Managing long term recovery from substance misuse in primary care, by Howard Marsden-Hughes

Recovery from substance misuse

The practical implications of a study into long term recovery from alcohol addiction for primary care professionals responsible for managing the process by Howard Marsden-Hughes, Lead Therapist in Addictions at The Priory Hospital Preston.
There is little doubt that the level of self-determination required on the part of the individual seeking to achieve sobriety is in itself a significant accomplishment. This is, however, only one component of a complex process in which the end goal is to achieve long term recovery from alcohol addiction.

For the general practitioner and wider primary care team responsible for managing the health and wellbeing of the individual, this task is made more challenging by the fact that academic debate in the field of alcohol addiction is fraught with inconsistency.
Extensive empirical evidence has analysed the effectiveness of various therapeutic modalities, although the goals of treatment often vary. Is abstinence a goal of treatment or an imperative of it? Should alcohol addiction be treated as a disease, an obsessive-compulsive disorder or a lifestyle choice? Most fundamentally of all, perhaps, is the question, “what defines recovery”?

Undertaking the study

In seeking a suitable answer to these questions, my colleague Professor Gubi at the University of Central Lancashire and I undertook a detailed study into a cohort of stakeholders who have been subject to minimal research to date; namely, recovered addicts themselves.

To implement the study, I adopted the qualitative method of Interpretative Phenomenological Analysis - an interview-based approach which engages with the individual and attempts to understand their experiences in order to gain greater insight into the subject matter itself (in this case, alcohol addiction). 

At the heart of this research was a need to understand why some people can achieve long term recovery, whilst others cannot. My approach therefore was to explore how the participants were able to transition from alcohol dependence towards recovery, and how this state of recovery was maintained. 

I delineated “recovery” as a period in excess of five years - the accepted remission period within oncology. Each of the participants of the research had achieved long term sobriety and fulfilled all categories of DSM-IV and ICD-10 diagnostic criteria.

Implications for the primary healthcare professional

The catalyst to make the first step towards sobriety varies and is idiosyncratic to each individual. The progression from alcohol dependence to alcohol addiction, however, is an area that is well documented and was reflected by the life experience of each interviewee. Physical and emotional dependence on alcohol - caused by dissatisfaction with the self, the need to conform, and the demulsifying effect that the consumption of alcohol was able to prescribe - eventually led to a crescendo that was described as a feeling of having hit rock bottom. 

At some point, each of the interviewees established an awareness of the causal link between alcohol and their current situation – their “rock bottom”.  

To a greater or lesser extent, the interviewees described this transition as a tripartite process that was comprised of: being sober, achieving sobriety and eventually, recovery. 

The study highlighted that not only was total abstinence regarded as a predicate of any treatment model, but that more significantly perhaps, a life-long philosophy of recovery management was required in order to achieve this goal. 

For the GP, relapse should be understood within this life-long context. Whilst abstinence was agreed to form a central component of treatment for each of the interviewees, relapse can form an emotional and psychological burden which can heighten an existing sense of shame. It is important therefore to impress upon the individual that acclimatising oneself to a state of full sobriety takes several years and that the process of achieving long term recovery is comprised of daily, ongoing management of the addiction: recovery is a state that cannot be hurried and one that grows organically. 

Whether or not intervention from the individual’s general practitioner played a direct part in the individual’s “spiritual awakening” (as described by one interviewee) – it is evident that the role that the GP plays in assisting the transition from addiction to recovery is critical.

Of course as part of this role, it may be incumbent upon the GP to signpost appropriately to positive supportive networks such as Alcoholics Anonymous, who offer the opportunity for the individual to observe and hear the success narratives of others. Such networks promote feelings of empathy and congruence within and amongst members, whilst also addressing underlying feelings of self-contempt manifested by the addiction. The GP can also advise on appropriate therapeutic intervention to address the causes and nature of addictions which help prevent relapse, such as psycho-educational classes and cognitive behaviour therapy programmes. 

However, this approach also requires the GP to assist the individual to establish a positive wider social network which considers the emotional, social and psychological wellbeing of the individual in order to support this fundamental shift in dynamic. In short, a holistic approach is needed, one which will promote personal development beyond the myopic focus on the need to resist temptation.

Exploring the processes involved in long-term recovery from chronic alcohol addiction is published by Routeledge and features in the September 2013 edition of the Journal of Counselling and Psychotherapy Research (13: 3). Howard Marsden-Hughes is the co-author of the research and is Lead Therapist in Addictions at the Priory Hospital Preston.

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