Why do individuals delay accessing treatment for alcohol concerns? A pilot study

Note: This report was funded and/or written by our predecessor organisation, the Alcohol Education Research Council (AERC).

In England, it is estimated that a quarter of people drink to harmful and hazardous levels with the highest prevalence amongst men, young people and the homeless. However, it is suggested that only one in fourteen of the ‘in-need’ alcohol dependent population actually access treatment each year.

This pilot was undertaken by Gloucestershire Community Research Unit, where local figures highlight that alcohol users take an average of twelve years longer to access treatment from their first use of alcohol versus drug users. This suggests that problem alcohol users experience a set of treatment barriers that are specific to alcohol use. Research exploring the treatment pathway for alcohol users has recognised that multiple factors are at play, including social influence, personal attitudes, psychological influences and treatment-specific factors.

The study was guided by a framework for understanding the processes involved in seeking alcohol treatment, which identifies four steps:

• problem recognition,
• making the decision that change is necessary,
• deciding that professional help is needed, and then finally
• seeking professional help and keeping appointments.

Whilst the academic literature identifies a number of general factors relating to treatment seeking barriers, little in-depth research has been carried out focussing specifically on why people delay seeking treatment. Within Gloucestershire, little is known about the delay into treatment or the differences between those who eventually seek treatment and those who do not. It was thought that an increased understanding would aid the development of interventions that could shorten the delay into treatment for those who are in need.

The aim of the current study was to inform alcohol treatment service development in Gloucestershire by exploring the reasons why individuals may delay treatment seeking for problematic alcohol use. Interviews were conducted with nineteen adult alcohol users recruited from a variety of agencies in Gloucestershire. Common themes were indentified and demonstrated with reference to extracts of the interview text.

Four main themes emerged which contributed to why problem alcohol users delay seeking treatment: (1) social influence, (2) psychological influence, (3) situational influence, and (4) access barriers. Within these main themes ‘delay influences’ (factors that increased the delay in seeking treatment) and ‘recognition influences’ (factors that alerted the individual to the need to change their drinking behaviour and seek treatment) were identified. For the most part, the presence of ‘delay influences’ (e.g. a pro-drinking social network) and the absence of ‘recognition influences’ (e.g. health consequences) appeared to slow down the pathway into treatment seeking.

The interviews revealed two main influences upon peoples’ drinking behaviour and treatment seeking. ‘Delay influences’ perpetuate ambivalence to change and ‘recognition influences’ help individuals acknowledge their problem drinking and the steps to seeking help.

We reviewed the current treatment seeking model and proposed a contrary framework for understanding problematic alcohol users’ experiences which does not follow a stepwise model.

The treatment seeking pathway

**Treatment seeking for alcohol

Notably, accepting an alcohol problem and acknowledging the need to change seemed to be a phase that lasted well beyond starting to seek treatment. The relevance of the four themes seemed to vary across the different phases. Specifically, social influence and situational factors played a role throughout whereas psychological influences were more important once the individual starts to become aware of their alcohol problem. Treatment barriers were more apparent once they were fully aware of their problem and started to accept that they needed to change.

The findings have a range of implications for local treatment agencies and recommendations for service improvements. The importance of increasing awareness amongst staff working in all capacities with problem alcohol users was apparent. Staff should play a role in highlighting ‘recognition influences’ to clients. Early intervention services and routine screening are crucial in the detection of alcohol concerns and should be balanced with tailored aftercare and relapse prevention.

Considering the needs of those with dual dependencies and focussing on the underlying and maintaining factors of drinking (e.g. emotional aspects) are vital to long-term treatment success. Promoting services as having a dual focus may alter the perceptions and the reported stigma associated with traditional drug services.

We recommend further qualitative research of a longitudinal nature, which follows individuals through their help-seeking pathway (including exploration of both baseline and subsequent predictors of help seeking). Additionally, collaborative projects with drug and alcohol staff exploring the types of interventions that can be implemented and evaluating their effectiveness.

Psychosocial Influences

• More attention to underlying factors of drinking. Referral onto more specialist mental health services if appropriate.
• Aftercare involving family/partners.
• When advertising services, alert individuals to ‘recognition influences’.
• Assess situational factors.

Access barriers/Service experiences

• Flexible approach to treatment and aftercare.
• Alcohol screening.
• First episodes of care should be positive experiences.
• Implement intervention initiatives.
• Relapse prevention work in prisons.
• Presentation of services as having a dual focus, drugs and alcohol.
• Inter-agency care planning.

Training Issues

• Increased awareness of services/support by all staff working in the alcohol field.
• Better identification and referral.
• Comprehensive training.
• Development of community based detox programmes.
• Training to staff to recognise treatment barriers.
• Use the treatment seeking pathway model to inform training.