Clinical guidelines for alcohol treatment

25. Developing inclusive services

How alcohol treatment services can become accessible and effective for everyone, especially groups who face barriers to accessing care. This includes ethnic minority groups, LGBTQ+ people, women, older adults and people with learning disabilities or neurodevelopmental conditions.

25.1 Main points

Making alcohol treatment accessible to everyone

Alcohol treatment and recovery support should be accessible to everyone who needs it and should be delivered in a way that meets the needs of diverse groups of people and communities.

People experiencing socioeconomic deprivation, multiple disadvantage and some people with protected characteristics experience barriers to accessing alcohol treatment services. Services may not adequately meet their needs unless they reach out to these groups and tailor their treatment offer to them.

Diverse experience and identities

There is wide variation in experience within any group of people. A range of factors intersect and contribute to a person’s individual experience and needs including:

• socioeconomic status
• age
• race and ethnicity
• sex
• sexual orientation
• gender identity
• disability

While it’s helpful to consider some common experiences or needs shared by particular groups, services should recognise the diversity within each group as well.

Involving different groups in commissioning processes

Commissioners and services should work in partnership when assessing local need, and planning, designing, and delivering services. They should work with people and communities:

• who experience socioeconomic deprivation or multiple disadvantage
• with protected characteristics

Promoting equality, diversity and inclusion

The organisation should have policies, practices and an ethos that promote equality, diversity and inclusion. They should have a diverse staff team that is representative of their local community and trained and supported to be culturally competent.

Promoting and reaching out to particular groups

Services should design service messages and materials in partnership with people from the under-served communities they are aiming to reach. And they should promote the service through various media and in settings people are likely to use.

Services should reach out to people and communities using targeted promotional messages and flexible engagement approaches. These should be designed and delivered in partnership with people from the communities they are aiming to reach.

Having an inclusive and non-judgemental culture

The service should:

• look and feel inclusive
• make reasonable adjustments for disabled people
• meet people’s communication needs, such as having independent interpreters available

Practitioners should have a non-judgemental approach based on empathy, trauma-informed practice and cultural competence.

Personalised treatment and recovery planning based on individual needs

Practitioners should never make assumptions about the person’s needs because they have a particular protected characteristic or are from a particular socially excluded group. Treatment and recovery plans should be personalised to meet the person’s unique goals and treatment needs.

Joint working arrangements

Services should have referral pathways and joint working arrangements with community organisations serving particular groups.

It’s important that the main alcohol treatment service works in partnership with local specialist services and peer-based organisations working with particular communities or groups.

Adapting interventions and other arrangements

It can be helpful to make some adaptations to the interventions and other arrangements that are delivered to people from particular groups. Service staff, clinical supervisors and people from the relevant group should be involved in adapting interventions.

25.2 Alcohol harms and health inequalities

People with problem alcohol use have much higher levels of illness and early death than the general population (Institute for Health Metrics and Evaluation, 2024; Roerecke and Rehm, 2013). They also often experience stigma associated with their alcohol use, including in healthcare services.

Within this group of people, many experience further disadvantage or discrimination based on:

• socioeconomic deprivation
• multiple disadvantage
• their protected characteristics

25.2.1 People experiencing economic and social deprivation

People who experience socioeconomic 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 showed that the mortality rate for deaths in Scotland caused solely by alcohol was 4.5 times higher in the most deprived fifth of the population than in the least deprived. The Office for National Statistics Socioeconomic inequalities in avoidable mortality in England and Wales data shows that in England in 2023 the mortality rate was twice as high in the most deprived tenth of the population than in the least deprived.

It is important that alcohol treatment services are designed to reach and meet the needs of people in the most socioeconomically deprived areas in the locality they serve. The local needs assessment should involve people and communities from those areas to understand their needs.

Alcohol treatment services should work with partner services, including local voluntary and community sector services, to address barriers to engagement and issues that worsen alcohol harms for people experiencing socioeconomic deprivation.

To support engagement, services should:

• make it clear in promotional literature that the service is free
• be geographically accessible to avoid high transport costs and difficult journeys or areas where transport is poor
• consider offering support with transport costs or mobile phone data

To reduce health harms, services should provide:

• an individual healthcare assessment and where relevant, referrals to primary and secondary healthcare
• health promotion advice and interventions such as smoking cessation
• harm reduction advice and interventions

When people attend an alcohol treatment service, it is a chance to help them address any problems linked to social determinants of health, including poverty and poor housing. Services should help people access:

• advice on welfare benefits and debt
• information on foodbanks and other community services such as warm spaces in winter
• support for problems with housing and homelessness
• social prescribing

To support people’s longer term recovery goals and reduce social exclusion, alcohol treatment services should help people access:

• education, training and employment support
• volunteering opportunities
• involvement with peer networks, recovery organisations and mutual aid
• involvement with local community groups and activities

25.2.2 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 worsen disadvantage, including:

• health inequalities
• poverty
• housing instability
• 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.

The barriers people with multiple disadvantage experience accessing services will vary. But there are many barriers, related to the individual and to the services. These include people:

• having difficulty understanding and navigating the healthcare system
• having had past experiences of being turned away from services or being badly treated
• not speaking English or be able to read or write
• being afraid of punitive action after accessing services

At the same time, services may find the complex nature of the person’s problems challenging and might not have policies and competencies to respond to them.

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

There is guidance on working with groups of people who experience multiple disadvantage in:

• chapter 9 on alcohol assertive outreach and a multi-agency team around the person
• chapter 17 on criminal justice settings
• chapter 21 on people experiencing homelessness

There is also guidance on working with specific groups that experience high levels of multiple disadvantage in section 25.12.

25.2.3 Protected characteristics

There is a public sector equality duty for services in England, Scotland and Wales to consider the need to reduce disadvantage and meet the particular needs of people from protected groups.

The Health and Social Care (Reform) Act (Northern Ireland) 2009 places a duty on each health and social care trust to:

exercise its functions with the aim of improving the health and social well-being of, and reducing health inequalities between, those for whom it provides, or may provide, health and social care.

It is against the law to discriminate against anyone because of:

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

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

People will often have more than one protected characteristic and may experience the cumulative effect of discrimination or disadvantage based on the intersection of those characteristics.

Alcohol treatment services should be designed to reach people and groups with protected characteristics and to make sure that they meet their treatment and recovery support needs.

25.2.4 Designing inclusive services

A number of things can affect how easy it is for people to access and engage with services and whether the treatment and support that services offer meets their particular needs. These include:

• social and economic deprivation
• multiple disadvantage
• discrimination and disadvantage based on protected characteristics

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. These include the 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.

25.3 Structure of this chapter

The rest of this chapter is in 2 main parts. The first outlines some shared principles that will help to develop inclusive services. The second is a set of summaries showing actions that services could take to become more inclusive and meet the needs of some specific groups of people, including:

• ethnic minority groups
• LGBTQ+ groups
• women
• older people
• people with disabilities
• people with learning disabilities
• people with neurodiverse conditions
• several groups experiencing multiple disadvantage

These summaries give examples of what commissioners, services and practitioners can do to reduce barriers to access and to tailor services for particular groups. Research evidence for these areas is often limited. So, the guidance is based on recurring themes in the research, as well as evidence from practice and lived experience.

25.4 Principles for developing inclusive services

Principles to help develop inclusive services include:

• assessing local need for alcohol treatment, working with people and communities
• promoting equality, diversity and inclusion
• promoting the service to local groups and communities
• using flexible, targeted approaches to reach underserved groups
• supporting people to engage in treatment
• offering alcohol harm reduction interventions
• tailoring treatment and recovery support to the needs of specific groups and to each individual

You can find more information about these principles below.

25.4.1 Assessing local need for alcohol treatment working with people and communities

Equality impact assessments

Local populations vary widely. So, alcohol treatment should be based on a thorough assessment of local need. Commissioners are normally responsible for making local needs assessments, involving strategic partners. Services should be aware of the diverse needs of their local population and can contribute to needs assessments.

Local needs assessments should include equality impact assessment processes to understand the diverse needs of local populations, including people and communities:

• experiencing socioeconomic deprivation
• with multiple disadvantage
• with protected characteristics
• in specific inclusion health groups

Services in Wales should ensure they meet the requirements of the Welsh Language (Wales) Measure 2011 and consider ways of delivering the Welsh Government’s Active Offer of Welsh language provision.

Working with local people and communities when assessing need

When assessing need and planning services, commissioners and service providers should seek the views of local people and communities, including community organisations. This should include the views of people from underserved groups.

Commissioners and service providers need to hear about:

• the barriers specific groups experience when accessing and engaging with alcohol treatment
• how these groups think services could improve access

Commissioners, service providers, people with lived experience and local people and communities can then work in partnership to develop a needs assessment and develop services designed to:

• remove service barriers to accessing alcohol treatment and recovery support
• improve the experience of people in treatment
• tailor treatment and recovery support approaches to the needs of particular groups

The resources section at the end of this chapter includes guidance on working together with people and communities.

25.4.2 Promoting equality, diversity and inclusion

Providing equal access and appropriate treatment to diverse populations requires an organisation to be culturally competent. 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 several things at organisational and practitioner level, such as:

• policies
• behaviours
• awareness
• attitudes
• knowledge and skills

These should promote effective interactions with people from diverse backgrounds, and equitable treatment for them. There is more information on cultural competence in section 2.3.2 in chapter 2 on principles of care.

The organisation should have a framework and a service ethos that promotes equality, diversity and inclusion that should include:

• recruiting a diverse staff team, which contributes a range of perspectives to treatment provision
• developing organisational policies and practices that promote equality, diversity and inclusion, including equality audits
• training and supervision in delivering treatment based on principles of equality, diversity and inclusion, with enough time and space for staff to develop their practice
• staff training and support to develop cultural competence
• staff training and supervision on skilfully addressing discriminatory behaviour from colleagues or people accessing treatment, so that people can engage in treatment in a safe space

25.4.3 Promoting the service to local groups and communities

There is international evidence that people with alcohol problems underuse alcohol treatment services (Rehm and others, 2015). Alcohol treatment services should be promoted very widely and in ways that will reach local underserved populations.

There are many ways that services can advertise and promote their services locally, including through:

• local and community media including radio, newspapers, community websites and social media
• attending community events and local meeting places
• public facilities like laundrettes and community centres
• community organisations that represent or have links with specific underserved communities or groups with protected characteristics
• wider health and social care services, including children and family services
• promoting the service in the most socioeconomically deprived areas and isolated rural areas

Some of the most marginalised people may not have access to digital platforms, so it’s important to include other forms of media, to make sure there is equitable access to information about treatment for everyone.

The promotional messages and images that you use should be clear that alcohol treatment is free, available to everyone and that diverse populations will be welcomed. Examples include:

• positive images showing diverse populations
• service information or health information tailored to specific groups or communities
• information in languages spoken in the community
• easy read information for people with literacy problems and other accessible formats for people with sensory disabilities or neurodiverse needs

You should involve people from the groups the information is aimed at in designing information and promoting the service and make sure that the images and language you use are not stigmatising.

25.4.4 Using flexible, targeted approaches to reach under-served groups

Some groups of people are unlikely to come to a service for a range of reasons including:

• past experiences of discrimination or marginalisation in services
• perceptions that alcohol treatment services are not inclusive
• difficulty trusting services due to experiences of trauma
• stigma about alcohol linked to religion, culture or gender
• lack of knowledge about problem alcohol use and alcohol treatment services
• language or communication needs
• fears that children may be taken into care
• fears about immigration status
• difficulty making or keeping appointments due to life circumstances (for example, homelessness)
• travel problems for people who are frail or have physical disabilities
• lack of public transport or cost of transport

Alcohol treatment services need to make proactive attempts to reach underserved populations, using flexible, tailored approaches including:

• working in partnership with community organisations and peer support organisations who have established relationships with specific underserved groups
• running in-reach sessions (running sessions in services or organisations attended by under-served groups) or being co-located with partner services or community organisations
• joint working with support workers from organisations that work with specific groups to support individual people
• community awareness raising about alcohol harm and alcohol services
• having open access services so appointments are not necessary
• assertive outreach, including home visits (see chapter 9 on alcohol assertive outreach and a multi-agency team around the person)
• running sessions in general health and wellbeing services, so people do not have to attend an identifiable alcohol treatment service
• having an option of digital interventions so people can make initial contact without coming to a service site
• having independent interpreters or staff who speak community languages available

25.4.5 Supporting people to engage in treatment

Practitioner approach

Practitioners should encourage people to engage with alcohol treatment by:

• having inclusive attitudes
• building trusting relationships
• discussing potential barriers to ongoing engagement with each person

The principles of care in chapter 2 that should underpin all alcohol treatment will help to engage people from groups that experience barriers to accessing and engaging in treatment. These principles include:

• having a non-stigmatising approach
• putting the person at the centre of their own care and personalising treatment
• using trauma-informed practice (see the Office for Health Improvement and Disparities’ Working definition of trauma-informed practice for more information)
• cultural competence

Building a therapeutic alliance (a trusting working relationship) is vital to effective treatment and will be particularly important where people from underserved groups are ambivalent or anxious about engaging in treatment. Building a therapeutic alliance takes time and requires attention. So, staff need manageable caseload sizes and people will need to be engaged long enough for them and the practitioner to build an effective therapeutic alliance. Once they have established a therapeutic alliance, it’s important for the person to keep the same keyworker because changes in keyworker can be very disruptive. There is guidance on therapeutic alliance in section 5.5.1 in chapter 5 on psychosocial interventions.

Discussing how to reduce barriers to engaging in treatment

At referral, services should make it standard practice to ask if there are any adjustments that the person needs to engage in treatment, so they can make these arrangements before the person attends. For example, services can ask about:

• independent interpreters
• reasonable adjustments for physical, sensory or learning disabilities, alcohol related brain damage and neurodiverse conditions
• mental health conditions, for example social phobia

At assessment, the practitioner can discuss needs with the person in more detail.

Practitioners should discuss with the person how they can work together to reduce any barriers that could stop them engaging in treatment. Barriers can include:

• practical barriers, like appointment times
• physical safety issues, such as women experiencing domestic abuse
• emotional safety issues, for example fears related to previous experiences of lack of understanding, discrimination or trauma

The service should do things that make it easier for people to engage with treatment. For example:

• timing appointments around childcare or working arrangements
• making sure a woman who has experienced intimate partner violence is not seen at the same service or site as the perpetrator
• involving a family member, support worker or peer, with the person’s consent
• providing clear information on confidentiality
• offering interventions tailored to a person’s individual needs (see section 25.4.7 below)

Wherever possible, it’s important that people have a choice about their keyworker or peer support worker. For example, women who have experienced domestic or sexual violence in heterosexual relationships may prefer to have a woman keyworker.

Peer support can often help to support engagement, so the practitioner should introduce the person to peer-based support organisations or individual peers where appropriate. In some areas, there are independent lived experience recovery organisations (LEROs) that some people find more accessible than treatment services. People may approach and engage with a LERO initially and may continue to engage with it instead of treatment services, or the LERO can help them to engage with treatment services when they are ready.

There are more examples of reducing barriers to engagement for particular groups in sections 25.5 to 25.10 below.

25.4.6 Offering alcohol harm reduction interventions

Practitioners should offer alcohol harm reduction interventions where people are not yet ready to enter structured treatment.

If people from underserved populations are unsure about accessing structured treatment but they have established a relationship with a practitioner (for example, an outreach worker), this provides an opportunity to offer harm reduction interventions. These harm reduction interventions may be beneficial in themselves and can help to strengthen a person’s engagement in treatment. The practitioner can offer access to structured treatment again at a later stage. There is guidance on harm reduction in chapter 8 and guidance on assertive outreach and a multi-agency team around the person in chapter 9.

25.4.7 Tailoring treatment and recovery support

Personalised treatment and recovery plans

Alcohol treatment services and practitioners should deliver treatment and recovery interventions in a culturally competent way and that meet the person’s individual needs.

The person should be at the centre of their treatment and recovery planning and this should be tailored to meet their individual needs and goals. Practitioners should be aware of specific needs that may be relevant for people from particular groups, but they should never make assumptions about the person’s needs because they have a particular protected characteristic or are from a particular disadvantaged group. Practitioners should try to understand the person’s own unique identity and needs and take account of this when working with them to address their problem alcohol use.

Alcohol treatment services need to work with other organisations to help people access inclusive treatment and recovery support. There are a number of organisations and groups that can help people recover by showing what recovery looks like and giving them tailored support, advocacy and community. These include:

• diverse recovery communities
• peer support networks linked to the service
• community organisations serving specific populations

Tailoring treatment interventions

It may be appropriate to tailor psychosocial interventions, so they are more relevant and effective for specific groups of people. Clinical advisors and people from the group the intervention is targeting should be involved in considering how to tailor interventions. There are some examples of tailoring interventions below in sections 25.5 to 25.12.

Practitioners should make sure any presentations or work sheets that they use in treatment interventions are inclusive. For example, when running a relapse prevention group, they should make sure that any examples of high-risk situations they discuss with the group include the kind of situations that might be risky for people in the group.

Some people with protected characteristics or from socially excluded groups might need or may benefit from having the option of dedicated treatment groups or activities, which are specifically for people with particular characteristics or from particular groups (for example, women-only groups or LGBTQ+ specific groups). This can help to create emotional safety where people feel aspects of their identity and experience may be better understood and accepted, or where people can talk about shared experiences that may have been painful or traumatic.

Addressing discriminatory behaviour in group settings

Many treatment services create shared environments where people in treatment meet with others, like treatment in groups or open access drop-in sessions. Staff need training and supervision so they can address discriminatory behaviour appropriately in group settings in a treatment service.

25.5 Ethnic minority groups

25.5.1 Language

Language is important and we aim to use inclusive language in this guidance. We realise there are different views on language to write about ethnicity, but these guidelines use the Writing about ethnicity guide.

25.5.2 Prevalence and harms

Alcohol dependence occurs in all ethnic groups. But the evidence on prevalence of harmful or dependent drinking in ethnic minority groups is very limited.

A rapid evidence review of drinking problems and interventions in Black and ethnic minority communities found that overall, there are higher rates of abstinence and lower rates of harmful drinking among ethnic minority groups compared to the White British group (Gleeson and others, 2019). However, there is some evidence that says rates of alcohol dependence may be similar for some ethnic minority groups and White groups (Drummond and others, 2004). Much of the data that exists and was reviewed is now quite old.

The evidence review found concerns about problematic drinking and alcohol harm among:

• South Asian men, and Sikh men in particular (Bayley and Hurcombe, 2011; Galvani and others, 2013)
• refugees and asylum seekers (Horyniak and others, 2016)
• Irish nationals living in England, Wales and Scotland (Hurcombe and others, 2010)
• Polish migrants (Herring and others, 2019)

It also found concerns among service providers that the prevalence of harmful drinking in most ethnic minorities is under reported due to stigma and inadequate recording.

The Scottish Health Survey - topic report: equality groups found that between 2008 and 2011, people in most ethnic minority groups were less likely to drink at hazardous or harmful levels than the national average.

White British and White Irish respondents were most likely to have exceeded the recommended daily limit on their heaviest drinking day in the previous week.

Office for National Statistics (ONS) data on deaths caused by alcohol is not routinely analysed by ethnic group.

Scottish research on health and ethnicity found that Indian men had a 75% higher risk of alcohol related liver disease than White Scottish men (Bahla and others, 2016). It also found that White Irish men and women described as from “any Mixed background” had almost double the risk of alcohol-related diseases, compared to the White Scottish population. However, the causes of these differences in alcohol related diseases are not clear.

There is some evidence from England that South Asian men are over-represented for alcohol related cirrhosis (Douds and others, 2003). And that Sikh men in particular are over-represented for liver cirrhosis (Hurcombe and others, 2010).

25.5.3 Considerations for services

Variation between ethnic minority groups

There is wide variation between and within ethnic minority groups in rates of harmful alcohol use and attitudes to drinking and drinking problems.

Commissioners and services should adapt the guidance in sections 25.5.4 and 25.5.5 to the needs of specific ethnic minority groups in their local area and practitioners should tailor interventions to each individual.

Inequality and discrimination

The NHS Race and Health Observatory Ethnic inequalities in healthcare: a rapid evidence review published in 2022 found strong evidence of ethnic inequalities in access to general healthcare services and in experience of care. Other research shows this is also the case for alcohol treatment (Hurcombe and others, 2010).

Experience of institutional and interpersonal racism in treatment services has led to a lack of trust that prevents people accessing services. Tackling inequality and discrimination in services and building trust should be a priority.

Stigma and shame

Harmful alcohol use is stigmatised across British society. But in some ethnic minority groups there is additional stigma associated with mental ill health and with religious prohibitions on alcohol use. This is most often reported for South Asian ethnic minority groups.

Culturally, alcohol use can be considered and experienced as a source of individual, family and community shame, so people are less likely to seek help from outside the family. Alcohol use or alcohol problems among women in South Asian ethnic groups and Muslim groups more widely is often considered unacceptable and more likely to remain hidden, including from the family (Gleeson and others, 2019). Services should work with local people and communities to find acceptable ways for them to access treatment.

Monitoring ethnicity

It’s important that services record a person’s (self-defined) ethnicity so they can have information about alcohol treatment access and outcomes for different ethnic minority groups. Services should make sure they carry out ethnic monitoring consistently. People should be able to choose whether they want their ethnicity to be recorded.

Vulnerable migrants

Most migrants to the UK come to work or study and are young and healthy. However, there are some groups of migrants who may have increased health needs associated with their experiences before, during and after migration.

Section 25.12.3 provides a definition and guidance for working with vulnerable migrants.

25.5.4 Reducing barriers to treatment

Assessing need for alcohol treatment among ethnic minority groups

Commissioners should use census, national and local data, and information from local services on ethnicity and religion to identify which ethnic minority groups in their area are underserved. However, available data will be limited. Commissioners should work with people from under-served ethnic minority groups, including people with lived experience of problem alcohol use and alcohol treatment, when carrying out the needs assessment and the equality impact assessment.

Working in partnership with people from ethnic minority groups and communities

Commissioners and services should have an ongoing partnership with local ethnic minority people and communities because building trust and developing accessible and culturally appropriate interventions takes time. This work requires:

• leadership
• dedicated managerial and staff capacity
• resources for promoting the service in community languages through different media and interpreters

Commissioners and service providers should work with a range of people from local ethnic minority communities to do the needs assessment and improve access to treatment. This includes:

• community organisations
• community leaders
• treatment staff
• people in treatment and their family members
• peer-support organisations

Partnerships should include people and community leaders representing different perspectives within an ethnic minority group or community, including different:

• ages
• sex
• gender identity
• sexual orientation
• abilities
• religions (including people with no religion)

Partnerships can then co-produce:

• a needs assessment
• an understanding of barriers to accessing treatment and what can help people to access it
• interventions to engage and appropriately support people from ethnic minority communities

There is guidance on working with people and communities to reduce health inequalities in the resources section.

Recruiting an ethnically diverse workforce

Services should aim to recruit a workforce at all levels of seniority that is diverse and as representative of local ethnic groups as possible. Staff from ethnic minority groups should be able to contribute to service planning and development. Services should make sure there are equal opportunities for staff from ethnic minority backgrounds, including for:

• training
• supervision
• career development

Working with ethnic minority peer networks

Services should support and work with ethnic minority and faith peer networks, recovery communities and services who understand the needs of their communities. Peer involvement can help to build trust and reduce stigma by providing a range of support including co-delivering community outreach.

Being proactive and flexible in helping people to access the service

Services should help people to access treatment in flexible ways as described in sections 25.4.3 and 25.4.4. They should tailor those principles to meet the needs of the specific ethnic minority groups they are aiming to engage. An example of a flexible, targeted approach to reaching a community is the Under the Influence Recovery Podcast produced by the Sikh Recovery Network and Turning Point (see resources section 25.13 for more details).

Research reports differences among people from ethnic minority groups about how they prefer to seek help. For example, some would prefer to access help through a GP, while others would prefer to access help from their family and would prefer home visits. (Hurcombe and others, 2010). So, services should provide different options.

Reducing language barriers

Language is repeatedly identified as a major barrier to accessing services. Services can do several things to reduce this barrier, including having:

• a service policy for working with interpreters
• resources for trained, independent interpreters and translation services
• a range of formats for communicating information, including video or audio
• basic training for staff in working with interpreters and considerations for practice
• allowing additional time for sessions with interpreters because everything is repeated
• where appropriate, employing staff who can speak community languages

You should avoid translation software because it may not be accurate for describing complex health problems and alcohol treatment needs.

The migrant health guide has useful guidance on language interpretation and translation.

Ensuring confidentiality and anonymity

When reaching out to communities where alcohol is religiously prohibited or there is cultural stigma associated with alcohol problems, services should:

• offer appointments in generic healthcare settings like GP practices or health and wellbeing centres
• offer home visits and online contact
• emphasise confidentiality and anonymity in all their promotional messages

Community awareness raising about alcohol and alcohol treatment

If services think that local ethnic minority communities lack knowledge about alcohol harms and alcohol treatment services, they should offer awareness raising sessions tailored to the needs of these communities. These sessions could be part of broader sessions on health and wellbeing (in person or online) to avoid the stigma associated with alcohol use. Ethnic minority community representatives should be involved in identifying need for community awareness raising, as well as planning and delivering the sessions.

Reducing financial barriers

People from ethnic minority groups are over-represented among those experiencing the highest levels of socioeconomic deprivation, so recommendations in section 25.2.1 may be relevant.

25.5.5 Tailoring treatment for ethnic minority groups

Cultural competence

Research repeatedly shows that treatment services need cultural competence. There is a description of cultural competence in chapter 2 on principles of care.

Organisational cultural competence

Quality governance audits should include equality audits.

Services should make sure their staff receive training and supervision to develop cultural competence.

The culture of the service should feel inclusive to diverse ethnic groups. For example, service arrangements should take account of:

• religious or ethical dietary requirements
• religious requirements such as prayer times
• religious and cultural festivals

Practitioner cultural competence

Practitioner cultural competence includes offering treatment and support that take account of the person’s cultural and faith-based perspectives and experiences but does not make stereotypical assumptions.

Practitioners need skills in building a therapeutic alliance with people from cultures that are different to their own and to be able to reflect on how their own culture and background influences their perspective. Services should support them through training and supervision to challenge unconscious bias that can affect their practice.

Cultural competence can also involve understanding the impact of racism or discrimination on the person’s wellbeing and whether they see this as a factor in their alcohol use.

Diversity within ethnic minority groups

Services and practitioners should recognise the diversity within any ethnic and cultural group. People from the same ethnic, cultural or faith background are diverse and will have different intersecting identities and experiences. These include:

• sex
• gender identity
• age
• sexual orientation
• disabilities
• socioeconomic status

If a person has several intersecting factors that are protected characteristics or are associated with social exclusion, they are likely to experience more discrimination and disadvantage. This can then affect their problem alcohol use, their experience of healthcare, and their individual treatment needs.

Treating the person as an individual

Practitioners should always offer treatment based on understanding the person as an individual and not make assumptions based on their ethnicity or faith. They should tailor interventions to meet the person’s unique needs. Treatment should be based on the principles of care set out in chapter 2, including a non-stigmatising, empathic, trauma-informed approach.

Considering women’s needs

Women who drink harmfully or dependently experience more stigma than men in all communities across British society (Gleeson and others, 2019). In ethnic minority groups where alcohol use is religiously prohibited and culturally unacceptable, women experience additional stigma. This often leads to their drinking being hidden or not discussed, including at times within the family. It also puts women at increased risk of harm if they feel they cannot ask for help. Services should target information for women in those ethnic minority groups, offering free, confidential and discrete support in a women only setting. See resources (in section 25.13) for information about guidance on providing alcohol support for South Asian women.

Adapting psychosocial interventions

There have been no UK-based randomised controlled trials of psychosocial alcohol interventions adapted to meet specific cultural or religious needs. Evaluations of specialist projects contain some examples of adapted interventions (see resources section below). If services want to adapt interventions, they should work with their senior clinical staff and members of ethnic minority groups to develop adaptations.

Working with family members

Some people will not want to involve family in their treatment because of stigma and shame. But where there is consent, services should involve families in supporting the person’s treatment.

In communities where alcohol problems are often not spoken about outside the family, women are more likely to ask about help on behalf of a family member. There may be particular stress on women who usually provide care and support within the family, as well as potential risks like domestic abuse. So, services should make sure women family members can access culturally appropriate support for their own needs. You can read more on working with families in chapter 5 on psychosocial interventions.

Considering specialist projects or services

Commissioners, service providers and community representatives should consider whether specialist projects or services should be commissioned alongside mainstream alcohol treatment services. The limited evidence reports mixed stakeholder views on whether alcohol services designed for people from particular ethnic or faith-based groups, or for people from ethnic minorities in general, would be more helpful than mainstream alcohol treatment services. But the evidence would support local areas considering if it’s appropriate to have a specialist service (Hurcombe and others, 2010; Gleeson and others, 2019).

There are examples of specialist projects for ethnic minority communities in the resources (see section 25.13) below. If there are local specialist services that offer support to people from ethnic minorities with problem alcohol use, alcohol treatment services should work with them. Even where there are local specialist services for ethnic minority groups, mainstream alcohol treatment services should still be culturally competent and provide appropriate treatment for people from ethnic minority groups. People should always have a choice of which service they want to attend and it may be appropriate for them to attend both.

Alcohol treatment service providers can discuss with people from ethnic minority or faith groups whether a dedicated group or activity within the service programme would help meet their needs.

25.6 LGBTQ+ people

25.6.1 Language

LGBTQ+ stands for lesbian, gay, bisexual, transgender, queer (or questioning) and other identities. We realise that there are versions of this acronym that include other sexualities and identities like intersex, asexual and non-binary, but we use LGBTQ+ in this guidance.

25.6.2 Prevalence and harms

Studies of alcohol use in LGBTQ+ populations consistently show higher rates of increasing risk (hazardous) and higher risk (harmful) drinking as defined by the UK chief medical officers’ low risk drinking guidelines.

An analysis of data from the Health Survey for England found that around 7% of lesbian, gay or bisexual adults reported drinking at harmful (higher risk) levels from 2011 to 2018. This was higher than the approximately 4% of heterosexual adults reporting drinking at higher risk. For more information, see Health Survey England Additional Analyses - Health and health-related behaviours of Lesbian, Gay and Bisexual adults

All studies in a review of alcohol use among sexual and gender minority communities in the UK found higher rates of drinking above low risk levels (as defined by UK chief medical officers’ low risk drinking guidelines in LGBTQ+ populations compared to heterosexual or cisgender populations (Meads and others, 2023)).

There is little UK research on alcohol and trans people (Glynn and van den Berg, 2017) but the Trans Mental Health Study 2012 found that 47% of trans people who responded were drinking above low risk levels defined by the UK chief medical officers’ low risk drinking guidelines. About 24% of the heterosexual population and 32% of the lesbian, gay and bisexual population in England drink above low risk levels.

There is a lack of evidence about alcohol related harm among LGBTQ+ people, but because their rates of harmful drinking are higher, they are likely to experience increased health harms compared to the heterosexual population.

There is evidence that lesbian, gay and bisexual people have considerably higher rates of substance misuse, mental illness and higher risk of self-harm and suicide than the heterosexual population (King and others, 2008). Discrimination and prejudice contribute significantly to these higher risk levels.

The Stonewall report LGBT in Britain - Health (2018) found that:

• 1 in 8 lesbian, gay, bisexual and trans (LGBT) people aged 18 to 24 (13%) said they had attempted to take their own life in the last year
• almost half of trans people (46%) had thought about taking their own life in the last year, compared to 31% of lesbian, gay and bisexual people who were not trans
• 41% of non-binary people said they had harmed themselves in the last year, compared to 20% of LGBT women and 12% of gay, bisexual and trans men

Mental health conditions and problem alcohol use commonly occur together (Weaver and others, 2003; Delgadillo and others, 2012) and alcohol is a risk factor for self-harm and suicide (Ledden and others, 2022).

Estimates of prevalence of homelessness and LGBTQ+ people vary widely, but they show that LGBTQ+ people are at higher risk of homelessness than the rest of the population. Census 2021 data of people experiencing homelessness in England and Wales showed that 7.7% of people identifying as homeless also identified as LGBTQ+ (compared to 3.2% of the rest of the population). Young LGBTQ+ people can be particularly at risk of homelessness if their family withdraws support for them.

25.6.3 Considerations for services

Explanations for higher prevalence of problem alcohol use

Explanations for higher prevalence of problem alcohol use among LGBTQ+ people compared to the heterosexual population vary. Two research reports, London Friend’s Out of your mind and the report ‘What are LGBTQ+ people’s experiences of alcohol services in Scotland?’ (Dimova and others, 2022a; Dimova and others, 2022b) identify the following themes.

LGBTQ+ social activities tend to centre on bars and clubs, and this may be the first place LGBTQ+ people explore their sexual and gender identity with others.

Alcohol use has an important role in LGBTQ+ communities and drinking above low risk levels is often the norm.

LGBTQ+ people may use alcohol:

• to boost self-esteem and confidence in social situations
• as an attempt to cope with the stress of discrimination or harassment

Some people see experiences and feelings linked to their LGBTQ+ identity as a cause of their problem alcohol use, and some see other factors as more relevant.

Emotional and physical safety in alcohol treatment services

The same research reports highlight concerns about emotional or physical safety in alcohol treatment services for LGBTQ+ people.

LGBTQ+ people often reported that they:

• anticipated that alcohol treatment services would not be LGBTQ+ inclusive
• experienced or witnessed discrimination based on sexual orientation or gender identity in alcohol treatment services

The research findings on alcohol treatment services are consistent with research on LGBTQ+ people’s experience of wider healthcare services. The Stonewall report LGBT health in Britain found that in the last year before the report:

• 1 in 7 (14%) LGBT people had avoided treatment for fear of discrimination because they are LGBT
• 1 in 8 LGBT people (13%) had experienced some form of unequal treatment from healthcare staff because they are LGBT
• 6% of LGBT people, including 20% of trans people, had witnessed negative or discriminatory remarks about LGBT people from healthcare staff

The Out of your mind report and the report on LGBTQ+ people’s experiences of alcohol services in Scotland found that LGBTQ+ people’s experience of alcohol treatment services was that staff:

• often made assumptions based on heterosexual norms
• did not usually ask about their sexual orientation or gender identity
• were often not aware of aspects of LGBTQ+ experience

They were also concerned that heterosexual and cisgender peers at the service would not be LGBTQ+ inclusive and would judge them negatively or would not understand their experience.

Under-representation of LGBTQ+ in needs assessments

Although there is evidence that LGBTQ+ people are at higher risk of harmful alcohol use, the ‘Out of your mind’ report found that LGBTQ+ people’s alcohol and drugs needs were poorly represented in local needs assessments.

25.6.4 Reducing barriers to treatment

Commissioners and services should work with LGBTQ+ people and organisations to identify their needs as part of their local needs assessment. They should also involve LGBTQ+ people and organisations in planning services to meet their needs. They should consider where different LGBTQ+ people may have separate and distinct needs.

Services should record sexual orientation and gender identity so that commissioners and services can monitor take-up of the service and outcomes for LGBTQ+ people. But people should have the choice whether to have this information recorded.

Service equality, diversity and inclusion policies and processes should explicitly include the needs of LGBTQ+ people.

Commissioners and services should make sure that all staff are trained and culturally competent to work with LGBTQ+ people. The report on LGBTQ+ people’s experiences of alcohol services in Scotland (Dimova and others, 2022a; Dimova and others, 2022b) found that staff were anxious about making mistakes and would welcome training. Training could include:

• improved understanding of LGBTQ+ people’s experiences and their needs in alcohol treatment services
• a particular focus on the experience and needs of trans people because research suggests that staff have particularly low levels of understanding of the experience and needs of trans people and high levels of discrimination
• challenges to stereotypes and assumptions based on heterosexual and gender identity norms
• information about alcohol use among LGBTQ+ populations
• information about higher levels of mental health conditions, self- harm and suicide among LGBTQ+ populations
• appropriate ways to ask people about their sexual orientation and gender identity
• how to discuss if their LGBTQ+ identity is a factor in their alcohol use
• how to challenge discrimination or lack of understanding about LGBTQ+ people in group settings

Services should target promotional messages for LGBTQ+ people (see section 25.4.3) and actively reach out to LGBTQ+ people and communities to support them to engage in alcohol treatment (see section 25.4.4).

Commissioners and services can consider carrying out an LGBTQ+ audit of the alcohol treatment service to find any gaps in inclusive practice and develop a plan to address these. There is an example of an LGBTQ+ audit tool in appendices A to C of the ‘Out of your mind’ report. It includes LGBTQ+ audit tools and guidance for commissioners, services and practitioners.

It may be helpful for services to appoint an LGBTQ+ champion to share information and promote good practice.

25.6.5 Tailoring treatment to meet the needs of LGBTQ+ people

Asking about sexual orientation or gender identity

At initial assessment, practitioners should avoid assumptions about a person’s sexual orientation or gender identity. If the person does not share this information, practitioners should sensitively ask about their sexual orientation or gender identity.

Providing a safe environment

Safe and confidential care is vital for everyone in alcohol treatment services. A significant proportion of LGBTQ+ people identified a need for better safety in alcohol treatment services, as outlined in the ‘Out of your mind’ and ‘What are LGBTQ+ people’s experiences of alcohol services in Scotland?’ reports. So, services and practitioners should take particular care to provide treatment that helps them feel safe. A number of things can contribute to creating a safe environment, including:

• service policies
• service ethos
• inclusive service information
• staff training

It is vital that the therapeutic approach of practitioners establishes a feeling of safety so people can focus on changing their alcohol use. The principles of care set out in chapter 2 including a non-judgemental, empathic and trauma-informed approach are important in developing a therapeutic alliance and a safe therapeutic space.

Personalise treatment and recovery plans

Practitioners should always treat people as unique individuals. Practitioners should not make assumptions about the person’s sexual orientation or gender identity or how these might relate to their problem alcohol use. Treatment and recovery plans should be personalised and developed with the person.

Identifying mental health conditions and assessing risk

Identifying mental health conditions and assessing risk of self-harm and suicide should be a standard part of assessment for everyone in alcohol treatment. Practitioners should be aware of the higher levels of mental health conditions and higher levels of risk for self-harm and suicide among LGBTQ+ people, particularly trans people. There is guidance on assessment, including mental health and self-harm, in chapter 4 on assessment and treatment and recovery planning.

Specialist LGBTQ+ services

There is a lack of research on whether specialist services are more effective for LGBTQ+ people, but the ‘Out of your mind’ report found that respondents were positive about the benefits of a specialist LGBTQ+ service. Many felt it was a safer environment where they felt understood. LGBTQ+ respondents had different views on whether they preferred a specialist service or an inclusive generic alcohol treatment service, but thought there should be options.

Commissioners can consider whether a specialist LGBTQ+ service, working in partnership with the main alcohol treatment service, would be appropriate on a local or a regional level.

Even if there is a local specialist LGBTQ+ alcohol service, general alcohol treatment services should still be inclusive and effective for LGBTQ+ people. This could include offering dedicated LGBTQ+ groups or spaces.

Alcohol-free activities

Since alcohol plays an important role in many LGBTQ+ social settings, people can benefit from the option of LGBTQ+ alcohol-free spaces and activities. Services and practitioners should be aware of local LGBTQ+ peer-based groups and mutual aid groups, and other LGBTQ+ groups that do not involve drinking and support people to access them.

Diversity among LGBTQ+ people

Services and practitioners should recognise the diversity within LGBTQ+ groups. LGBTQ+ people and communities include people with a range of sexual orientations, genders, gender identities and related experiences.

The Stonewall report shows differences in levels of alcohol use, mental health and self-harm between lesbians, bisexual women, bisexual men, gay men and trans women and men (see section 25.6.2). It also shows differences in reports of discrimination in healthcare settings. A notable finding, echoed in other reports, was that trans people have higher levels of alcohol use, mental health conditions and self-harm and suicide than LGBTQ+ people who are not trans.

LGBTQ+ people also have different intersecting identities and experiences that include:

• age
• ethnicity, culture and religion
• disabilities
• socioeconomic status

If a person has several intersecting factors that are protected characteristics or are associated with social exclusion, they are likely to experience more discrimination and disadvantage. This can then affect their problem alcohol use, their experience of healthcare, and their individual treatment needs.

For example, women can benefit from gender specific groups and spaces. Among LGBTQ+ people interviewed for the report ‘What are LGBTQ+ people’s experiences of alcohol services in Scotland?’, lesbians and bisexual women reported more negative reactions in services than bisexual and gay men.

LGBTQ+ people from minority ethnic groups can benefit from support from others who have had similar experiences.

Young LGBTQ+ adults (age 18 to 24) have a particularly high risk of suicide and helping them to access appropriate mental health support and social support including housing is vital.

Services and practitioners should consider all intersecting aspects of a person’s identity and experience.

25.7 Women

25.7.1 Prevalence and harms

The Health Survey for England, 2022 part 1 reported that:

• 4% of women in England were drinking at harmful (higher risk) levels
• 6% of men in England were drinking at harmful (higher risk) levels

The ONS report Alcohol-specific deaths in the UK: registered in 2023 shows there were 3,490 female alcohol-specific deaths (deaths from conditions only caused by alcohol).

Over the last 20 years, female deaths in each of the England, Scotland, Wales and Northern Ireland typically account for around a third of all alcohol-specific deaths.

25.7.2 Considerations for services

Health harms for women

Women experience health harms at lower levels of alcohol consumption than men. The UK chief medical officers’ low risk drinking guidelines advise that the risk of harmful (higher risk) drinking begins at 35 units per week and above for women, and at 50 units per week for men. Chapter 19 on people with co-occurring physical health conditions describes health harms, including the risk of breast cancer in women, which increases at levels as low as 2 units per day.

Multiple disadvantage

Many women using alcohol treatment services experience multiple disadvantage which is made worse by the fact that they also experience it as women. Women in alcohol treatment services are often vulnerable and a high proportion have experienced both childhood and adult trauma, including sexual abuse, sexual exploitation and domestic abuse.

Diversity among women

Women are diverse and have different intersecting identities and experience which contribute to their individual identity, experience including:

• age
• sexual orientation
• ethnicity, culture and religion
• abilities
• socioeconomic status

If a person has several intersecting factors, they are likely to experience more discrimination and disadvantage. This can then affect their alcohol problem and their experience of healthcare, and their individual treatment needs will vary.

Pregnancy

Alcohol use, especially harmful or dependent alcohol use, poses significant risks to the pregnant woman and fetus. Alcohol treatment services should prioritise treatment for pregnant women and women in the perinatal period.

You should read the guidance on pregnancy and perinatal care in chapter 24.

Women as parents and carers

Women are more often responsible for childcare than men. Services and practitioners should consider the needs of parents or carers when planning services and developing individual treatment and recovery plans. There is guidance on working with parents in alcohol treatment in chapter 26.

25.7.3 Reducing barriers to treatment

Commissioning and planning services

Commissioners and services should consider the needs of women as part of equality impact assessment processes when carrying out a needs assessment and planning services. They should involve:

• women with lived experience of alcohol dependence and alcohol treatment
• women working in alcohol treatment services
• local specialist organisations for women, including those working with women experiencing multiple disadvantage

The distinct needs of different groups of women should be considered in the assessment taking into account differences in:

• age
• sexual orientation
• gender identity
• abilities
• socioeconomic status
• women who are parents and carers and those who are not

A gender sensitive non-stigmatising approach

Research shows that stigma experienced by people with alcohol problems in society is greater for women than for men (Schober and Annis, 1996). Feelings of shame and anticipation of stigma from services are barriers to women accessing treatment (Thom, 1987).

Services and practitioners should provide:

• a non-stigmatising service culture that treats women with dignity and respect
• service information with positive strengths-based images and messages targeted at women (you can find more information on taking a strengths-based approach in section 2.2.7)
• practitioners with non-judgemental, empathic attitudes who show they understand the impact of stigma on women

Services and practitioners trained to work with domestic abuse

Current or recent domestic abuse can be a barrier to women accessing treatment, because the perpetrator, or fear of the perpetrator can prevent the woman from attending.

If the service knows the woman is experiencing or at risk of domestic abuse, they should check whether the woman feels safe coming to the service site or whether alternative arrangements are needed. For example, the service could offer an assessment at a domestic abuse service if the woman is attending one.

If the perpetrator is attending the local alcohol treatment service, the service should arrange for the woman to be seen by another service, or at least on a separate site in a completely confidential setting.

Services and practitioners should be trained to work with women experiencing domestic abuse. There is guidance on working with victims and perpetrators of domestic abuse in chapter 22.

Parent friendly services

Women can feel anxious and receive conflicting messages, where they are labelled bad mothers because of their alcohol use. But they also experience barriers to treatment like lack of childcare and fear of losing their children to social services (Peralta and Jauk, 2011).

Services and practitioners should offer:

• a non-judgemental and empathic approach to mothers with alcohol problems
• appointment times to take account of childcare responsibilities
• access to appropriate childcare or flexibility so the woman can arrange childcare
• transparent information about safeguarding responsibilities, confidentiality and information sharing

There is guidance on working with parents in chapter 26.

Reducing financial barriers

Women in treatment may have fewer financial resources than men in treatment.

Services should:

• make it clear the service is free in their promotional literature
• be geographically accessible so transport costs are not too much
• consider offering support with transport costs
• provide information on how the service can provide access to individualised employment support

Reaching women who are unlikely to approach alcohol treatment services

Services should follow the guidance in section 25.4.3 on promoting the service and section 25.4.4 on reaching people. They should use these approaches with women, including specific groups of women who are less likely to approach services. For example, section 25.5.4 and 25.5.5 has advice on reducing barriers for women in some ethnic minority groups affected by cultural norms that particularly stigmatise women who drink or have alcohol problems.

Chapter 9 on assertive outreach and a multi-agency team around the person provides guidance on working with people who experience multiple disadvantage.

25.7.4 Tailoring treatment for women

Gender responsive service culture

Being gender-responsive means creating an environment that reflects an understanding of the realities of the lives of women and responds to their strengths and challenges (Covington and Bloom, 2007).

The service should understand and acknowledge that gender makes a difference to some of the causes of people’s alcohol problems and to their alcohol treatment needs. For example, there should be an organisational understanding of how women experience safety, or lack of it, and barriers they can experience in mixed gender environments.

Women only services and spaces

Some women will feel intimidated by mixed gender services, where there are normally more men than women. Women who have experienced traumatic abuse from men may not feel physically or emotionally safe in mixed gender alcohol treatment services.

Services should:

• be in locations that reduce physical risks (such as being well–lit, accessible through open streets not narrow alleys or subways and well-staffed)
• increase emotional safety by offering women only groups or spaces where women can share aspects of their experience as women in an environment that is free from mixed gender dynamics
• based on individual assessment, provide the option of women-only residential treatment
• promote a culture where women are supported to report any sexual harassment they experience at the service
• consider offering women only services

A gender sensitive trauma-informed approach

A high proportion of women with alcohol dependence have experienced trauma including:

• childhood abuse (emotional, physical or sexual)
• adult abuse including domestic abuse, sexual violence or exploitation

Services and practitioners should take a trauma-informed approach, which takes account of the kind of trauma women are more likely to experience than men. Women are more likely than men to experience abuse from people they are in relationship with, which erodes trust in relationships.

For women who have experienced multiple traumas, it is likely to take time to build trust. Practitioners should be trained and supervised to develop a therapeutic alliance using a trauma-informed approach.

A personalised treatment and recovery plan

Each woman should be at the centre of her own care. The practitioner should work with her to develop a treatment and recovery plan that addresses her unique personal goals and needs and not make assumptions based on her gender or other aspects of her identity.

For women who have experienced trauma, at an appropriate stage in the woman’s treatment, the multidisciplinary team should consider with the woman whether a referral to a specialist psychological service for post-traumatic stress is appropriate.

There is guidance on treatment and recovery planning in chapter 4.

Working in partnership with organisations that work with women and women’s issues

Services should have pathways with local women’s organisations and practitioners should support women to access relevant organisations. This should include support to access women-only mutual aid and peer-based recovery support.

A strengths-based approach

Women with alcohol dependence who have experienced abuse and multiple disadvantage often have very low self-esteem. A strengths-based approach can help to gradually build confidence and a belief in their ability to change. Support from women peers who are further on in recovery can also show that change is possible.

Health assessment and harm reduction advice for women

Since women experience health harms at lower levels of alcohol consumption than men, it is important that alcohol services provide them with information on health harms, including the increased risk of breast cancer.

Services should provide information about the risks of drinking during pregnancy to any woman who could become pregnant.

The healthcare assessment offered by the service should include information on sexual health and contraception and signposting to sexual health services. Women should be able to access pregnancy tests at the alcohol treatment service and signposting for counselling if they are considering a termination.

Chapter 19 provides guidance on physical health harms and chapter 8 provides guidance on harm reduction.

Working with women during pregnancy and the year after birth

Alcohol treatment services should prioritise treatment for pregnant women because harmful drinking and alcohol dependence are associated with risk of harm to the mother and the fetus. The service should:

• ensure pregnant women drinking harmfully, or who have alcohol dependence are assessed without any delay and treated by a competent alcohol specialist clinician with input from an obstetrician (see section 10.6.4 in chapter 10 on pharmacological interventions)
• help pregnant women to access specialist antenatal care and perinatal care after the birth of the baby
• contribute to a multi-agency response to safeguarding the fetus, and after birth the baby, and support the mother throughout
• consider home visits in the weeks or months after the birth

Alcohol treatment services should be aware that the year after birth can be a challenging time for women who are at higher risk of return to problematic drinking, mental health problems and death. Services should continue to prioritise support for the woman and work with other services involved with the woman and her baby.

Alcohol treatment services should be aware that a woman who loses a child through death or removal into care is at increased risk of return to problematic drinking as well as at increased risk of mental health problems and suicide. They should continue to offer support to the woman.

There is guidance on pregnancy and perinatal care in chapter 24.

Supporting women to gain education and employment skills

Education, training and meaningful employment are important aspects of recovery and services should support women to access education, training and employment if they want this. Financial independence provides increased opportunities for women to be autonomous. If women are parents or carers, employment support should be tailored around their childcare responsibilities.

25.8 Older people

This section summarises the main points for reducing barriers and tailoring treatment for older people in alcohol treatment. The Royal College of Psychiatrists (RCPsych) report Our invisible addicts provides detailed guidance on working with older people with alcohol and drug problems.

25.8.1 Prevalence and harms

Throughout the UK, the evidence is that older age groups  are more likely than other age groups to exceed the ‘UK chief medical officers’ low risk drinking guidelines’.

The age groups that had the highest proportion of people drinking 14 units and over each week (increasing (hazardous) or higher risk (harmful) drinking) were:

• 55 to 64 years in England and Scotland (from the Health Survey for England, 2022 part 1 and The Scottish Health Survey 2022 - volume 1: main report)
• 45 to 64 years in Wales (from the National Survey for Wales: adult lifestyles by age and gender, 2020 to 2021 onwards)
• 45 to 54 years in Northern Ireland (from the Health Survey Northern Ireland: first results 2023 to 2024)

Alcohol use and associated harm is increasing more among people between 65 and 74 in England, Scotland and Wales, and between those aged 60 and 75 in Northern Ireland, than in any other age group (IAS, 2020).

The Adult Psychiatric Morbidity Survey 2014 shows that between 2007 and 2014 in England, overall levels of harmful and dependent drinking remained stable but trends varied between age groups. Harmful drinking became less common among 16 to 24 year olds (6.2% in 2007, 4.2% in 2014), but more common in 55 to 64 year olds (1.4% in 2007, 2.8% in 2014).

The ONS report Alcohol-specific deaths in the UK: registered in 2023 shows 61% of alcohol-specific deaths were of people over 55 years old. It also found 53% of alcohol-specific deaths were of people aged 55 to 75 years (premature deaths).

25.8.2 Considerations for services

Age sensitive treatment

The RCPsych report ‘Our invisible addicts’ notes that the ageing process makes people more susceptible and at risk of the physical and mental health harms caused by alcohol.

They are also more likely to:

• have other mental health conditions
• have other physical health conditions
• be taking medication that can interact negatively with alcohol, by reducing or compounding its effects

This means it is very important to identify older people who are drinking harmfully or dependently and offer them age sensitive treatment.

Conditions associated with ageing

Older people are particularly likely to be vulnerable to alcohol related brain damage (RCPsych, 2018).

Alcohol use in later life can exacerbate or accelerate the start of conditions that are associated with ageing, such as:

• cognitive impairment
• high blood pressure
• imbalance
• increased risk of falls and injuries, particularly when a person is also taking prescription or over the counter medication

Harmful and dependent alcohol use can lead to greater bone density loss for post-menopausal women and alcohol may worsen feelings of anxiety and depression that are related to hormonal fluctuations (Hannan and others, 2000).

Alcohol use in older adults

The ‘Evaluation of the Drink Wise, Age Well programme’, available at the Professional resources page on the Drink Wise, Age Well website, notes that older adults who drink alcohol harmfully or dependently fall broadly into 3 categories. They are people who have:

• continued their previously unproblematic use into older age, but age-related changes in metabolism have resulted in harms later in life
• had problem alcohol use for many years
• developed problem alcohol use as older adults

People with a long history of problem alcohol use which persists into later life often have a number of comorbidities and health conditions associated with ageing. These people may have had previous unsuccessful experiences of treatment and be reluctant to try again. The majority of older people experiencing alcohol harm are in this group.

For people who developed problem alcohol use as older adults, this is usually associated with difficult life transitions such as retirement, bereavement or loss of sense of purpose (Holley-Moore and Beach, 2015).

Psychosocial factors such as social isolation, financial problems, life events, pain and insomnia also have strong associations with problem alcohol use in older adults (RCPsych, 2018).

Agism and age discrimination

A study of drinking in older people (Wadd and others, 2017) found:

• examples of ageism and age discrimination in the alcohol sector
• several residential treatment services did not accept people over a certain age

25.8.3 Reducing barriers to treatment

Including age in equality impact assessments

Commissioners and services should include actions to address inequalities based on age in their impact assessments. Older people with lived experience and organisations working with older people should contribute to the equality impact assessment, service design, planning and where possible, delivery.

Making sure referral criteria are not based on age alone

Commissioners, community alcohol treatment services and residential treatment services should all make sure that decisions about referring a person, and accepting a person for community or residential treatment, are based on whether the person can benefit from the service, and whether the service can meet their treatment needs, not on age alone. Age is a protected characteristic under the Equality Act 2010 (see section 25.2.3).

Raising awareness about alcohol use and older people among relevant organisations

Professionals in health and social care services often are not aware of alcohol harm among older people and do not identify their problem alcohol use. There is also evidence that healthcare professionals are more likely to refer older people with problem alcohol use for clinical management of alcohol harms such as rehydration or vitamin supplementation, or general community or residential care rather than referring them for alcohol treatment to make changes in their alcohol use. This can be based on an assumption (wrongly) that older people cannot make changes in their alcohol use (Wadd and others, 2017).

Alcohol treatment services should work with local organisations for older people, such as Age UK, and broader health and social care services including those targeted at older people to:

• raise awareness among staff of the increasing level of problem alcohol use in older people and how to recognise signs of an alcohol problem
• promote routine screening of older people in health and social care services using a validated tool such as the alcohol use disorders identification test (AUDIT) (see chapter 3 on identification and brief interventions)
• agree and review pathways between services so older people can be easily referred for alcohol treatment

Barriers related to attitudes and awareness of older people

Older people may be less willing to approach services than other adults because they are:

• particularly concerned about stigma and feel asking for help is shameful
• reluctant to try again after previous unsuccessful experiences of treatment
• unaware of treatment services

Approaches for promoting the service (see section 25.4.3) and flexible processes for engagement (see section 25.4.4) targeted to the needs of older people are important to attract and encourage them into treatment.

Adapting screening thresholds

Services that carry out alcohol screening should have a lower threshold for referring older adults into alcohol treatment because they are likely to experience harm at lower levels of consumption than other adults. Referral criteria for alcohol treatment services should take account of the fact that older people can need treatment at lower levels of consumption.

Staff training and support to challenge ageism

Service policies and training for staff should challenge beliefs about older people that can act as a barrier to them accessing treatment. For example, some professionals might believe that it is too late for older people to change, even though there is evidence that older people achieve better alcohol treatment outcomes than younger adults (Oslin and others, 2002).

Disability reasonable adjustments

Older people who are frail or physically disabled may need reasonable adjustments so they can access services and receive appropriate support if they have sensory disabilities. Even where people do not have disabilities, there are simple adjustments that can help older people such as:

• having higher chairs that make it easier to get up from
• offering appointments on the ground floor to avoid stairs
• having toilets nearby

If older people are unable to access the service site, services should provide home visits.

Avoiding busy waiting rooms

Busy waiting rooms in alcohol and drug treatment services where most people are younger can feel stressful for older people. Services should find ways of managing this. For example, they can offer appointments for older people at designated ‘quiet’ times or at alternative sites.

25.8.4 Tailoring treatment for older people

Referral

At referral, practitioners should ask if there are any disability adjustments the person needs so they can access and make use of the service, for example full disabled access or large print information. Services should invite carers and family members to the assessment, with the person’s consent.

Age sensitive assessments

To make age sensitive assessments of older people’s needs, you should consider the following.

Assessment of dependence

The RCPsych report ‘Our invisible addicts’ advises that the standard criteria for assessing alcohol dependence were developed in younger people, so the assessor should bear this in mind. Where possible, a geriatrician and a specialist in old age psychiatry should contribute to the assessment as well as the alcohol treatment specialist.

Physical and mental health and cognitive function

Physical health and mental health assessment, and screening for alcohol related brain damage as part of a comprehensive assessment, are particularly important for older people. They are at higher risk of alcohol-related and other physical and mental health problems including anxiety and depression and alcohol related brain damage.

There is guidance on comprehensive assessment in chapter 4 on assessment and treatment and recovery planning.

Alcohol treatment services should routinely carry out a brief cognitive assessment, such as the mini Addenbrooke’s Cognitive Examination (mini ACE) or Montreal Cognitive Assessment (MoCA). If this brief assessment shows possible cognitive decline, the person should be referred for a specialist neuropsychological assessment. This is particularly important for older adults because they are at higher risk of alcohol related brain damage and cognitive decline from other conditions.

There is guidance on alcohol related brain damage including on adapting interventions in chapter 20.

Other needs to consider

Other areas that may be particularly important to consider when assessing and planning treatment and recovery for older people include:

• diet and nutrition
• risk of dehydration
• safety in their home such as fire and trip hazards
• social networks and community support
• drink driving risks (see annex 2 for guidance on fitness to drive)
• adult safeguarding concerns
• mental capacity to make the decision in question (see glossary)

More frequent re-assessment

It is particularly important to review assessments frequently and if there is a change in the person’s circumstances. This is because older people often have multiple health conditions and there can be quite rapid changes in physical health, mental health, cognitive function and day to day functioning. Support and care needs may change quite rapidly.

Multi-agency assessments and treatment and recovery planning

Older people can have several health and social care needs, so it is important to work with other professionals who are supporting the person, to co-ordinate care and to integrate or align care plans. It is often important to consult with specialists who work with older people. There is guidance on multi-agency treatment and recovery planning in section 4.10.4 in chapter 4. It is also often helpful to involve family members or carers with the consent of the person.

Practitioners developing treatment and recovery plans with the person should identify any age-related motivating factors such as maintaining independence and improvements in memory, sleep and energy levels.

Psychosocial interventions and recovery support

Length and frequency of sessions may need to be adapted to the older person’s individual needs.

When planning and providing psychosocial interventions, practitioners should consider issues that can affect older people including:

• difficult life transitions such as retirement
• bereavement
• loss of former capacities
• serious illness
• loss of sense of purpose
• social isolation

A focus on day-to-day functioning and on social support may be helpful.

Social isolation can be a problem in older age, so helping people to access peer networks and recovery organisations, including peer activities designed for older people is important.

A strengths-based approach is important. Practitioners should work with older people to find and access other activities that will promote independence, long term resilience and recovery. For example, older people often have experience and skills they can offer as volunteers or peer supporters. They may also want to take part in community-based social activities, education or part-time employment. National Institute for Health and Care Excellence (NICE) guideline Older people: independence and mental wellbeing (NG32) provides guidance on identifying older people most at risk of a decline in their independence and mental wellbeing and suggests a range of activities.

Pharmacological interventions

When assessing for and providing pharmacological interventions, the clinician needs to consider age related adjustments. You should read the guidance on prescribing for medically assisted withdrawal and for relapse prevention in section 10.6.2 in chapter 10 on pharmacological interventions.

Older people often take (and may misuse) prescribed and over the counter medications where alcohol can interact negatively and cause adverse effects. So, the clinician should make sure they have information on all medicines and substances the person is taking. They should also consider the impact of the person’s alcohol use, all their medications and any illicit substances on the pharmacological interventions they offer (RCPsych, 2018).

Age specific support

Evidence suggests that older people can achieve good outcomes from standard treatment and that age specific treatment may produce even better outcomes (RCPsych, 2018). Older people respond well to age specific groups and peer-based support, so services should offer these where possible. It may be helpful for older peer support workers to introduce these groups and accompany the person to them initially.

25.9 People with disabilities and reasonable adjustments

Under the Equality Act 2010, organisations in England, Scotland and Wales have a legal duty to make changes in their approach or provision to ensure that services are as accessible to disabled people as they are for everybody else.

Health and social care organisations must make reasonable adjustments to ensure that disabled people are not disadvantaged.

Details of reasonable adjustments a person requires should be clearly noted and flagged in their record on the service case management system. Wherever possible, a practitioner should ask for information about adjustments required at the referral stage, so they know this before the first appointment.

In England, the Reasonable adjustment flag is included in the national care record. The digital flag shows a person needs extra support and may include details about their disabilities or conditions and necessary adjustments.

25.10 People with learning disabilities

25.10.1 Definition of learning disability

Mencap defines learning disability as a “reduced intellectual ability and difficulty with everyday activities – for example household tasks, socialising or managing money – which affects someone for their whole life”. They highlight that “people with a learning disability tend to take longer to learn and may need support to develop new skills, understand complicated information and interact with other people”.

25.10.2 Prevalence and harms

There is a lack of evidence on the prevalence of harmful drinking or alcohol dependence in people with learning disabilities. People with profound learning disabilities have limited opportunities to consume alcohol problematically. However, people with mild learning disabilities and living independently in the community may be vulnerable to problem use.

Some evidence suggests that prevalence of harmful drinking in people with learning disabilities may be lower than the general population. But this may be an underestimate because prevalence estimates are normally based on people with learning disabilities who are already in in specialist services (Robertson and others, 2000; Reis and others, 2017).

There is some evidence that larger proportions of adolescents with mild learning disabilities are abstinent, but young men who begin to drink are at an increased risk for intoxication and subsequent at-risk behaviours (Reis and others, 2017).

There is no evidence available on alcohol-specific deaths among people with learning disabilities.

People with learning disabilities are at increased risk of several health conditions compared to the general population including:

• epilepsy
• gastro-oesophageal reflux disease
• some cancers
• accidents
• nutritional problems

Harmful alcohol use can make these conditions worse (Williams and others, 2018).

People with learning disabilities have an increased risk of mental health conditions, which harmful alcohol use can also make worse.

25.10.3 Considerations for services

Health and health inequalities

People with learning disabilities have poorer health compared to the general population as well as poorer access to NHS services. People with learning disabilities have an increased risk of several physical and mental health conditions. But there is also evidence that they have high levels of unmet health need and a higher risk of avoidable medical causes of death (Michael, 2008).

Possible reasons for vulnerability to alcohol use

Research found people with learning disabilities described the main reasons for using alcohol and other drugs was to self-medicate against life’s negative experiences (Taggart, 2008). These negative experiences included:

• psychological trauma caused by bereavement or abuse
• social distance from their community
• isolation
• loneliness

Other studies have identified peer pressure and low self-esteem as risk factors for alcohol use (Reis and others, 2017).

Identifying people with learning disabilities

People with mild learning disabilities have not always been formally diagnosed with a learning disability and may be difficult to identify in alcohol services. For some people, their disability can co-exist with alcohol related brain damage. Screening for cognitive impairment as part of comprehensive assessment in alcohol treatment services can help services identify people with learning disabilities. There is guidance on screening for cognitive impairment in section 4.9.10.

Adult safeguarding

People with mild learning disabilities living in the community can be victims of exploitation and abuse, so services should consider adult safeguarding needs as part of assessment.

25.10.4 Reducing barriers to access services

Commissioning and service planning

People with learning disabilities and the organisations that work with them should be involved in equality impact processes as part of needs assessment for alcohol treatment services. Services should also involve people with learning disabilities and relevant support organisations in service planning, so that their needs can be met.

The National Development Team for Inclusion’s Green Light Toolkit helps mental health services to effectively support people with learning disabilities and is relevant for alcohol treatment services. This has been designed for services in England, but the content could be relevant for other UK nations too.

Staff training and support

Staff in alcohol treatment services should be trained to be sensitive to, and aware of, the specific needs of people with learning disabilities. They should also be trained to know about human rights and the Equality Act. Services should provide staff with clinical support and supervision to help them work effectively with people with learning disabilities.

Services can consider creating roles for staff who are specifically trained and supervised to enable them to work with people with learning disabilities.

Working with learning disability services

Alcohol and learning disability services should work together to develop and maintain pathways between services. They should also raise awareness of problem alcohol use and alcohol services with local groups for people with learning disabilities. Learning disability services, family members, carers and advocates can all play an important role in identifying problem alcohol use among people with learning disabilities and should be an important part of the referral into alcohol services.

Easy read information

Services should promote themselves in ways that are accessible and meaningful to people with learning disabilities, such as providing information in easy read formats. There are some examples of easy read booklets on alcohol use in the resources section.

Involving family and carers in helping people access treatment

Many people with formally identified learning disabilities are supported by family or professional carers to a greater or lesser extent. With the person’s consent, services should encourage family members or carers to help the person access and remain engaged with services and provide information and support to family members.

Learning disability champions

Alcohol services should consider having learning disability champions who can:

• work with local learning disability services
• share expertise with alcohol service staff
• co-ordinate adaptations, such as providing easy read or video versions of psychoeducational interventions
• arrange training on alcohol for learning disability staff, and training on learning disability for alcohol treatment service staff

25.10.5 Tailoring treatment for people with learning disabilities

Involving family or professional carers in treatment

As well as helping people to access treatment, with the person’s consent, family members or professional carers can be involved in their treatment, for example supporting them between sessions to remember and work towards their agreed alcohol use goals, or goals in other areas of their life. There is guidance on involving family members and offering them support in their own right in section 5.6.6 in chapter 5 on psychosocial interventions.

Highlighting reasonable adjustments at referral

Services should ask the referrer or the person about any disabilities they have at referral stage. And if the person has a learning disability or literacy difficulties, they should put a note on the referral record. This will help the assessor to make any reasonable adjustments before the assessment and from that point on.

Screening for cognitive impairment

Screening for cognitive impairment should be a routine part of comprehensive assessment for alcohol treatment. But screening is particularly important if the assessor thinks the person has a learning disability or the person tells the assessor that they have one.

If screening shows there may be cognitive impairment, the assessor should refer the person for a more specialist cognitive assessment or occupational therapy-led functional assessment and support them to access this.

Health assessment

A health assessment should be a part of comprehensive assessment for all people in alcohol treatment. People with learning disabilities have an increased risk of several physical health and mental health conditions.

NICE quality standard Learning disability: behaviour that challenges (QS101) recommends that GPs should provide an annual learning disability health check. Clinicians in alcohol treatment services can help people to access this health check if they are not supported by specialist services to do so. This is important because there is evidence of high unmet health needs and avoidable deaths in people with learning disabilities (Michael, 2008).

People with literacy and numeracy difficulties

Many people in the general population will have literacy or numeracy difficulties and many of the adjustments for people with learning disabilities are relevant for those people as well.

Personalised treatment and recovery plan that includes strengths

The practitioner should work with the person (and their family or carer where appropriate) to develop a personalised treatment and recovery plan that the person can understand. The plan should recognise strengths as well as needs and include interventions that support appropriate independence and new opportunities. Longer term recovery goals are important and people with learning disabilities should be supported to access volunteering or employment if they want this. In some areas there are specialist employment projects for people with learning disabilities.

People with learning disabilities can experience social isolation and loneliness. Peer led networks and recovery organisations can be a supportive environment offering social connection. The person may also benefit from involvement in community projects, including specific projects for people with learning disabilities.

Individual sessions

People with learning disabilities may not all benefit from group work, so services should make sure that they have the option of individual work with keyworkers.

Understanding behaviour that staff experience as challenging

People with learning disabilities may not be able to express their feelings easily in words and this can make it difficult to accurately assess their problem alcohol use. For some people with learning disabilities, difficulties in expressing feelings in words can lead to behaviour that staff experience as challenging. A person’s apparent lack of co-operation may be due to a lack of understanding or communication difficulties rather than a lack of motivation to engage in treatment. Services should be flexible in how they recognise and respond to these needs.

Adjusting length and number of sessions

People with learning difficulties are likely to find face to face appointments easier than online appointments.

Services should consider adjusting the length and number of sessions to take account of varying levels of understanding and need. Practitioners might need extra time to do assessments and plan interventions, but it may be more useful to carry out assessments and treatment planning over several shorter but more frequent sessions than they normally would.

When providing psychoeducational interventions, practitioners will often need to repeat information and exercises, particularly when there is more than a week between sessions. They will also often need to recap the coping skills the person has been practising.

Focus on behaviour

Practitioners should consider focusing less on cognitive elements and more on behavioural elements of psychosocial interventions.

Breaking down questions

Practitioners should break down questions with multiple components and ask each element one at a time.

Accessible resources

Practitioners should use accessible resources that the person can take away with them, which can include:

• easy read formats
• audio and video recordings

They can use visual prompts and pictures to help explain important concepts. They can also adapt mapping techniques. You can read more about mapping techniques in Routes to recovery from substance addiction.

The person with learning disabilities can also use audio or video as an alternative to a written drink diary or to record thoughts and feelings instead of writing them down.

Mental capacity to make the decision in question

People with learning disabilities should be able to make decisions about their own lives as far as possible. So, when a practitioner is working with people with learning disabilities, if they have a proper reason to believe that the person lacks capacity to make the decision in question, the practitioner will need to carry out a capacity assessment.

There should be clinical support for practitioners to make decisions about mental capacity, such as assessing a person’s capacity to make the decision in question and making best interests decisions. There is information on mental capacity legislation and statutory guidance in annex 1.

All staff should be trained so they fully understand their responsibilities under mental capacity legislation.

Safeguarding

People with learning disabilities can be vulnerable to exploitation. For example, they can:

• be financially abused
• be coerced into sex work
• be working in the drug trade
• have their homes taken over for selling drugs
• experience harassment

Some people with learning disabilities and mental health conditions can be at risk due to self-neglect. Practitioners should be aware of this when conducting risk assessments and they must follow the relevant legislation, guidance and organisational guidelines on adult safeguarding. There is information on adult safeguarding legislation and guidance in annex 1.

Consultation or clinical supervision

Alcohol service staff should have working agreements with services for people with learning disabilities. They should consult specialist staff for advice on making appropriate adjustments, and where possible access clinical supervision, for work with people with learning disabilities. In turn, staff from alcohol treatment services can offer consultation, and where possible clinical supervision, to services for people with learning disabilities working with people with problem alcohol use.

25.11 Autism and attention deficit hyperactivity disorder

Autism and attention deficit hyperactivity disorder (ADHD) are neurodevelopmental conditions that affect the development of brain function and can lead to significant difficulties with everyday activities. Appropriate support and environmental adjustments can help to mitigate these impacts.

Autism and ADHD often co-occur. Some research suggests around 40% of autistic people also have ADHD (Rong and others, 2021) and 20% to 50% of people with ADHD are also autistic (Van de Meer and others, 2012).

25.11.1 Defining autism and ADHD

Autism

Autism is a lifelong condition that affects how people perceive the world and communicate and interact with others. Autistic people experience differences in social interactions, sensory processing and information interpretation. They may also demonstrate different behavioural preferences, such as a need for routines and behaviours that regulate sensory experiences. Autism affects people to varying degrees so some people will require more help and support than others.

ADHD

ADHD is a condition that affects people’s experience of the world and sometimes their behaviour. It is defined by the World Health Organization as a persistent pattern of inattention or hyperactivity-impulsivity that has a direct negative impact on academic, occupational or social functioning. NICE estimates that 3% to 4% of adults and 5% of children and young people have ADHD.

Symptoms of ADHD involve a person’s ability to pay attention to things (being inattentive), having high energy levels (being hyperactive) and ability to control impulses (being impulsive). ADHD affects people in different ways and to varying degrees so some people will require more help and support than others.

25.11.1 Problem alcohol use and harms among people with autism and ADHD

Problem alcohol use among autistic people is under-researched and recent estimates of prevalence vary widely. A recent evidence review (Barber and others, 2025) estimated the prevalence of alcohol use disorders (AUD) among autistic people including an estimated:

• 1.6% in large population registers (including population health registers, insurance registers)
• 16.1% in clinical populations (for example, people in alcohol services and autism services)

By comparison, the most recent estimate of higher risk drinking AUD in England is 4.8% of the general population. The evidence review concludes that overall, autistic people may be at somewhat lower risk than the general population for developing AUD. However, the authors note that co-occurring conditions such as ADHD and anxiety put autistic people at increased risk for AUD. They also note that autistic people may turn to alcohol to manage sensory processing differences or for greater confidence in social interactions.

There is limited research into the relationship between ADHD and alcohol use specifically, with most research focusing on the link between ADHD and substance use more broadly.

One piece of research (Luderer and others, 2021) found that:

• people with ADHD are at increased risk of AUD due to impulsive decision making
• ADHD was present in up to 20% of people seeking treatment for AUD
• co-occurring ADHD in people with AUD is under-recognised and undertreated
• symptoms of ADHD and alcohol use in adolescence mutually affect the severity of the other, potentially increasing the impact of ADHD symptoms and the risk of developing AUD
• adults with ADHD and AUD are associated with increased severity of both conditions, several other conditions and worse treatment outcomes

25.11.2 Considerations for working with autistic people and people with ADHD

Making reasonable adjustments and adaptations to treatment

This guidance on autism and ADHD is not about providing specialist support for these conditions. People who need support for autism and ADHD should have access to a service or clinician with expertise in those conditions.

This guidance (in section 25.11) is a brief summary of reasonable adjustments and adaptations alcohol treatment services can make to reduce barriers for autistic people and people with ADHD in accessing alcohol treatment and adapting interventions. There is more information in the resource section.

Staff training, supervision and support

Staff in alcohol treatment services should be trained to have a broad understanding of autism and ADHD, including up-to-date evidence on the likely risk factors that contribute to AUD in both groups. Training should also include information about appropriate adjustments and adaptations they should consider. It should also build awareness of the risks of additional co-occurring mental health difficulties, including increased risk of suicide, among autistic people and people with ADHD. Practitioners should have supervision and support from a multidisciplinary team or a senior clinician.

The National confidential enquiry into suicide and safety in mental health annual report 2024 suggests clinicians may require specific training to recognise and support autistic people and people with ADHD. It also recommends that clinicians are aware of the high rates of suicide-related internet use among autistic people before suicide. Due to their increased risk of suicide and suicidal thoughts, the Suicide prevention strategy for England: 2023 to 2028 includes autistic people as a priority group for providing tailored and targeted support.

Alcohol treatment practitioners can also consult a specialist autism or ADHD team for advice on supporting people with these conditions in the alcohol treatment service. Services should make sure staff are aware of local services with specialist expertise in autism and ADHD.

Co-occurring autism and ADHD with mental health conditions and suicide risk

Although autism and ADHD are different conditions, they have some features in common and the 2 often co-occur. Also, autistic people and people with ADHD are significantly more likely to have co-occurring mental health conditions than the general population.

An evidence review estimated that 1 in 4 autistic people are affected by an anxiety disorder at any given time and 42% experience an anxiety disorder in their lifetime (Hollocks and others, 2019). Rates of depression are similarly high. Autistic people are also around 3 times more likely to die by suicide, with greater risk for autistic women (Santomauro and others, 2024; Kirby and others, 2019).

Evidence shows that mental health conditions and ADHD often co-occur (Kessler and others, 2006). Other evidence (Chen and others, 2018) describes a number of psychiatric conditions that are over 9 times more likely in adults with ADHD than those without ADHD.

Mothers with ADHD are at increased risk for both depression and anxiety disorders after birth. And this group are 5 times more likely to be diagnosed with either an anxiety or depressive disorder during that period (Andersson and others, 2023). Adults with ADHD are known to be 5 times more likely to attempt suicide, with 1 in 4 women with ADHD attempting suicide (Fuller-Thompson and others, 2020).

A review of studies on the association between ADHD and self-harm (Allely, 2014) found evidence to support that ADHD is a potential risk factor for self-harm in adults and children. The author noted the limitations of the studies involved in the review and recommended more research in this area.

Undiagnosed autism and ADHD

Clinicians often mistake autism and ADHD for other conditions, so misdiagnose people with autism and ADHD. Adults are more likely to be undiagnosed or misdiagnosed than children and this is also the case for more women than men. Girls are more likely to be undiagnosed or misdiagnosed than boys (O’Nions and others, 2023; Luderer and others, 2021).

If the keyworker thinks that the person might be autistic or have ADHD, they should refer the person to an appropriate clinician. This could be someone from either the alcohol treatment service or a mental health service. The clinician can then refer the person for assessment if clinically indicated.

25.11.3 Reducing barriers to access treatment

Involving autistic people and people with ADHD

Commissioners and service providers should involve autistic people and people with ADHD in the local needs assessment and in planning and delivering the service, so they can advise on appropriate adjustments and adaptations. Service providers can also consult national and local peer support and advocacy organisations for autistic people and people with ADHD when planning and delivering their service.

See section 25.4.1 for guidance on involving people in the needs assessment and service plans.

Making reasonable adjustments at referral stage

It is important to make reasonable adjustments to reduce barriers based on each person’s individual needs. If you know that the person is autistic or has ADHD when they are referred to the alcohol treatment service, you should:

• ask what adjustments might help them navigate the care pathway, such as attending appointments and communicating with the service
• clearly document any adjustments made and highlight this information in their notes
• make sure these adjustments are in place before the first appointment because the person’s first experience of the service will be a significant factor in whether they continue to attend

The NHS England guidance meeting the needs of autistic adults in mental health services provides information about reasonable adjustments and examples of these.

Many of the adjustments that can help autistic people and people with ADHD to engage with a service can also be helpful to other people accessing that service. For example, making information about the service accessible and available in multiple formats.

Adjusting the environment

Autistic people can experience extreme sensitivity to sights, sounds and smells, which can be overwhelming, distressing and can deter them from approaching services. People with ADHD can also find environments with lots of stimulation distracting and overwhelming.

So, you should consider how you could reduce sensory stimulation or manage it in the waiting room and therapy room, to reduce the risk of the person becoming overstimulated and overwhelmed. If you cannot adapt the waiting room sufficiently, you should identify a designated quiet waiting space or an alternative setting in case it is needed. These should be calm, quiet spaces with low light, comfortable seating and minimal objects in the room and on the walls.

Providing information in an appropriate way

Autistic people and people with ADHD often process information differently, which can make it harder to remember or act on information provided by services. Autistic people and people with ADHD can also find new and unfamiliar environments and situations anxiety provoking, which can become a barrier to them engaging with services.

You can adjust for this by providing clear, concise and specific written information about what to expect from the service and the first appointment (as a minimum) in advance. You should provide this in hard copy, not only digitally.

It is often helpful to supplement this written information with visual representations of important information, such as:

• a map showing where the service is located and how to get there if possible
• pictures of relevant rooms in the service
• pictures of staff the person will be meeting

You can also consider creating a web-based access guide for your service through AccessAble.

Make sure to include details like:

• how long the session will last
• what you expect the person attending to do and say
• who they can contact to discuss reasonable adjustments to help them access the service

It is also important to stick to communicated schedules and timings, particularly for autistic people, who may experience distress if there are last-minute changes to plans.

People with ADHD may benefit from appointment reminders. These could be by text, email or phone, or a combination. Discuss the person’s individual needs with them.

Informing people that they can attend with someone to support them

Make it clear that the person can be accompanied by a family member, friend or advocate at the initial appointment and throughout their time at the service.

25.11.4 Tailoring treatment

Discuss adjustments and adaptations at assessment

If the referral describes that the person is autistic, or has ADHD, and sets out their adjustment needs, it is helpful to:

• check in with the person to ensure that the adjustments they requested have been put in place and these needs met (so far)
• ask if they need any change to their adjustments, or any additional adjustments, to help them engage effectively with the service

If the person says they are autistic, or have ADHD, at the assessment appointment, you should:

• discuss whether there are any adjustments or adaptions that would help them engage with the service and interventions
• ensure any adjustments or adaptions are clearly documented and highlighted in their notes
• provide information on their next appointment in line with these adjustments, to the best of your ability
• check in with the person at their next appointment, to ensure their access needs are being met

If it’s not possible to meet their adjustment needs immediately, agree how this will be done, for example by following up in writing.

Once these adjustments are in place, it is important to review them regularly throughout the time the person is in treatment to make sure their needs are still being met. Autistic people and those with ADHD can find it difficult to communicate additional requests or the need for change unless invited to.

Involving other services that the person is working with

If the person is receiving specialist support for autism, ADHD or co-occurring mental health conditions, with the person’s consent, involve the practitioner they are working with in their assessment, treatment and recovery planning so care plans can be aligned. Seek advice from specialist services where needed.

Involving people in developing their treatment and recovery plan

Involve the person in developing their individual treatment and recovery plan and make it clear that adaptions can be made throughout the process.

Offering flexibility around length of treatment and appointments

Autistic people and people with ADHD may need longer in treatment than average. It may take time for them to form a relationship with the practitioner, and for the practitioner to understand and adapt to how the person presents, and their communication style.

Offer flexibility around appointments. Autistic people and people with ADHD may prefer:

• longer appointments to provide extra time for the person to process information or for movement breaks
• shorter appointments for those who find social interaction tiring or find it difficult to sustain their attention

Discuss with the person what they would prefer and check periodically if this is still working for them.

Understanding the person’s communication style and adapting your communication

Ask the person about how they prefer to communicate and adapt communication as far as possible to meet those needs. It may be helpful to:

• provide a written summary of the session for the person
• allow time for the person, or someone accompanying them, to make notes
• have someone accompany them to the appointment, who can also listen and retain information
• recap the main points at the end of the session to support understanding and retention
• consider using diagrams or visual symbols as these can be easier to understand or remember
• use clear, direct and unambiguous language
• ask specific questions and be clear what information you are asking for
• avoid using jargon or metaphors
• check for mutual understanding between the keyworker and the person

Discuss with the person what they would prefer and check regularly if this is still working for them.

Being aware of an increased risk of suicide among autistic people and people with ADHD

Be aware that autistic people and people with ADHD are at higher risk of self-harm and suicide (see section 25.11.2).

You can find guidance on working with autistic people, including managing increased risk of suicide, in the resources section.

Accessing peer support

Provide information about local peer support groups and national resources for autistic people and people with ADHD and help people to use these groups and resources.

Autism peer support workers can also offer support to autistic people. These roles are for autistic people to provide support to other autistic people who are experiencing health difficulties, based on their own lived experience of autism. You can find more information on the skills and capabilities required at Autism Peer Support.

Peer support can help to reduce social isolation and help people learn about how others manage their condition.

Structured recreational activity

Where this is acceptable to the person, encourage them to take part in some form of structured activity involving their interests as this may act as a distraction from alcohol and enable the person to meet other people.

If the person does not feel comfortable or able to join a group activity, some individual structured recreational activity can still be helpful. For example, physical exercise may help people with ADHD to meet other people and channel their energy.

If it’s acceptable to the autistic person or person with ADHD to attend group activities, peer support for people with lived experience of problem alcohol can be helpful. Even if there are no other members with neurodiverse conditions, they may experience peer support as inclusive.

Tailored employment support

Individualised, employment support that includes people with neurodiverse conditions can help autistic people and people with ADHD to:

• find employment that is suited to their strengths and needs and navigate the process of applying for and starting work
• help those in employment, and their employers, understand what reasonable adjustments to remove disadvantages that autistic people, or people with ADHD, may experience at work

It is a legal requirement for employers to make reasonable adjustments, under the Equality Act 2010.

Involving family members, friends or advocates

Ask people if and how they would like family members, friends or an advocate to be involved in their treatment. Provide information for family members in line with the person’s preferences.

Pharmacological interventions

If alcohol treatment for autistic people or people with ADHD involves pharmacological interventions, these should be provided by an experienced specialist clinician who is aware of specific considerations when prescribing for people with these conditions.

25.12 Specific groups experiencing multiple disadvantage

25.12.1 Inclusion health groups

Inclusion health groups is a term used to describe specific groups of socially excluded people likely to experience multiple disadvantage. These groups experience barriers that prevent them accessing healthcare and lead to extremely poor health outcomes. People from these groups are often unaccounted for in health records.

A systematic review of ill health and deaths in several inclusion health groups found very high levels of physical and mental ill health and much lower average age of deaths compared to the general population (Aldridge and others, 2018).

Inclusion health includes any population group who is socially excluded. People with problem alcohol and drug use can be considered an inclusion health group. Within the broader group of people with problem alcohol use, some people experience particularly high levels of social exclusion. This includes but is not limited to:

• people experiencing homelessness
• vulnerable migrants
• Gypsy, Roma and Traveller (GRT) groups
• sex workers
• people in contact with the criminal justice system
• victims of modern slavery

25.12.2 Reducing barriers to services for inclusion health groups

Alcohol treatment services have expertise in working with people with multiple disadvantage who are socially excluded and can extend this expertise so they can meet the needs of specific inclusion health groups.

Section 25.2.2 provides guidance on working with people and groups experiencing multiple disadvantage.

Services and practitioners should follow the guidance Inclusion health: applying All Our Health. It provides information to help frontline health and care staff, managers and strategic leaders to improve access and health outcomes for inclusion health groups. It includes resources for working with several inclusion health groups.

25.12.3 Vulnerable migrants

Vulnerable migrants living in the UK

Groups of vulnerable migrants living in the UK include:

• asylum seekers and refugees
• unaccompanied children
• people who have been trafficked
• undocumented migrants (people who are living in the UK with no legal status)
• low paid migrant workers

Vulnerable migrants experience barriers to accessing services, related to their life circumstances and their immigration status.

The migrant health guide provides comprehensive guidance on working with vulnerable migrant groups.

Treatment needs of vulnerable migrants

Most migrants to the UK come to work or study and are young and healthy. However, there are some groups of migrants who may have increased health needs associated with their experiences before, during and after migration.

The migrant health guide says that practitioners should be “alert to whether a migrant is subject to vulnerability and be particularly vigilant for potential physical and mental health problems in those who are vulnerable”.

You can find advice and guidance on the mental health needs of vulnerable migrants on the mental health page of the migrant health guide.

Entitlement to care

It is essential that alcohol treatment service providers and practitioners are aware of vulnerable migrants’ entitlements to NHS care so they can access the care they need. There is different guidance for each UK country, which you can find at:

• NHS entitlements: migrant health guide (England)
• Healthcare for overseas visitors: immigration health surcharge (Scotland)
• Overseas visitors and the NHS (Wales)
• Entitlement to NHS services and first time registration (Northern Ireland)

Practitioners may need to advocate for people to access primary care.

Alcohol treatment services and practitioners in England should be aware of guidance NHS cost recovery - overseas visitors. This explains that community drug and alcohol treatment services (which it calls a “first point of contact service”) are free to overseas visitors, regardless of immigration status, if the providers consider that the services they provide are equivalent services to primary medical services.

Supporting vulnerable migrants to access services

To help vulnerable migrants access treatment, services will likely need access to independent interpreters. Treatment staff also need training to work with the interpreters. Services should follow guidance on interpretation and translation when working with vulnerable migrants.

Vulnerable migrants will be unfamiliar with UK healthcare systems and unaware of alcohol treatment services. Services need to work with relevant local support organisations to promote the service and arrange access where appropriate.

25.12.4 Gypsy, Roma and Traveller groups

Data on alcohol use

Specific data on alcohol use among people from GRT backgrounds in the UK is not currently available. It is also not currently possible to measure alcohol-related ill health in GRT populations because the ethnicity classifications for GRT groups are not included in hospital statistics data.

There is health data available that shows high levels of health inequality in GRT groups in the UK.

Life expectancy

The House of Commons Women and Equalities Committee report Tackling inequalities faced by Gypsy, Roma and Traveller communities found that people in GRT communities have life expectancies of between 10 and 12 years shorter than the general population.

Mental health

Friends, Families and Travellers’ Focus report on Gypsy, Roma and Traveller communities found they are nearly 3 times more likely to be anxious than others, and just over twice as likely to be depressed.

The Traveller Movement’s Policy briefing addressing mental health and suicide among Gypsy, Roma and Traveller communities in England reports that in Ireland, the Irish Traveller suicide rate is 6 to 7 times higher than the general population and that anecdotal evidence shows disproportionately high rates of suicide in GRT communities in England.

Reducing barriers to treatment

The ONS report Gypsies and Travellers in England and Wales: lived experiences found evidence of difficulty accessing healthcare as outlined in the sections below.

Registering with a GP

Gypsies and Travellers in England and Wales described challenges in registering with a GP surgery without a fixed address, particularly among people living in Gypsy and Traveller sites or on the roadside. This can result in delays in diagnosis and treatment.

It is essential that alcohol treatment service providers and practitioners are aware that people can access primary care without a fixed address or proof of immigration status. Practitioners may need to advocate for people from GRT communities to access primary care. You can find more about this in chapter 15 on primary care and community health services and in the resources section below.

Lack of trust in services based on experiences of discrimination in healthcare

The ONS study found that anticipation and experiences of discrimination and derogatory attitudes of healthcare staff led to concerns among participants about the likelihood of receiving help and fears of facing negative judgement or discrimination.

If there are GRT communities in a local area, the alcohol treatment commissioners and services should work with local organisations representing those communities to identify any need for alcohol treatment and design a plan with them to reach out to those communities. If there are no local organisations, services can consult national organisations representing GRT groups (see resources section below).

Low levels of literacy and lack of information

The ONS study found that low levels of literacy in GRT communities and lack of information about services also create barriers to accessing healthcare.

Stigma and shame about problem alcohol use

Telling our own stories: an exploratory study of alcohol use and harm by people who identify as Roma, Gypsies and Travellers found that people in GRT communities considered it shameful to have an alcohol problem and ask for help from a service. This is a barrier to them accessing treatment.

Since there is shame and stigma about alcohol problems, it might be helpful for the alcohol treatment service to work with any generic healthcare services who are reaching out to GRT communities. They can then provide information on alcohol harms and on alcohol treatment services as part of a broader approach to health. Information should be tailored to people with low literacy levels. It is important to stress that services are confidential.

It could be helpful to have a dedicated practitioner who is allocated time to build up a relationship with members of local GRT communities. All staff need to be culturally competent and to have knowledge about the culture of GRT communities and the discrimination and health inequalities they face.

25.13 Resources

Working with people and communities

Health and wellbeing: a guide to community-centred approaches outlines evidence-based community-centred approaches to health and wellbeing, including community engagement service planning and co-production projects.

NHS England’s Working in partnership with people and communities: statutory guidance supports effective partnership working between people and communities to improve services.

The Health equity assessment tool (HEAT) provides resources and e-learning to support systematic action on health inequalities and equalities.

The Alcohol Change UK report Exploring communities of belonging around drink looks at how being a member of a ‘community of belonging’ affects drinking behaviour and engagement with services. It also asks if it is possible to reduce drinking and maintain your links with your original community of belonging. It focuses on Polish, South Asian and LGBTQ+ communities across Yorkshire and the Humber in rural and urban settings.

Ethnic minority groups

The Sikh Recovery Network and Turning Point has produced a number of videos of their Under the Influence Recovery Podcast You can find them by searching YouTube for ‘under the influence recovery podcast’. The podcast involves culturally sensitive conversations about recovery.

Culture, connection and belonging: a study of addiction and recovery in Nottingham’s BAME community reports on qualitative findings from research exploring the experiences of people from ethnic minority backgrounds who face severe and multiple disadvantage. The study also examines BAC-IN, a peer-led, culturally sensitive drug and alcohol recovery support service, and compares it with other services.

The Alcohol Change UK resource Supporting solutions for South Asian women: Developing models for alcohol support, contains:

• a study that focuses on the lived experiences of South Asian women who use alcohol and other drugs, exploring their problematic use, and their engagement with support
• ‘Supporting South Asian women with problematic substance use: policy and practice guidance’, which includes a tool for improving existing alcohol treatment services
• ‘Alcohol, Izzat and me: South Asian women in recovery’, which focuses on the experiences of 18 women from South Asian communities in the UK

Minority Communities Addiction Support Services is a Scottish charity that helps and supports people and their families affected by addiction issues in minority communities. They provide services in Glasgow and the surrounding areas.

The Alcohol Change UK report Understanding the association between mental health and alcohol use in minority ethnic communities looks at how the association between mental health and alcohol use varies between ethnic groups.

Women

The report ‘Understanding domestic abuse interventions for women experiencing multiple disadvantage’ is a report that is part of the Evaluation of the Changing Futures programme. It looks at what domestic abuse interventions work for women experiencing multiple disadvantage.

Older people

The Professional resources page on the Drink Wise, Age Well website presents the research, recommendations and advice developed through the Drink Wise, Age Well programme, which took place between 2015 and 2020 across the UK. The programme aimed to:

• challenge stereotypes of drinking and older people
• raise awareness about alcohol use and harms in older people
• reach more hidden older drinkers
• deliver interventions that focus on building resilience and social connection

People with learning disabilities

Substance misuse in people with learning disabilities: reasonable adjustments guidance summarises the resources that can be used by health professionals, social care staff and families to support people with learning disabilities and substance misuse problems.

Easy health provides easy-read information on alcohol. Registration is free.

Autism and ADHD

The National Autistic Society Good practice guide aims to help mental health professionals adapt talking therapies for autistic adults and children. The guide describes simple adjustments and adaptations which can make a huge difference. It includes advice on what services can do to improve the experience of autistic people, and suggestions for therapy sessions.

The Sensory-friendly resource pack outlines projects commissioned by NHS England in a resource pack for local health systems to use to support autistic children, young people and adults and prevent mental health crisis.

The Royal College of Psychiatrists has produced an online resource Autism and mental health, which explains what autism is, how it is diagnosed and what care autistic people with mental health problems are entitled to. It is aimed at autistic adults and their family and carers but may also be helpful for younger people. The information may also be useful for clinicians working with autistic people.

The British Psychological Association guidance Working with autism provides best practice guidance for practitioner psychologists who work with autistic people and their families and carers.

NHS resources for working with autistic people

Future NHS resources are for anyone working in health and social care across the UK. To access the resources, you will need to create a free account (by following the instructions on the website).

The website has guidance on working with autistic people, which supports NHS England guidance Staying safe from suicide. It also includes guidance on reasonable adjustments that services should make when working with autistic people. Many of these adjustments will also be relevant for people with ADHD.

Inclusion health groups

The Inclusion health audit tool is an online tool designed to help organisations in the voluntary, community and social enterprise sector audit their engagement with inclusion health groups to help address health inequalities.

GP access cards for England, Scotland, and Wales provide information about the right to access a GP that people can show to GP surgeries.

The Alcohol Change UK report Telling our own stories: an exploratory study of alcohol use and harm by people who identify as Roma, Gypsies and Travellers is based on a study of alcohol use and harm among four diverse ethnic and cultural groups who had a background of nomadism, using community based participatory research methods.

Friends, Families and Travellers developed a guide for tackling health inequalities in Gypsy, Roma and Traveller communities, which is based on the experiences and knowledge of staff, volunteers and people from GRT communities.

Improving Roma health: a guide for health and care professionals supports health and care professionals to improve services by better understanding the health outcomes that some people in the Roma community face.

25.14 References

Aldridge RW, Story A, Hwang SW, Nordentoft M, Luchenski SA, Hartwell G, Tweed EJ, Lewer D, Vittal Katikireddi S and Hayward AC. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. Lancet 2018: volume 391, issue 10117, pages 241 to 250.

Andersson A, Garcia-Argibay M, Viktorin A, Laura Ghirardi L, Butwicka A, Skoglund C, Bang Madsen K, D’onofrio M, Lichtenstein P, Tuvblad C and Larsson H. Depression and anxiety disorders during the postpartum period in women diagnosed with attention deficit hyperactivity disorder. Journal of affective disorders 2023: volume 325, pages 817 to 823.

Allely C. The association of ADHD symptoms to self-harm behaviours: a systematic PRISMA review. BMC Psychiatry 2014: volume 14, article 133.

Bahla N, Caezard G, Ward HJT, Bansai N and Bhopal R on behalf of the Scottish Health and Ethnicity Linkage Study (SHELS) Collaboration. Ethnic variations in liver and alcohol related disease hospitalisations and mortality: the Scottish health and ethnicity linkage study. Alcohol and Alcoholism 2016: volume 51, issue 5, pages 593 to 601 (registration and subscription required for full article).

Barber W, Aslan B, Meynen T, Marsden J, Chamberlain SR, Paleri V and Sinclair JMA. Alcohol use among populations with autism spectrum disorder: narrative systematic review. British Journal of Psychiatry Open 2025: volume 11, issue 1, article e15.

Bayley M and Hurcombe R. Drinking patterns and alcohol service provision for different ethnic groups in the UK: a review of the literature. Ethnicity and Inequalities in Health and Social Care 2011: volume 3, issue 4, pages 6 to 17 (registration and subscription required for full article).

Bramley G, Fitzpatrick S and Sosenko F. Hard Edges Scotland full report. Heriot-Watt University 2019: pages 44 to 47.

Carew AM, Cafferty S, Long J, Bellerose D and Lyons S. Travellers accessing addiction services in Ireland (2007 to 2010): analysis of routine surveillance data. Journal of Ethnicity in Substance Abuse 2013: volume 12, issue 4, pages 339 to 355 (registration and subscription required for full article).

Chen Q, Hartman C, Haavik J, Harro J, Klungsøyr K, Hegvik T-A, Wanders R, Ottosen C, Dalsgaard S, Faraone S and Larsson H. Common psychiatric and metabolic comorbidity of adult attention-deficit/hyperactivity disorder: a population-based cross-sectional study PLOS One 2018: volume 13, issue 9.

Covington SS and Bloom BE. Gender-responsive treatment and services in correctional settings. Women and Therapy 2007: volume 29, issue 3 to 4, pages 9 to 33 (registration and subscription required for full article).

Delgadillo J, Godfrey C, Gilbody S and Payne S. Depression, anxiety and comorbid substance use: association patterns in outpatient addictions treatment. Mental Health and Substance Use 2012: volume 6, issue 1 (registration and subscription required for full article).

Dimova E, O’Brien R, Elliott L, Frankis J and Emslie C. What are LGBTQ+ people’s experiences of alcohol services in Scotland? A qualitative study of service users and service providers (PDF, 3.1MB). Scottish Health Action on Alcohol Problems, 2022a.

Dimova E, O’Brien R, Elliott L, Frankis J and Emslie C. Exploring the experiences of alcohol service use among LGBTQ+ people in Scotland: a qualitative study. International Journal of Drug Policy 2022b, volume 109, article 103859.

Douds AC, Cox MA, Iqbal TH and Cooper BT. Ethnic differences in cirrhosis of the liver in a British city: alcoholic cirrhosis in South Asian men. Alcohol and Alcoholism 2003: volume 38, issue 2, pages 148 to 150 (registration and subscription required for full article).

Drummond C, Oyefeso A, Phillips T, Cheeta S, Deluca P, Perryman K, Winfield H, Jenner J, Cobain K, Galea S, Saunders V, Fuller T, Pappalardo D, Baker O and Christoupoulos A. Alcohol needs assessment research project (ANARP). Department of Health, 2004.

Fuller-Thomson E, Nahar Riviere R, Carrique L and Agbeyaka S. The dark side of ADHD: factors associated with suicide attempts among those with ADHD in a national representative Canadian sample. Archives of Suicide Research 2020: volume 26, issue 3, pages 1,122 to 1,140 (registration and subscription required for full article).

Galvani S, Manders G, Wadd S and Chaudhry S. Developing a community alcohol support package: an exploratory study with a Punjabi Sikh community. University of Bedfordshire and the Tilda Goldberg Centre for Social Work and Social Care, 2013.

Galvani S, Fox S, Guru S and Khan N. Keep it to yourself’ Supporting solutions for South Asian women: developing models for alcohol support. Manchester Metropolitan University, 2023.

Gleeson H, Thom B, Bayley M and McQuarrie T. Rapid evidence review: drinking problems and interventions in black and minority ethnic communities. Alcohol Change UK, 2019.

Glynn TR and van den Berg JJ. A systematic review of interventions to reduce problematic substance use among transgender individuals: a call to action. Transgender Health 2017: volume 2, issue 1, pages 45 to 59.

Hannan MT, Felson DT, Dawson-Hughes B, Tucker KL, Cupples LA, Wilson PWF and Kiel DP. Risk factors for longitudinal bone loss in elderly men and women: the Framingham osteoporosis study. Journal of Bone and Mineral Research 2000: volume 15, issue 4, pages 710 to 720.

Herring R, Gleeson H and Bayley M. Exploring pathways through and beyond alcohol treatment among Polish women and men in a London Borough. Alcohol Change UK, 2019.

Holley-Moore G and Beach B. Drink Wise, Age Well: alcohol use and the over 50s in the UK (PDF, 1.7MB). Drink Wise, Age Well, 2015.

Hollocks M, Lerh JW, Magiati I, Meister- Stedman R and Brugha T. Anxiety and depression in adults with autism spectrum disorder: a systematic review and meta-analysis Psychological Medicine 2018: volume 49, issue 4.

Hurcombe R, Bayley M and Goodman A. Ethnicity and alcohol: a review of the UK literature. Joseph Rowntree Foundation, 2010.

Institute of Alcohol Studies. Alcohol through the life course: older drinkers. IAS, 2020.

Kessler R, Adler L, Barkley R, Beiderman J, Conners C, Demler O, Faraone S, Greenhill L, Howes M, Secnik K, Spencer T, Bedirhan Ustun T and Walters E. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. American Journal of Psychiatry 2006: volume 163, issue 4.

King M, Semlyen J, See Tai S, Killaspy H, Osborn D, Popelyuk D and Nazareth I. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry 2008: volume 8, article number 70.

Kirby AV, Bakian AV, Zhang Y, Bilder DA, Keeshin BR and Coon H. A 20-year study of suicide death in a statewide autism population. Autism Research 2019: volume 12, issue 4, pages 658 to 666.

Ledden S, Moran P, Osburn D and Pitman A. Alcohol use and its association with suicide attempt, suicidal thoughts and non-suicidal self-harm in two successive, nationally representative English household samples. British Journal of Psychiatry Open 2022: volume 8, issue 6, article e192.

Luderer M, Quiroga J, Faraone S, Zhang-James Y and Reif A. Alcohol use disorders and ADHD. Neuroscience and Biobehavioural Reviews 2021: volume 128, pages 648 to 660.

Meads C, Zeeman L, Sherriff N and Aranda K. Prevalence of alcohol use amongst sexual and gender minority (LGBTQ+) communities in the UK: a systematic scoping review. Alcohol and Alcoholism 2023: volume 58, issue 4, pages 346 to 356.

Michael J and the independent inquiry into access to healthcare for people with learning disabilities. Healthcare for all: report of the independent inquiry into access to healthcare for people with learning disabilities (National Archives). Department of Health, 2008.

O’Nions E, Petersen I, Buckman J, Charlton R, Cooper C, Corbett A, Happe F, Manthorpe J, Richards M, Saunders R, Zanker C, Mandy W. Autism in England: assessing underdiagnosis in a population-based cohort study of prospectively collected primary care data. The Lancet Regional Health - Europe 2023: volume 29, article 100626.

Oslin DW, Pettinati H and Volpicelli JR. Alcoholism treatment adherence: older age predicts better adherence and drinking outcomes. The American Journal of Geriatric Psychiatry 2002: volume 10, issue 6, pages 740 to 747 (registration and subscription required for full article).

Peralta RL and Jauk D. A brief feminist review and critique of the sociology of alcohol‐use and substance‐abuse treatment approaches. Sociology Compass 2011: volume 5, issue 10, pages 882 to 897 (registration and subscription required for full article).

Pryce R, Buykx P, Gray L, Stone A, Drummond C and Brennan A. Estimates of alcohol dependence in England based on APMS 2014, including estimates of children living in a household with an adult with alcohol dependence: prevalence, trends, and amenability to treatment. University of Sheffield, 2017.

Rehm J, Allamani A, Elekes Z, Jakubczyk A, Manthey J, Probst C, Struzzo P, Della Vedova R, Gual A and Wojnar M. Alcohol dependence and treatment utilization in Europe – a representative cross-sectional study in primary care. BMC Family Practice 2015: volume 16, article number 90.

Reis O, Wetzel B and Häßler F. Mild or borderline intellectual disability as a risk for alcohol consumption in adolescents – a matched-pair study. Research in Developmental Disabilities 2017: volume 63, pages 132 to 141 (registration and subscription required for full article).

Robertson J, Emerson E, Gregory N, Hatton C, Turner S, Kessissoglou S and Hallam A. Lifestyle related risk factors for poor health in residential settings for people with intellectual disabilities. Research in Developmental Disabilities 2000: volume 21, issue 6, pages 469 to 486.

Rong Y, Yang C-J, Jin Y and Wang Y. Prevalence of attention-deficit/hyperactivity disorder in individuals with autism spectrum disorder: a meta-analysis. Research in autistic spectrum disorders 2021: volume 83, article 101759.

Royal College of Psychiatrists. Our invisible addicts (2nd edition), College Report CR211. RCPsych, 2018.

Schober R and Annis HM. Barriers to help-seeking for change in drinking: a gender-focused review of the literature. Addictive Behaviors 1996: volume 21, issue 1, pages 81 to 92 (registration and subscription required for full article).

Santomauro D, Hedley D, Sahin E, Brughan T, Naghavi M, Vos T, Whiteford H, Ferrari A and Stokes M. The global burden of suicide mortality among people on the autism spectrum: a systematic review, meta-analysis, and extension of estimates from the Global Burden of Disease Study 2021. Psychiatry Research 2024: volume 341, article 116150.

Taggart L. An exploration of psychosocial risk factors of hazardous alcohol use in people with learning disabilities. School of Nursing, University of Ulster, Northern Ireland, 2008.

Thom B. Sex differences in help‐seeking for alcohol problems—2. Entry into treatment. British Journal of Addiction 1987: volume 82, issue 9, pages 989 to 997.

Van de Meer J, Oerlemans A, van Steijn D, Lappenschaar M, de Sonneville L, Buitelaar J, Nanda and Rommelse N. Are autism spectrum disorder and attention-deficit/hyperactivity disorder different manifestations of one overarching disorder? Cognitive and symptom evidence from a clinical and population-based sample. Journal of the American Academy of Child and Adolescent Psychiatry 2012: volume 51, issue 11, pages 1,160 to 1,172.

Wadd S, Holley-Moore G, Riaz A and Jones R. Calling time: addressing ageism and age discrimination in alcohol policy, practice and research (PDF, 1.78MB). Drink Wise, Age Well, 2017.

Weaver T, Madden P, Charles V, Stimson G, Renton A, Tyrer P, Barnes T, Bench C, Middleton H, Wright N, Paterson S, Shanahan W, Seivewright N and Ford C. Comorbidity of substance misuse and mental illness in community mental health and substance misuse services. The British Journal of Psychiatry 2003: volume 183, issue 4, pages 304 to 313.

Williams F, Kouimtsidis C and Baldacchino A. Alcohol use disorders in people with intellectual disability. British Journal of Psychiatry Advances 2018: volume 24, issue 4, pages 264 to 272.