vital because this can identify an individual who needs direct access to specialist care and thereby prevent the delay and negative impact associated with multiple failures at lower intensity interventions. Indeed, in trajectory 5 in Figure 8.1b, a friend at work who has experienced a drinking problem advised the individual to attend the open-access assessment clinic with the local community alcohol team; the team recommends a course of individual counselling. An early accurate assessment enabled this individual to be identified and referred to a supportive resource.