2. Principles of care

These principles of care outline evidence-based approaches for supporting people with problem alcohol use. This includes building trusting relationships, reducing stigma, working with families and carers, and promoting inclusive services and a recovery-oriented system of care.

2.1 Introduction

These principles should underpin all support for people with problem alcohol use. They are relevant to staff in any health, social care or community service working with a person with problem alcohol use. References to these principles of care appear throughout the guidelines.

The principles are based on the clinical consensus of the alcohol guidelines development group.

2.2 Experience of care

Principles 2.2.2 to 2.2.5 are based on the National Institute for Health and Care Excellence (NICE) clinical guideline Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence and other evidence as referenced.

2.2.1 Building a trusting relationship

Practitioners should work to build a trusting relationship with people with problem alcohol use, taking a supportive, empathic and non-judgemental approach.

Practitioners should ensure that a compassionate and humanising approach is evident in every contact with people with problem alcohol use.

Over time, a trusting relationship can develop into a strong therapeutic alliance, with the practitioner and the person working together to achieve the person’s goals. A strong therapeutic alliance is essential to effective treatment and is associated with better treatment outcomes.

You can read more about therapeutic alliance in chapter 5 on psychosocial interventions.

2.2.2 Reducing stigma

Services and practitioners should work to reduce stigma.

People with problem alcohol use experience stigma in society (Kilian and others, 2021) and can also internalise stigma, resulting in feelings of shame and guilt. Past experiences of stigmatising services or assumptions, and internalised stigma can deter people from approaching services.

Staff in health and care services sometimes hold stigmatising attitudes which can result in discrimination, for example, they may not offer the same length of intervention or level of contact to people with problem alcohol use (Van Boekel and others, 2013). Stigmatising service policies can also lead to discrimination in the form of inappropriate exclusion from services. Research consistently identifies stigma as a major barrier to help-seeking and treatment engagement for people experiencing problem alcohol use (Kilian and others, 2021).

The World Health Organization European framework for action on alcohol 2022 to 2025 (PDF, 2.2MB) includes a priority action for healthcare services to reduce social stigma and discrimination that prevent people from accessing alcohol treatment. Services and practitioners should address policies, practices and attitudes that can contribute to experiences of stigma, ensuring people feel respected, heard and not judged or treated differently because of their alcohol use. Health, care and support services should not exclude people from care that they need on the basis that they are experiencing problem alcohol use.

Language used to describe people with problem alcohol use can also be stigmatising. Preferred language and terminology around alcohol use can vary between individuals and over time. It is useful for services to regularly review the language they use by speaking to people with lived and living experience to understand what language they find stigmatising and what are their preferred terms.

2.2.3 Privacy and dignity

People seeking alcohol treatment and related services have a right to privacy and can expect to be treated with respect and in a way that preserves their dignity. Practitioners should make sure that any care or treatment and conversations about treatment take place in private and appropriate settings, including by having welcoming and safe waiting areas and suitable and pleasant confidential spaces.

2.2.4 Confidentiality and information-sharing

Services and practitioners should maintain clear confidentiality policies which they should discuss with each person at the start of their treatment and recovery journey. Policies should outline the boundaries of confidentiality, including the process for seeking the person’s consent before disclosing their information to any external agencies or individuals.

It is important that people seeking support understand what confidentiality means and how and when information can be shared without consent, for example if a safeguarding issue is identified.

Services should develop information-sharing arrangements with partner agencies. Information-sharing between agencies can support an integrated approach to helping people with problem alcohol use to address their health and support needs.

Local agreements between services should describe and support suitable information-sharing arrangements that are consistent with legal and ethical obligations and avoid unnecessary barriers or delays. Where possible and with the person’s consent, alcohol treatment services should arrange access to relevant sections of the person’s national electronic health records. This can help services to access a summary of the most recent relevant health information rapidly.

Services should set out how, with the person’s consent, they will share information with families and carers.

See chapter 4 on assessment and treatment and recovery planning for more on information-sharing and details of national electronic records.

2.2.5 Access to information

All healthcare services and support services should be able to provide basic information on what the local alcohol treatment service offers and how to access the service.

Alcohol treatment services should provide appropriate information to people seeking help about:

  • their service
  • the nature of alcohol dependence, harmful drinking and alcohol related problems
  • available evidence-based treatments including their risks and benefits

Providing this information supports shared decision making (see section 2.2.6 below).

Services should make comprehensive written information available in an accessible format considering the person’s literacy, digital literacy and access, sensory ability, cognitive ability and neurodiversity (see definition of neurodiversity in the glossary). Practitioners should avoid clinical language and jargon, and if they need to use it, they should explain what it means. Where English is not the person’s first language, services should offer an independent interpreter (someone not known to the person) if they need one. Services should also translate written or video information into the person’s language if necessary.

Where practitioners in the alcohol treatment service communicate with other healthcare professionals, they should provide the person with copies of any letters or medical reports and check that the person understands the content.

2.2.6 Shared decision making and person-centred treatment

Services should provide care based on shared decision making and train practitioners in this approach.

Shared decision-making means practitioners and people with problem alcohol use work together to agree on the treatment and support the service will provide for the person. The person should always be at the centre of decisions about their own care as far as possible, including where they lack capacity to make care decisions (see annex 1 for legislation and guidance on mental capacity). Where the person lacks such capacity, the practitioner must make a ‘best interests’ decision by considering all the relevant circumstances. This includes the person’s wishes and feelings and the views of family members, carers and others with an interest in their welfare, as far as practicable and appropriate.

Practitioners should:

  • inform each person that they have choices about their care
  • help each person to think about the treatment options
  • provide each person with information on associated risks and benefits of each treatment option - consider each person’s individual needs
  • support each person to decide on their preferred choice of treatment

Shared decision making is the basis for developing individually tailored, person-centred treatment and recovery support. Practitioners should always take account of a person’s individual needs, strengths and aspirations, and their family and social situation, when offering them treatment and recovery support.

NICE guideline Shared decision making (NG197) provides more information.

People with lived and living experience of problem alcohol use should also be involved in decisions about the design and delivery of the service.

2.2.7 A strengths-based approach

Services and practitioners should take a strengths-based approach when working with people experiencing alcohol problems. A strengths-based approach means that practitioners help people to identify their personal strengths (for example, their skills and aspirations) and assets in their community (for example, their supportive social networks). A strengths-based approach does not mean ignoring problems. Practitioners should help people identify and address problems, but this should not be the only focus of treatment. Practitioners should support people to use their personal and community strengths to support their treatment and build their recovery.

Practitioners should help people access peer-delivered and peer-led recovery support from the beginning of treatment. Recovery projects show what people with lived experience can achieve and can instil hope, resilience and a sense of community (see section 2.6.5 on accessing peer-delivered and peer-led support).

2.2.8 Trauma-informed practice

Services should offer trauma-informed practice.

A high proportion of people experiencing problem alcohol use have had experience of childhood trauma and a significant proportion have also experienced trauma as adults. The experience of trauma can be individual (for example, child abuse) or collective (for example, war). Many people use alcohol as an attempt to manage the impact of trauma on their lives.

Trauma-informed practice aims to increase practitioners’ awareness of how trauma can negatively affect individuals and communities, and their ability to feel safe or develop trusting relationships with health and care services and their staff. It aims to improve the accessibility and quality of services by creating culturally sensitive, safe services that people trust and want to use.

The purpose of trauma-informed practice is not to treat trauma-related difficulties, which is the role of trauma-specialist services and practitioners. Instead, it seeks to address the barriers that people affected by trauma can experience when accessing health and care services.

Trauma-informed practice is based on 6 principles, which are:

  • safety
  • trust
  • choice
  • collaboration
  • empowerment
  • cultural consideration

You should read the full working definition of trauma-informed practice for practitioners working in the health and care sector.

In Scotland, the National Trauma Transformation Programme resource A roadmap for creating trauma-informed and responsive change provides extensive guidance, much of which is relevant for other parts of the UK.

2.2.9 Alcohol-specific interventions and staff competencies

People with alcohol dependence or harmful (high risk) alcohol use should have access to evidence-based alcohol interventions delivered by staff with appropriate alcohol-specific competencies.

Alcohol treatment can be effectively delivered by services that provide alcohol treatment only, or by integrated drug and alcohol services. Where services are integrated, staff should identify and address the distinct needs of people with:

  • problem alcohol use
  • problem drug use
  • both problem alcohol and problem drug use

Integrated services should fully include people whose main problem is alcohol. Services should offer evidence-based interventions for alcohol dependence and for harmful drinking delivered by staff with alcohol-specific competencies.

See chapter 13 on community alcohol treatment and recovery services for more on alcohol treatment delivered by integrated drug and alcohol treatment services.

2.2.10 Family involvement

Services and practitioners should involve family members or carers in a person’s care where the person consents and it is appropriate. There is evidence that family involvement in a person’s care can lead to better treatment outcomes (Copello and others, 2006). Services should also offer support to family members and carers in their own right.

If the person consents to a family member being involved, practitioners should discuss and agree with the person engaged in alcohol treatment, and then the family member or carer, what is the appropriate level and type of family involvement. Practitioners should also agree with the person in treatment and their family member or carer what information will be shared and what information will remain confidential to each of them.

Services should offer family members and carers information on alcohol dependence and harmful drinking, as well as alcohol treatment interventions. They should also offer appropriate support for their involvement with the person’s care.

Family and carers may have their own support needs and services should offer information on how family members can be affected by a person’s problem alcohol use. Practitioners should offer initial support (including support for urgent needs) and where appropriate, offer extended support or let families and carers know about self-help resources, as well as local and national support organisations for families of people with problem alcohol use.

Practitioners should be aware what level of caring responsibility entitles a carer to a carer’s assessment and they should refer the family member or carer for one where appropriate (see definition of carer’s assessment in the glossary). You can find information about legislation and guidance on carers in annex 1.

Services should offer information and support to family members and friends, even where the person with problem alcohol use is not attending the treatment service (Orford and others, 2013).

You can read more about interventions involving families in chapter 5 on psychosocial interventions.

Practitioners should also consider the needs of any children in the family who are in regular contact with the person with problem alcohol use and provide information on local services for children and families. Services should have procedures for both child and adult safeguarding and practitioners should be trained to identify child and adult safeguarding needs and make referrals to children’s or adult social care where indicated. They must work in line with national child and adult safeguarding legislation and organisational procedures. You can find information on child and adult safeguarding legislation and guidance in annex 1.

2.3 Equality, diversity and inclusion

Service policies, procedures and ethos, and practitioners’ approach should be based on the principles of equality, diversity and inclusion and aim to reduce health inequalities. They should promote equitable access and personalised treatment that meets the diverse needs of all groups and local communities.

2.3.1 Promoting equality, diversity and inclusion

Alcohol harms and health inequalities

People with problem alcohol use have much higher levels of illness and early death than the general population (IHME, 2024; Roerecke and Rehm, 2013).

People experiencing economic and social deprivation

People who experience economic and social deprivation are disproportionately affected by the harm caused by alcohol dependence and harmful drinking. For example, the National Records of Scotland report Alcohol-specific deaths 2023 found the mortality rate for deaths caused solely by alcohol was 4.5 times higher in the most deprived fifth of the population than in the least deprived. And the Office for National Statistics report Alcohol-specific deaths in the UK: registered in 2023 shows that the mortality rate in England in the most deprived fifth of the population compared to the least deprived was 3.6 times higher for men and 3 times higher for women.

It is important that alcohol treatment services are designed to reach and to meet the needs of people in the most socioeconomically deprived areas in the locality they serve.

Alcohol treatment services need to work with partner services (including local voluntary and community services) to address barriers to engagement and issues that make alcohol harms worse for people experiencing social and economic deprivation. For example, in addition to ensuring people can access appropriate physical and mental healthcare, alcohol treatment services should provide or support access to:

  • welfare benefits and debt advice
  • social prescribing
  • housing support
  • employment support
  • peer-based networks

Multiple disadvantage

Many people with problem alcohol use experience multiple disadvantage. In these guidelines, ‘multiple disadvantage’ is defined as the co-occurrence and interaction of adverse circumstances leading to social exclusion, marginalisation, and extreme inequality. People can experience complex, intersecting issues that can contribute and compound disadvantage, including health inequalities, poverty, housing instability and systematic discrimination.

People who experience multiple disadvantage often find it very difficult to access healthcare, including alcohol treatment services. They also tend to experience extremely poor physical and mental health compared to the general population and often have poorer health outcomes when they engage with health services.

Alcohol treatment services need to target groups that experience multiple disadvantage using flexible engagement approaches and tailor interventions to meet their specific needs.

You can read more about targeting and tailoring care for people experiencing multiple disadvantage in:

  • chapter 9 on assertive outreach
  • chapter 21 on people experiencing homelessness
  • chapter 25 on developing inclusive services

People with protected characteristics

There is a public sector equality duty for services in Great Britain to consider the need to reduce disadvantage and meet the particular needs of people with protected characteristics.

Protected characteristics mean that it is against the law to discriminate against anyone because of:

  • age
  • disability
  • sex
  • race, including colour, nationality, ethnic or national origin
  • religion or belief
  • being pregnant or on maternity leave
  • sexual orientation
  • gender reassignment
  • being married or in a civil partnership

For more information on protected characteristics, read Discrimination: your rights.

Alcohol treatment services need to promote equality in access and appropriate treatment for people with protected characteristics.

Designing inclusive services and tailoring interventions

Social and economic deprivation, multiple disadvantage, and discrimination and disadvantage based on protected characteristics can all affect how easy it is for people to access and engage with services and whether the treatment and support they offer meets their particular needs. Alcohol treatment services, working with the wider health and care system can help to promote equality, diversity and inclusion and reduce health inequalities.

They can do this by providing accessible and inclusive services which are designed to meet the needs of everyone experiencing problem alcohol use in their local area, including specific needs of people experiencing social and economic deprivation and multiple disadvantage, and people with protected characteristics. Individual treatment and recovery plans and interventions should always be tailored to each person’s individual needs.

Local actions to develop inclusive services

Local commissioners and services should work with local people, communities, and organisations. In particular, they should work with representatives of groups from local areas of social and economic deprivation, groups experiencing multiple disadvantage and people with protected characteristics to:

  • assess local need for alcohol treatment using equality impact assessment processes to understand the diverse needs of their local population and to identify which people and groups are under-represented or experiencing poor outcomes in their services
  • develop ways to target and increase access for each local under-represented group
  • tailor services and interventions to meet the diverse needs of their local population

Services should develop an inclusive service ethos which means:

  • people with lived and living experience of problem alcohol use from different groups and local communities contribute to service commissioning, planning and delivery
  • there is a diverse team of practitioners and where possible, peer support workers, who are culturally competent (see section 2.3.2 below)

You can read more about developing inclusive services in chapter 25.

2.3.2 Cultural competence

Services and individual practitioners should be culturally competent. Services should make sure their staff receive training, supervision and support to develop this important competency.

The term ‘cultural competence’ refers to the ability of organisations and individual practitioners to effectively deliver services that meet the social, faith, cultural, and linguistic needs of people from diverse groups and communities. Cultural competence involves policies, behaviours, awareness, attitudes, knowledge and skills at an organisational and a practitioner level that promote effective interactions with, and equitable treatment for people from diverse backgrounds.

Culture intersects with other factors that shape identity and experience such as sex, sexual orientation, gender identity, age, disability, and socioeconomic resources. These combined factors affect how easy it is for each person to engage with alcohol treatment services and what kind of treatment approach will meet their needs. Cultural competence in this guideline means working effectively and equitably with people from all cultures and across intersecting identities. It also means challenging the discrimination and exclusion that people experience and the resulting impact on their treatment and recovery outcomes.

While cultural competence involves sensitivity and knowledge about other people’s cultures, it is important not to label people or make stereotypical assumptions. Everyone is unique and treatment and recovery support should always be based on understanding the person as an individual and tailoring interventions to meet their specific needs.

Practitioners should also understand how their own culture and background can influence their perspective. Services should support them through training and supervision to challenge any unconscious bias that can affect their practice.

2.3.3 Accessible services

Services should make sure that they are easy to get to, welcoming and easy to engage with for everyone in the diverse local population.

Services should review their treatment processes and procedures and amend them to address any factors that might prevent people from accessing or engaging in treatment. This will include offering appointment times that can accommodate parents with childcare responsibilities and people who work in the day. Also, services should be offered at sites that are easy to access by public transport so that people in any part of the local area can get there easily. The services should be in places where people feel physically safe, for example in areas with good lighting. The cost of travel can act as a barrier and services should help people to access support with transport costs where possible.

Services should have flexible engagement arrangements to meet the needs of specific groups, including those with protected characteristics. For example, these arrangements might include:

  • direct access (drop-in) sessions at treatment service sites
  • satellite services in primary care for people who would not want to go to a specialist alcohol and drug service, because of their concerns about stigma
  • satellite services in community services and organisations used and trusted by specific groups such as specific minority ethnic groups, LGBTQ+ groups and older people
  • satellite services in areas of deprivation and in more remote rural areas
  • access to services and facilities for people with physical disabilities
  • initial contact and (where appropriate) further appointments online or by phone for people who find it very difficult to attend a service in person
  • methods of communication and information adapted to the needs of people with physical, sensory or cognitive disabilities, neurodiversity or limited literacy

Services should make arrangements to help the most vulnerable people, including those experiencing multiple disadvantage to access treatment. Where possible, they can offer to take the service to the person in their home, or a community setting of their choice. You can read more about this in chapter 9 on assertive outreach and a multi-agency team around the person.

Pathways between prison and community or residential alcohol treatment services are vital to support access and provide effective continuing care for people on discharge from prison. Effective local pathways between acute hospitals into community alcohol treatment are also vital.

Where possible, services should employ diverse staff teams that include staff and peer support workers who are members of local groups or communities. These team members can contribute cultural perspectives on how to increase access and can support relationship building with communities and individuals seeking treatment. Where language prevents some people from accessing treatment, services should provide independent interpreters.

You can read more about accessible services in chapters 4 (section 4.4.2), 9 and 25.

2.3.4 Better care for people with co-occurring mental health conditions

Commissioners and providers of alcohol treatment services and mental health services should work together to make sure that people with co-occurring problem alcohol use and mental health conditions can access treatment and support for both conditions.

Co-occurring mental health conditions and problem alcohol use are common among people in alcohol treatment and mental health services. But there is evidence from the Recovery Partnership that services often exclude people with these co-occurring conditions so they cannot access the care they need (see the definition of co-occurring conditions in the glossary).

Alcohol treatment services and mental health services should respond flexibly to people with co-occurring alcohol and mental health conditions to actively prevent their exclusion from services.

The 2 main principles of care for working with people with co-occurring mental health conditions and problem alcohol use are:

  1. Everyone’s job. Mental health and alcohol and drug use services have a joint responsibility to meet the needs of people with co-occurring conditions by working together to reach shared solutions.
  2. No wrong door. Providers of alcohol and drug, mental health and other services should have an open-door policy for people with co-occurring conditions and make every contact count. Treatment for the co-occurring conditions should be available no matter which service they first contact.

No wrong door does not mean that everyone should receive ongoing care at the service they first attend, but it does mean that all services and practitioners should be:

  • proactive, flexible, compassionate and anti-discriminatory in their response
  • able to offer an initial rapid assessment, address any urgent physical and mental health needs and refer the person onto an appropriate specialist service if needed
  • active in planning longer-term care with other services

Services should work together to develop and maintain collaborative pathways of care and a shared approach to treatment and recovery planning so multiple agencies can provide a co-ordinated response to the person’s individual needs.

Healthcare Improvement Scotland’s National mental health and substance use protocol is an example protocol setting out how services in Scotland should work together to provide more integrated care for people with co-occurring conditions. Some of the content will be relevant for other UK nations.

You can read more on people with co-occurring mental health conditions in chapter 18.

2.4 Quality governance

Alcohol treatment services and recovery support services must have comprehensive quality frameworks to help them deliver evidence-based treatments and care, by practitioners with appropriate competences.

2.4.1 Quality governance frameworks

Quality governance is a term used to describe processes that assure delivery of high-quality services. Quality governance may also be known as clinical governance or care governance. Health and social care organisations and some individuals are directly and statutorily accountable for elements of quality governance.

Organisational components to assure quality governance include:

  • clear lines of responsibility and accountability
  • quality improvement activities, including regular quality audits of services
  • policies that manage risk
  • procedures to identify and remedy poor performance

The main components of an effective service are:

  • delivering interventions in line with the evidence base
  • having a competent workforce, who are effectively supported and supervised (see section 2.5 below)
  • working in partnership with other services to deliver positive outcomes

Services need to make sure they have appropriate policies and procedures in place to support these professional and organisational objectives.

Commissioners and senior clinicians in the local healthcare system should take a leading role in reviewing significant safety incidents and adverse events, including deaths of people in alcohol treatment. The purpose of reviewing safety incidents is to make sure everybody learns from the incident and that there is a structure to support system improvements and to monitor their impact.

Alcohol treatment services should also have their own internal processes for reporting and reviewing incidents affecting the safety of people attending the service.

Individual practitioners and the organisations in which they work normally have a duty for:

  • safety incident reporting
  • contributing to investigation and review
  • risk assessment
  • risk management
  • safeguarding assessment and management
  • infection control

Services should refer to more detailed guidance on quality governance and quality standards. For example:

There is some content in each of the documents that is relevant across the UK.

2.4.2 Measuring outcomes

Services should routinely monitor all interventions for people with problem alcohol use, using a validated outcome measure.

These include formal tools that measure self-reported changes in alcohol use and aspects of health, wellbeing and recovery. For example:

Both TOP and SURE are recommended by the International Consortium of Health Outcomes Monitoring as part of its set of patient-centred outcome measures for addiction.

Where relevant, practitioners can also use tests including blood tests, liver fibrosis tests, or other health tests to contribute to measuring health outcomes.

Practitioners should make outcome measures central to a person’s treatment and recovery planning process. Practitioners should plan all clinical interventions with personalised and mutually agreed outcomes in mind and routinely review progress against these outcomes with the person.

When they review the outcomes, practitioners may agree with the person to alter these outcomes or the interventions they are providing to achieve them, if it becomes clear that working towards other outcomes would be more useful.

Supervisors and practitioners should review outcomes in clinical supervision, as this can help to identify staff training and development needs.

Services should also include monitoring of treatment outcomes across all those who use the service as part of regular quality audits. Services should monitor outcomes across different groups including people in treatment for alcohol alone and people in treatment for alcohol and other substances, and people from different demographic groups.

2.5 A skilled and competent workforce

All alcohol treatment practitioners need to have appropriate competencies for their clinical roles and receive training and supervision to achieve and maintain them.

2.5.1 Clearly defined competencies

Competencies need to be agreed and clearly defined at a local or service level for the full range of roles covered in these guidelines, based on relevant national competency or capability frameworks and national occupational standards.

2.5.2 Professional development structures

Training and professional development structures and resources are essential to develop and maintain the required competencies. Important components of this include:

  • individual or peer supervision
  • personal development plans
  • mentoring
  • other forms of professional support

2.5.3 The role of professional bodies

The professional regulatory bodies are responsible for setting the standards of behaviour, competence and education of regulated healthcare professionals. These bodies include the:

  • Health and Care Professions Council
  • General Medical Council
  • General Pharmaceutical Council
  • Royal Pharmaceutical Society
  • Nursing and Midwifery Council
  • social work councils and regulators across the UK, which are:
    • Scottish Services in Social Care
    • Social Care Wales
    • Northern Ireland Social Work Council
    • Social Work England

These bodies are also responsible for registering professionals who meet those standards and taking action where the standards are not met. Clinicians in registered roles who deliver alcohol treatment need to have appropriate certification, such as specialist registration, and meet professional revalidation requirements.

2.5.4 Competencies and qualifications for non-registered staff

It is particularly important for staff who are not from one of the registered professions and do not have the additional support of a professional body (like alcohol and drug workers), to be properly trained, supported, regularly assessed and supervised by their employers to carry out their roles effectively. Locally agreed role descriptions or person specifications should set out the competencies and qualifications required for non-registered staff, based on relevant national occupational standards and capability or competency frameworks.

Volunteers and peer mentors may also have relevant qualifications for their roles and need to be appropriately supported and trained by the services they work in. It is also important that the roles of volunteers and peer mentors are clearly defined.

2.5.5 Updating knowledge and skills

All clinicians have a professional obligation to update their knowledge and skills base in line with emerging evidence and developments in practice.

2.5.6 Non-clinical skills

Non-clinical skills such as leadership and management are also important and need to be supported by employers.

2.5.7 Supervision and appraisal

Supervision and reflective practice structures are essential for effective interventions, particularly psychosocial interventions. They are an important part of good clinical governance, alongside monitoring intervention quality and outcomes.

Annual appraisal is mandatory for all clinicians working in the NHS and is established good practice in other settings.

2.5.8 A full range of competencies in each local area

Each local alcohol treatment system will need to have doctors providing treatment, ranging from those able to provide medical services for the treatment of comorbidities to those with specialist competencies in treating alcohol dependence. Other health and social care professionals with a range of competencies are also needed in a treatment system, based on an objective assessment of local need.

Multidisciplinary teams are essential to alcohol treatment and should include doctors, nurses, psychologists, peer support workers, family support workers and social workers.

2.5.9 Alcohol specific competencies

Most alcohol treatment and drug treatment is integrated into single alcohol and drug treatment services. Many of the competencies needed to treat and support recovery from alcohol dependence are the same as those needed to treat and support recovery from drug dependence. However, some of the competencies needed to deliver the interventions in this guideline are specific to alcohol. So, it’s vital to maintain a sufficient level of alcohol specialism in teams in integrated alcohol and drug treatment services. Where services are integrated, they should support individual staff to develop and maintain their alcohol specific competencies.

2.5.10 Therapeutic alliance

Evidence and feedback from people with lived experience consistently tell us that the working relationship, or the therapeutic alliance, between practitioners and the people they support is vital to the effectiveness of all interventions. This is particularly true for psychosocial interventions. Knowing this helps us to focus on relevant competencies such as:

  • active listening
  • giving structured feedback
  • reflective practice
  • a non-judgemental approach

It’s also important to focus on caseload size and the staffing to patient ratio in services, to make sure staff have the time they need to develop supportive relationships.

2.5.11 Training future alcohol specialists

All alcohol treatment systems need to have the resources, time and expertise, including qualified supervisors, to support the next generation of alcohol specialists. Services should have clear development and career pathways for regulated and un-regulated staff. This includes supporting training places for psychologists, nurses (including non-medical prescribers), specialist GPs, social workers, pharmacists and addiction psychiatrists.

2.6 Recovery-oriented care and systems of care

2.6.1 Working together to support recovery

Commissioners, treatment services and recovery support services should work together with other local support services and community groups to deliver recovery orientated care and to foster a recovery-oriented system of care (ROSC). The most effective recovery-oriented systems of care contain contributions from people with learnt, lived and living experience.

2.6.2 Recovery

There are several definitions of recovery. Witkiewitz and others (2020) define recovery as “a dynamic process of change characterized by improvements in health and social functioning, as well as increases in well-being and purpose in life”.

Alcohol dependence is often a long-term condition that can involve cycles of abstinence and relapse (see definitions of alcohol dependence and abstinence in the glossary). For some people, this can happen over several years and they may make many attempts to change. For many people, an episode of treatment that leads to abstinence (or low risk drinking where appropriate) does not mean that the person has the necessary support and resources to sustain this change in the long term or to develop a life that is meaningful to them. People with alcohol dependence and related alcohol problems typically need a personal programme of sustained recovery support and management to achieve those aims. This is likely to involve a need to change behaviour, outlook and identity over an extended period to sustain recovery.

Recovery requires the person, their family and other supportive people around them to develop aspirations and hope. Recovery can be associated with different types of support and interventions or can occur without any formal external help, so it can be achieved in different ways. It is a process, not a single event, and takes time to achieve and effort to maintain. The person must sustain recovery voluntarily for it to be lasting, although the recovery journey can sometimes start or be supported by court-ordered interventions such as community sentencing requirements.

2.6.3 Recovery-oriented systems of care

A ROSC is a network of local treatment and recovery services and community groups that help people to start and sustain their recovery. It incorporates the insight and work of people with lived and living experience and their families at all levels of planning and delivery to:

  • offer choice by providing a flexible and inclusive menu of services, community support and opportunities, including lived experience initiatives, recognising that there are many pathways to recovery
  • provide a range of responsive and inclusive support and opportunities for people in recovery and their families
  • build on the strengths and resilience of individuals, families, recovery communities and the wider community

Structured treatment services and recovery support services are organised into a framework that incorporates the whole health and social care system and related services such as housing and employment support. The support offered by treatment services and by recovery support services are both vital to a person’s recovery. The interaction of services and the local community contributes to the effectiveness of a ROSC. The ROSC should be easy to navigate, transparent and respond to the cultural diversity of the community where it operates.

In an effective ROSC, the relationships between treatment and recovery services:

  • are strong
  • have diverse access (and re-access) points into treatment and recovery support
  • have a varied and complementary offer of support

2.6.4 Recovery-oriented care

Treatment should be delivered in a way that is recovery-oriented, meaning it helps people to achieve healthier and fulfilled lives. This typically entails developing positive family and social relationships and networks, participating in meaningful activity, achieving economic and housing stability. This enables people to make progress in treatment and improves the chance of people successfully completing treatment.

Recovery support, including peer-delivered support, is important right from the beginning of the person’s treatment and recovery journey. But for people in structured treatment, there is likely to be a gradual transition from a focus on structured treatment interventions towards self-care and peer-support as the process of recovery develops. Some people prefer to first access peer-led recovery support and these services can act as a bridge, helping them to access structured treatment if and when they feel ready. Some people achieve recovery solely through peer-to-peer support and never access structured treatment.

Alcohol treatment services and peer support services are components of an integrated system and each should deliver their component to the highest level. This includes:

  • peer support including buddying and social support
  • meaningful activity
  • ‘facilitating access to mutual aid’, a short, simple and effective method for increasing mutual aid participation
  • employment support
  • housing support

Treatment services should link with recovery support services, resources in the surrounding community and, with the person’s consent, supportive family members.

Overall, outcomes improve significantly when episodes of structured treatment are combined with long-term recovery support (Simoneau and others, 2018).

You can read more about:

  • structured support (which includes recovery support interventions) in chapter 5
  • recovery support services in chapter 6
  • employment support in chapter 7

2.6.5 Post-treatment recovery support

Alcohol treatment services should support and work together with local recovery support services to help people sustain recovery post-treatment.

 It is important for a person to have ongoing monitoring to help them sustain recovery after they leave treatment. Recovery check-ups are an agreed series of scheduled in-person or phone appointments with the person after they leave a treatment service. Recovery check-ups are usually carried out by the person’s keyworker.

Recovery support services can provide emotional and practical support for continuing abstinence (or low risk drinking where that is appropriate) after the person has finished structured treatment. They can also provide daily structure and rewarding alternatives to alcohol use. Recovery support services can help people to take part in a process of gathering healthy life resources, often known as recovery capital.

There is further guidance on recovery support services in chapter 6.

2.6.6 Access to peer-delivered and peer-led support

Commissioners and providers of alcohol treatment services should work with and support local peer-delivered and peer-led projects and organisations.

Peer-delivered and peer-led projects and organisations and mutual aid groups such as Alcoholics Anonymous or SMART Recovery can help support and sustain recovery-oriented journeys for people experiencing problem alcohol use before, during and after treatment.

People can ask their keyworker and peers which groups they have heard of or find most useful and select groups to try based on these recommendations. If they do not feel comfortable in one group, they can try another until they find one they are happy with.

Effective peer support can:

  • enhance motivation
  • help members to develop a positive identity
  • improve coping mechanisms and social skills
  • provide benefits for both the person delivering the support and the person receiving it

Local arrangements for peer support projects will vary. They can:

  • be commissioned separately from treatment services
  • exist as part of the service
  • exist as self-funded and managed organisations

The range of support they offer also varies. Whatever the arrangement, services should support peer-delivered and peer-led organisations by involving them in service design and working with them to offer people integrated recovery-oriented treatment and support. Practitioners should inform a person about peer support options as part of the treatment and recovery planning process and help them to access them.

Peer-delivered and peer-led projects and organisations can become more resilient and more effective where they have a voice, a role and support within the system. These projects can also have a role in promoting a positive view of recovery in the wider local community and potentially overcoming stigma.

In areas where peer-delivered and peer-led support and organisations do not exist, commissioners and services should consider developing them. You can read more about peer-led initiatives in chapter 6 on recovery support services.

2.7. Local strategic partnerships

These guidelines are about clinical practice, rather than strategic planning. However, many of the recommendations in these guidelines involve effective working between alcohol treatment services and partner services. Local strategic partnerships are essential to develop and maintain effective multi-agency working arrangements.

In each local area, there should be an active partnership across the alcohol and drug treatment system, including:

  • commissioners
  • system leaders
  • NHS provider organisations
  • third sector provider organisations
  • organisations for people with lived experience

Partnerships should also include leaders of wider health, care, criminal justice systems and voluntary sector community services.

The partnership should work together to develop, implement and review joint strategic plans to meet the multiple needs of people with problem alcohol use in their local population. The strategic partnership should establish integrated care pathways, information-sharing and joint working arrangements, and regularly review their effectiveness.

The membership of local partnerships will vary according to national and local arrangements. In England, local partnerships are a requirement.

Local partnerships should usually include system leaders and service providers from:

  • the local alcohol and drug treatment system
  • lived experience recovery organisations, including families and carers
  • primary and secondary healthcare, including mental health care
  • housing and homelessness services
  • child and adult safeguarding services
  • adult social care
  • police, probation and prison healthcare
  • education and employment support services
  • community services working with groups likely to experience problem alcohol use (such as domestic abuse agencies)
  • organisations working with underserved groups (such as specific ethnic minorities)

An effective strategic partnership makes it possible for services to work together to provide integrated individual treatment and recovery support. Alcohol treatment practitioners, practitioners from partner services and peer support organisations should work together to offer an integrated personalised package of care tailored to the person’s individual needs. They should involve the person experiencing problem alcohol use in all decisions about their treatment and recovery.

2.8 References

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Bramley G, Fitzpatrick S and Sosenko F. Hard Edges Scotland full report. Heriot-Watt University 2019: pages 44 to 47 (registration and subscription required for full article).

Copello A, Templeton L and Velleman R. Family interventions for drug and alcohol use: is there best practice? Current Opinion in Psychiatry 2006: volume 19, issue 3, pages 271 to 276.

Institute for Health Metrics and Evaluation. Findings from the Global Burden of Disease 2021 study: alcohol use. IHME, 2024.

Kilian C, Manthey J, Carr S, Hanschmidt F, Rehm J, Speerforck S and Schomerus G. Stigmatization of people with alcohol use disorders: an updated systematic review of population studies. Alcohol: Clinical and Experimental Research 2021: volume 46, issue 12, pages 899 to 911.

Orford J, Velleman R, Natera G, Templeton L and Copello A. Addiction in the family is a major but neglected contributor to the global burden of adult ill-health. Social Science and Medicine 2013: volume 78, pages 70 to 77.

Roerecke M and Rehm J. Alcohol use disorders and mortality: a systematic review and meta-analysis. Addiction 2013: volume 108, issue 9, pages 1,562 to 1,578 (registration and subscription required for full article).

Sheedy C and Whitter M. Guiding principles and elements of recovery-oriented systems of care: what do we know from the research? (PDF, 1MB). Substance Abuse and Mental Health Services Administration, 2009, available on the website of NAADAC, the Association for Addiction Professionals.

Simoneau H, Kamgang E, Tremblay J, Bertrand K, Brochu S and Fleury MJ. Efficacy of extensive intervention models for substance use disorders: a systematic review. Drug and Alcohol Review 2018: volume 37, issue S1, pages S246 to S262 (registration and subscription required for full article).

van Boekel L, Brouwers E, van Weeghel J and Garretsen H. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug and Alcohol Dependence 2013: volume 131, issues 1 to 2, pages 23 to 35.

White W. Recovery/remission from substance use disorders: an analysis of reported outcomes in 415 scientific reports, 1868 to 2011. Philadelphia Department of Behavioral Health and Intellectual Disability Services and Great Lakes Addiction Technology Transfer Center, 2012.

Witkiewitz K, Montes K, Schwebel F and Tucker J. What is recovery? Alcohol Research: Current Reviews 2020: volume 40, issue 3, article 01.