5. Psychosocial interventions

How to provide evidence-based psychosocial interventions for people with alcohol problems. It covers formulation to identify appropriate psychosocial interventions for the person, structured support, psychological treatments and interventions for family members.

5.1 Main points

Psychosocial interventions are an essential part of treatment for everyone. They should always take place in the context of a broader personalised treatment and recovery plan.

Psychosocial interventions include effective psychological treatments and structured support. These evidence-based practices should be underpinned by a positive therapeutic alliance.

Structured support involves using specific psychosocial interventions which are common to evidence-based psychological treatments for alcohol and drug use. These common factors include:

a strong therapeutic alliance
session structure and goal direction
interventions to develop alternative rewards and activities to alcohol use
engagement with social networks that are recovery-oriented
building self-efficacy and coping skills to maintain abstinence or low risk drinking

Structured support is generally delivered in community alcohol treatment services by a keyworker.

Services should offer formal psychological treatments focused specifically on alcohol-related cognitions, behaviour, problems and social networks according to individual need. Formal psychological treatments include:

cognitive behavioural therapies
behavioural therapies
social network and environment-based therapies

These treatments are generally provided by a specialist member of the multidisciplinary team (MDT), alongside a keyworker who provides structured support.

The assessment and formulation determine the choice of psychosocial intervention. Formulation is a framework for understanding information gathered in the assessment. It helps the person to make sense of their situation and informs treatment and recovery planning.

Practitioners need to monitor interventions to see it they are effective, and if they are ineffective, they should adjust them based on a revised formulation agreed with the person.

A person’s involvement with treatment services is part of a treatment and recovery journey that extends beyond treatment and sits within a recovery-oriented system of care.

Recovery can be thought of as a journey. Treatment and recovery services can support people through engagement, behaviour change and early recovery with the formulation determining the selection of interventions to support this process.

The intensity of support practitioners offer should be based on the severity of the person’s alcohol dependence and any co-occurring complex needs. Most people can receive appropriate support in the community, but inpatient or residential services may be required for those with the most severe and complex needs.

Peer support and mutual aid have been found to be effective in supporting recovery. Practitioners should support people to engage with these groups and organisations throughout their recovery journey, during their time in treatment and once they have left structured treatment.

Practitioner competence affects the effectiveness of psychosocial interventions. Services should provide training and clinical supervision to all practitioners in the interventions they provide. Practitioners will need varying levels of specialist training depending on whether they deliver structured support or formal psychological treatments. Supervisors should be trained in supervision and trained in the psychosocial interventions they are overseeing.

5.2 Introduction

This chapter describes how practitioners can deliver psychosocial interventions for harmful drinking and alcohol dependence, consisting of structured support and formal psychological treatments. It focuses on how practitioners can develop personalised treatment and recovery interventions based on assessment, formulation and working with the person, and where appropriate, their family.

This chapter focuses on psychosocial interventions provided as part of structured treatment.

See chapter 4 on assessment, treatment and recovery planning for the context in which practitioners deliver these psychosocial interventions.

People with alcohol dependence often have complex needs or experience multiple disadvantage and some people will need more flexible approaches to engagement and delivering these interventions. For example, see:

chapter 8 on harm reduction
chapter 9 on assertive outreach
chapter 21 on people experiencing homelessness

Some people require more specialist approaches that focus on alcohol dependence and co-occurring conditions.

For example, see:

chapter 18 on co-occurring mental health conditions
chapter 20 on people with alcohol related brain damage

You can find guidance on targeting and tailoring psychosocial interventions to meet needs related to culture or identity in chapter 25 on developing inclusive services (with guidance on tailoring Interventions to specific cultural needs).

5.2.1 Aims of psychosocial interventions

Psychosocial interventions are used to support people to:

initiate and sustain changes in their alcohol use, including abstinence, low risk drinking (see definition of low risk drinking in the glossary) and reducing harm
maintain engagement with pharmacological interventions
address social or psychological issues that are contributing to, or made worse by alcohol use
prevent a return to problematic alcohol use
build recovery resources and strengths to sustain long-term change

5.2.2 Principles of care

You should read this chapter with chapter 2, which provides more detail on the principles of care that are essential to delivering alcohol treatment. These principles are the basis for this chapter and are vital for delivering psychosocial interventions.

There is evidence that the approach and style of delivering alcohol treatment is equally (if not more) important than the specific content of the interventions (Ashton and Witton, 2004 to 2006). There is more about this in the National Institute for Health and Care Excellence (NICE) clinical guideline Patient experience in adult NHS services: improving the experience of care for people using adult NHS services (CG138).

The following principles of care are vital to establishing a therapeutic alliance between the practitioner and the person and for agreeing a personalised treatment and recovery plan. They should inform the service ethos and the approach of individual practitioners providing psychosocial interventions.

Build a trusting relationship, and work in a supportive, empathic, and transparent way.
Respect the person’s confidentiality, privacy and dignity.
Understand how stigma and discrimination associated with alcohol use can affect how the person comes into treatment, their self-esteem and their ability to acknowledge the full impact of their dependence.
Work in a trauma-informed way (see section 2.2.8 in chapter 2 on principles of care).
Work in a culturally competent way (see section 2.3.2 in chapter 2 on principles of care).

5.3 A framework for delivering psychosocial interventions

5.3.1 Framework overview for delivering psychosocial interventions

A framework for delivering psychosocial interventions shows the context for an effective personalised treatment and recovery plan.

Treatment takes place within a broader recovery-oriented system of care. It starts with engaging a person with an assessment of their treatment and recovery needs. An allocated keyworker is essential to build and maintain a therapeutic relationship, while providing structured support to the person to enable them to overcome their problem alcohol use and work towards long term recovery. Keyworking takes place throughout a person’s treatment journey.

There are 3 main phases to this journey, which are:

assessment, formulation and engagement
behaviour change, which includes interventions tailored to severity of dependence (mild, moderate or severe) and complexity of need (including mental health, physical health, other drug use and social factors)
early recovery, which includes interventions to maintain behaviour change and build the foundations of longer-term recovery

Assessment and formulation include a person’s physical and mental health and social needs and assessing and managing complexity continues throughout the treatment and recovery journey.

You can find more information on each of the phases in section 5.3.3.

5.3.2 Delivering psychosocial interventions in a recovery-oriented system of care

This chapter focuses on psychosocial interventions which are delivered by practitioners. However, this is just one element within a broader range of support and activities that could be integral to the person’s recovery journey.

Recovery is a process that is more than achieving abstinence or low risk drinking. There are several definitions of recovery. Research by Witkiewitz and others (2020) defines recovery as “a dynamic process of change characterized by improvements in health and social functioning, as well as increases in well-being and purpose in life”.

A wide range of services and organisations can contribute to a person’s treatment and recovery journey at different stages and together these services can form a recovery-oriented system of care. A recovery-oriented system of care is a network of local treatment and recovery services and community groups that help people to start and sustain their recovery. Peer-delivered and peer-led support are an important part of a recovery-oriented system of care and can be central to the person’s recovery journey.

See section 2.6 in chapter 2 on principles of care for guidance on recovery and recovery-oriented systems of care and chapter 6 on recovery support services.

5.3.3 Treatment phases

Services may find it helpful to see treatment for alcohol dependence or harmful drinking as part of a recovery journey. This journey through treatment and recovery can be thought of as having 3 broad phases which can be described as:

assessment, formulation and engagement
behaviour change
early recovery

These phases can help to inform the psychosocial interventions and level of support the person needs at different points of the journey. The practitioner and the person should agree on the interventions and priorities for action during the ongoing assessment and formulation process. The practitioner should understand which interventions are likely to be useful as the person progresses through their recovery journey.

At the start of the treatment journey, interventions are likely to be focused on stopping or reducing drinking and will be delivered by practitioners. As the journey progresses, the person is likely to be more active in directing their own recovery, participating in a range of activities outside of treatment, including peer support.

The phases are only broad indicators and not rigid categories. For example, although there is likely to be more focus on recovery-oriented activities in the ‘early recovery’ phase, establishing recovery-oriented social networks and meaningful activities is important right from the beginning of the journey. Helping people to access peer support activities and mutual aid groups can contribute to developing these.

5.3.4 Assessment, formulation, and engagement

Everyone who has been referred to community alcohol treatment services with an alcohol use disorders identification test (AUDIT) score of 16 or more should be offered a comprehensive assessment of their alcohol use, severity of dependence, complexity of need and their strengths.

You can read about comprehensive assessment in chapter 4 on assessment and treatment and recovery planning.

Building on the assessment, the practitioner and the person develop a shared formulation. This is a way of making sense of the person’s problem alcohol use. They look at factors that may have made them vulnerable to developing the problem, what may have triggered it, what helps maintain it and what resources the person can use to address it (BPS, 2011).

The shared formulation informs the choice of interventions included in their treatment and recovery plan. This process helps to involve the person in decisions about their treatment and can support engagement with their treatment and recovery plan.

An initial formulation is based on findings from the assessment. Formulation is then reviewed and amended to reflect the person’s response to specific treatment interventions and their progress towards recovery goals.

A good formulation allows the practitioner and the person to evaluate which evidence-based psychosocial intervention may help and why. It is also a chance to identify potential barriers that could prevent progress. By using the formulation to explain how the intervention should work, the practitioner can instil hope that things can change for the better and help the engagement process.

A personalised formulation should:

be developed together with the person receiving treatment
be based on a shared understanding of the issues
normalise the person’s life experiences
respond to individual needs
consider a person’s social and cultural needs
be communicated avoiding unnecessary clinical terminology and in an accessible format, considering language, literacy, sensory disability, cognitive impairment and neurodiversity

The formulation explains why particular diagnoses or interventions are indicated and which treatment and recovery goals are important to the person. Formulation should also identify how a person’s strengths can be best used to support their recovery.

You can read about a clinical approach to formulation in section 5.4 of this chapter.

5.3.5 Severity of dependence and complexity

Assessment and formulation should identify the severity of alcohol dependence and complexity of a person’s need and should determine the choice of interventions to address these.

In many cases, the intervention intensity will increase according to the severity of dependence or complexity of need. People with harmful drinking but low dependence severity and low complexity (for example, strong social support and no mental health conditions) may respond to a less intensive intervention focused on motivational enhancement and goal setting.

People with moderate and severe dependence and complex needs (for example, physical and mental health conditions or additional drug use) are likely to need medically assisted withdrawal and psychosocial interventions will need to be integrated around this. They are more likely to benefit from ongoing structured support, more intensive interventions, multi-agency working and facilitated access to recovery services including peer networks to support recovery outcomes. The highest treatment intensity programme is inpatient medically assisted withdrawal followed by intensive therapeutic support in a residential setting. This is suitable for a small number of people with the most complex needs.

Severe dependence and greater complexity will often, but not always, occur together. People with mild dependence may not need pharmacological interventions but may still have highly complex needs. For example, a person with a depressive disorder may not have an alcohol dependence but heavy drinking episodes may exacerbate their depression and increase risk of self-harm. So, they may require a more intensive intervention and joint working with mental health services to help them manage their drinking and associated risks.

Assessing complexity will include an assessment of the person’s resources for long-term recovery (sometimes called ‘recovery capital’). Broadly, this will include assessing their level of individual health and wellbeing, family, social and peer support, economic and housing stability.

5.3.6 Duration of interventions or treatment episodes

The needs of people who engage with alcohol treatment services are very varied and so the appropriate duration of a psychosocial intervention (or complete treatment episode) will also vary. You should always base the duration of an intervention on individual need and not on a standard length of time. Arbitrary time limits on interventions are not helpful and may increase the likelihood of poor outcomes for the person. A person with personal and social recovery resources, with mild dependence without additional complex needs is likely to need a psychosocial intervention and treatment episode of much shorter duration than someone with little recovery resources, severe dependence and complex needs.

While you should avoid arbitrary or premature decisions about duration of intervention or treatment episode, structure and timeframes are helpful. As set out in section 5.5.2, practitioners should agree clear and ambitious treatment goals with the person, with planned timescales for action and regular reviews. These elements are essential parts of individualised treatment and recovery support.

As the practitioner and the person regularly review progress towards treatment and recovery goals, the appropriate duration for the intervention or treatment episode will become clear. You can then agree a date for ending the intervention or treatment episode and allocate adequate time to plan for this, as well as arranging support for the person after they leave treatment. See section 4.10.6 in chapter 4 on assessment and treatment and recovery planning for post-treatment recovery check-ups.

It is important that the end date leaves time and space to prepare the person for the end of their treatment or for moving on to another stage of their treatment and recovery journey. People can be at increased risk of relapse at transition or ending points without appropriate preparation and support.

5.3.7 Alcohol use goals

Identifying appropriate alcohol use goals

Identifying the appropriate alcohol use goals is vital to effective alcohol treatment. Alcohol use goals should be informed by assessment and formulation and you should regularly review these with the person as part of the treatment and recovery planning process.

You can read more about identifying and agreeing alcohol use goals in section 4.7 in chapter 4 on assessment and treatment and recovery planning.

Severity of dependence and complexity of need are broad indicators of what alcohol use goals are most appropriate. However, following discussion of the benefits and risks of different alcohol use goals, these should be aligned with what the person wants and should be regularly assessed at review. The practitioner should use an approach based on motivational interviewing principles and techniques when supporting the person to choose their alcohol use goal (see section 5.5.6 for more on motivational interventions).

Using psychosocial interventions with different alcohol use goals

In general, you can use the psychosocial interventions set out in this chapter whether a person’s alcohol use goal is:

abstinence
low risk drinking
cutting down drinking to reduce harm

However, some approaches may be more appropriate for certain goals (for example, behavioural self-control training for low risk drinking goals). The practitioner should consider the person’s alcohol use goal when choosing appropriate psychosocial interventions.

5.3.8 Psychosocial interventions: what they are

The term ‘psychosocial interventions’ refers to a broad range of structured interventions, techniques and practical help that support people to achieve their treatment and recovery goals. Psychosocial interventions address both psychological and social needs, which are often interconnected.

Psychological interventions include interventions focused specifically on alcohol-related cognitions, behaviour, problems and social networks.

Social interventions include practical help with immediate social needs such as accommodation and debt, as well as helping people to engage with support for longer-term recovery.

The specific focus of a psychosocial intervention will vary according to the:

person’s needs and goals
setting in which a psychosocial intervention is delivered
practitioner’s role and training

However, both psychological and social elements are essential in most people’s treatment.

Psychosocial interventions include structured support and formal psychological treatments. In community alcohol treatment services, a keyworker (see definition of keyworker in the glossary) is allocated to provide structured support and co-ordinate recovery-oriented care throughout the person’s treatment journey.

Formal psychological treatments are generally provided by a specialist member of the MDT alongside a keyworker providing structured support.

You can read about formal psychological treatments in section 5.6.

Where a person needs pharmacological interventions, psychosocial interventions should also be provided as part of an integrated personalised treatment and recovery plan. The person will need additional psychosocial interventions to address complexities often associated with harmful drinking and alcohol dependence, such as co-occurring mental health conditions, cognitive impairment, drug dependence or gambling.

5.3.9 Structured support

Providing structured support

Alcohol treatment services in community and residential settings should allocate a keyworker to each person to help their treatment and recovery process and to co-ordinate their care. The keyworker will be responsible for providing structured support.

Structured support involves using specific psychosocial interventions that are common to evidence-based psychological treatments for alcohol and drug use (Moos, 2007). Section 5.5 sets out these common factors and describes how the keyworker provides structured support.

Using these common factors to frame the use of specific interventions is a pragmatic and flexible approach to providing treatment and supporting recovery. These psychosocial interventions can be described as evidence-based practices to highlight the distinction from a comprehensive formal psychological treatment approach (Manuel and others, 2011).

Keyworkers should adapt structured support to a person’s needs based on assessment and the formulation. This should account for the severity of dependence and any associated physical health, mental health or social complexities.

Structured support may include practical help and co-ordination of care from an MDT, and across agencies. Alongside a keyworker providing structured support, a specialist member of the MDT may provide a formal psychological treatment where required.

Structured support can be delivered by alcohol workers in their keyworking role. Services should provide training and regular clinical supervision to practitioners who provide structured support, which should be underpinned by a quality governance framework.

You can read more about structured support in section 5.5.

Structured support and recovery-oriented care

Treatment should be recovery oriented, helping people to build healthier fulfilling lives. Structured support is central to helping people meet their alcohol use goals and related short-term goals. It also helps people engage with support for longer-term recovery. Outcomes improve significantly when treatment engagement is combined with long-term recovery support (Simoneau and others, 2018).

All 5 elements of structured support described in section 5.5 can help the person build longer-term recovery. Supporting people to engage in rewarding activities (section 5.5.3) and supporting people to engage with social support and recovery-oriented networks (section 5.5.4) are particularly relevant and you should read the relevant sections for more detailed guidance.

The keyworker may continue to support the person’s long-term recovery after they have completed their treatment through a mutually agreed schedule of recovery check-ups (see section 4.10.6 in chapter 4 on assessment and treatment and recovery planning).

5.4 Clinical formulation

5.4.1 Clinical formulation: aims and objectives

A clinical formulation builds on the comprehensive assessment (see chapter 4) and provides a framework for the practitioner and the person to understand how the person’s problem alcohol use began and developed, the associated difficulties and the person’s strengths and resources. It is also a way to identify the appropriate interventions to help the person change their alcohol use and build the foundations of their recovery.

So, clinical formulation is a way to further understand the person and their relationship with alcohol, while organising the information gathered as part of assessment. Information to develop a formulation can also be collected from:

existing clinical reports
clinical interviews
observations
standardised questionnaires
referral information
previous treatment summaries
knowledge of possible diagnoses

Clinical formulation allows practitioners to understand the person’s problems, which are often multiple and complex, but also to identify skills and strengths that they can develop. The clinical formulation is also a chance to review a person’s response to interventions and adjust the treatment plan if the interventions are ineffective (BPS, 2011).

The formulation should be personalised, accounting for the person’s individual needs, strengths and preferences. Aspects of a person’s identity such as ethnicity, culture, faith, age, gender, gender identity, sexual orientation and disability will shape the person’s experience and understanding of their problem alcohol use, so the formulation and plan should take this into account.

5.4.2 Formulation framework

The ‘5 Ps’ model is one way of structuring a clinical formulation. It involves looking at how different factors in a person’s life affect their alcohol use. Alcohol use is the presenting problem and the first of the 5 Ps. The other 4 are:

predisposing factors (vulnerability factors)
precipitating factors (triggers)
perpetuating factors (maintaining factors)
protective factors (modifying factors)

Predisposing factors

Predisposing factors are background factors that may have contributed to the development of a person’s problem alcohol use. This might include biological, family, and socioeconomic factors and adverse childhood experiences. For example, factors such as poverty and lack of social and economic opportunities, family patterns of problem alcohol use, experiences of physical, sexual or emotional abuse can make it more likely a person develops an alcohol problem.

Precipitating factors

Precipitating factors are those that have triggered an episode of problem alcohol use. Internal precipitating factors can include:

negative mood states
difficult memories
intrusive thoughts
withdrawal symptoms
cravings

External precipitating factors relate to the person’s social and environmental situation, and can include:

unstable housing
loss of role or employment
conflict with others
experience of discrimination or marginalisation

Perpetuating factors

Perpetuating factors are those that maintain problem alcohol use. Internal perpetuating factors might include beliefs about the positive effects of using alcohol. They could also include a strong desire to get rid of or escape from unwanted:

cognitive events (for example, intrusive memories, negative thoughts or low self-esteem)
physical sensations (for example cravings and withdrawal symptoms, pain, insomnia, or tiredness)
emotional feelings (for example, depression and anxiety symptoms)
social responsibilities (for example, social contact, parenting, or sustaining jobs)

Environmental factors like unstable housing, poverty and relationship difficulties may also be important perpetuating factors. Formulation can be used to show the person how alcohol use, intoxication and dependence can maintain these perpetuating factors and make them worse.

Protective factors

Protective factors are those that help to limit a person’s alcohol intake or have the potential to support a reduction in alcohol use. Internal protective factors include:

personal strengths
abilities, such as coping skills
individual and cultural values

External protective factors include:

close family or social support networks
employment
meaningful activities
cultural and faith organisations
peer support and mutual aid
stable housing
financial stability

Identifying these factors can help build hope and self-efficacy (or confidence in their ability to change behaviour). Exploring previous periods of low risk alcohol use or abstinence can be a useful way to identify protective factors and coping skills. A lack of protective factors also highlights areas that need to be developed, for example, linking the person with peer support and recovery communities.

5.5 Structured support: common factors in effective treatment

As outlined in section 5.3.9, structured support involves using psychosocial interventions which are common to evidence based psychological treatments for alcohol and drug use (Moos, 2007; Manuel and others, 2011). These common factors (or change mechanisms), include:

a strong therapeutic alliance
session structure and goal direction
interventions to develop alternative rewards and activities to alcohol use
engagement with social networks that are recovery-oriented
building self-efficacy and coping skills to control drinking or maintain abstinence

This section provides guidance on each of these factors.

5.5.1 Therapeutic alliance

A strong therapeutic alliance is vital to treatment. Evidence shows that a strong alliance between the practitioner and person is associated with significantly better outcomes relating to treatment goals and a range of quality of life measures (Maisto and others, 2015; Connors and others, 1997).

Confrontational approaches are not effective and are likely to lead to treatment disengagement (Miller and others, 2001). An empathic and supportive approach and working towards shared goals is important to develop a therapeutic alliance.

Core competencies in building a therapeutic alliance include being able to:

work together
engage a person appropriately while showing warmth and care
build trust and adopt a personal style suitable to the person
adjust the nature and intensity of the intervention to reflect where the person is in their journey
understand and work with a person’s emotional context and motivation
work in a culturally competent way

Services need to make sure they have regular clinical supervision to help practitioners develop their therapeutic engagement skills. Services should ensure that they prioritise these competencies and values when recruiting staff.

5.5.2 Support, structure and goal direction

Psychosocial interventions should be structured and goal-directed, while open to review. Setting and working to a clear session agenda linked to a treatment and recovery plan is essential to this process. The choice of Interventions is informed by assessment and formulation.

Practitioners should support the person to identify their own goals, and regularly review and adjust these where necessary. Supporting people to set and achieve goals can support the person’s aspirations, instil hope, help improve mood, and encourage greater self-efficacy. The practitioner should use an approach based on motivational interviewing principles and techniques when helping the person to identify their treatment and recovery goals and reviewing progress with them. See section 5.5.6 for more on motivational interventions.

Structure and goal direction should not come at the expense of the therapeutic alliance. The person should feel supported to make progress with their goals while developing autonomy and self-efficacy.

There is more information on treatment and recovery planning, including goal setting, in section 4.10 in chapter 4 on assessment and treatment and recovery planning.

There are tools or techniques to support keyworking. For example, mapping (sometimes known as node-link mapping) is a simple technique for presenting verbal information visually (with diagrams or maps). Research has shown mapping can support positive treatment engagement and outcomes (Beckwith and others, 2019).

You can read more about mapping in Routes to recovery from substance addiction, which is a manual to help healthcare practitioners build an effective plan for recovery.

Examples of interventions a keyworker can provide include:

forming a collaborative agenda at the start of every session
agreeing goals to work on between sessions and ensuring these are reviewed at the next session
modelling problem-solving when setbacks happen and the person does not achieve their goals
encouraging the person to develop a daily routine that promotes mental and physical wellbeing (such as exercising and eating well)
identifying additional support needs and arranging referrals to other professionals and agencies

5.5.3 Rewards and rewarding activities

Developing positive and meaningful alternatives to alcohol use is a central part of recovery. Alcohol and behaviours related to alcohol use are likely to have formed a significant part of a person’s life. They will often need to find new ways of spending their time and new sources of meaning and enjoyment.

A person-centred and strengths-based approach can support the person to identify and develop rewarding activities that are most meaningful to them.

Keyworkers can use the behavioural principle of positive re-enforcement to support change. This can include:

reflecting back the person’s positive comments about change, and affirming their strengths and resources
helping the person’s support network to reward them when they achieve their alcohol use goals
providing direct rewards or incentives for remaining abstinent (see section 5.6.3 on behavioural approaches)
planning for a more rewarding, recovery-oriented lifestyle

Planning for a more rewarding recovery-oriented lifestyle could include:

family activities
education or training
volunteering
employment
hobbies
sports
cultural and faith-based activities
peer support

There are several measures that the keyworker can use to assess recovery strengths and resources. These measures include tools such as the King’s College London SURE: Substance Use Recovery Evaluator.

It can sometimes take time for a person to build confidence and motivation to engage with new activities or groups, but the keyworker should discuss various recovery support options from the start and throughout treatment. This is particularly important as the person moves toward leaving treatment (Humphreys, 1999).

If the person wants to volunteer to offer peer support while they are still in treatment, the keyworker should help them to consider whether the timing and the role are right for them and find out what support will be available to them in their role. There is evidence that people benefit from offering peer support, but they need to have clarity about the role, and training and supervision to prevent a negative impact on their own health and wellbeing (Greer and others, 2021).

Examples of interventions a keyworker can provide include:

identifying alternative activities to drinking that connect with the person’s values and have intrinsic meaning and purpose to them
identifying and encouraging contact with friends and family members who can provide practical assistance and company to engage in alcohol free activities
providing practical assistance to help the person reconnect with past valued activities that are not related to drinking and encouraging them to try new things
encouraging the person to explore and engage in educational, vocational or volunteering opportunities
helping people to access employment support

There is strong evidence that being in good quality employment supports a person’s health and wellbeing. So, alcohol treatment practitioners should ensure that people in treatment can make informed choices about employment and accessing employment support.

You can find detailed guidance on accessing employment support in chapter 7.

People with alcohol dependence and those drinking at harmful levels may have developed social networks and relationships in which heavy alcohol use is the norm. This can lead to a loss of contact with supportive people or being excluded from activities and events where heavy drinking is less acceptable. In turn this can undermine a person’s efforts to change. Some people with alcohol dependence are very isolated and have no social networks at all. An essential part of structured support is helping people to establish or re-establish connections with people or groups who can provide useful support. There is evidence that changes in a person’s social network from one that reinforces drinking to one that reinforces abstinence significantly increases the probability of abstinence (Litt and others, 2007).

Evaluating and adjusting these social networks can help the person to:

make changes in their alcohol use
achieve their alcohol use goals
support longer-term recovery

Identifying strengths and deficits in the person’s social support should be part of ongoing assessment. The keyworker should regularly encourage the person to use the helpful support available to them and to develop new support networks.

Support from family, partners and friends can be very useful where this is available. You can read more about this in section 4.10.1in chapter 4 on assessment and treatment and recovery planning and in section 5.8 below.

Keyworkers should help people to consider other sources of support. For example, culture or faith-based communities and local community groups. There is increasing recognition of the impact of isolation on wellbeing and various local projects may exist to support social connectedness.

Peer support and mutual aid

Support that is specifically recovery-oriented can play a vital role in a person’s recovery. Peer-delivered and peer-led projects and mutual aid groups such as Alcoholics Anonymous (AA) or SMART Recovery can help support and sustain recovery-oriented journeys for people with problem alcohol use before, during and after treatment.

Keyworkers should be familiar with the peer-delivered and peer-led organisations and mutual aid meetings in their area and hold information on each of these. They should inform a person about peer support options as part of the treatment and recovery planning process and help them to access this.

Effective peer support can:

promote hope and optimism that change is desirable and possible
enhance motivation
help members to develop a positive identity
improve coping mechanisms and social skills
provide benefits for both the person delivering the support and the person receiving it

There are now a range of peer-delivered and peer-led support services and organisations. Their structures and activities vary widely across the different parts of the UK. The most common peer support organisations in the UK fall broadly into the following 3 groups.

Peer-delivered support that is linked to a particular treatment and recovery service.
Lived experience recovery organisations (LEROs), which are autonomous organisations led by people with lived experience.
Mutual aid groups such as AA and SMART Recovery, which are independent organisations offering a specific recovery programme that people follow together.

The activity of peer support varies from offering a specific kind of support, like making recovery visible and welcoming new people into an alcohol treatment service, to peer-led LEROs that offer a full range of non-clinical services.

Chapter 6 on recovery support services describes several kinds of peer support.

Keyworkers should encourage and support people to engage with peer support and mutual aid in a reflective and collaborative way. Simply providing information or leaving people to make contact themselves increases the risk that they will drop out or not attend (Humphreys, 1999). A motivational interviewing approach will be useful in this process.

Facilitating access to mutual aid

‘Facilitating access to mutual aid’ (FAMA) is a short, simple and effective method for increasing mutual aid participation. Alcohol treatment services should make sure keyworkers are trained to facilitate access to mutual aid.

The most common national mutual aid groups in the UK are:

AA
Narcotics Anonymous
Cocaine Anonymous
Families Anonymous
Al-Anon and Alateen
SMART Recovery

There are also additional emerging mutual aid groups and peer support options available in local areas and remotely.

FAMA involves 3 stages:

introducing mutual aid
encouraging the person to engage with mutual aid
taking an interest in the person’s involvement with the mutual aid group

1. Introducing mutual aid

Keyworkers should discuss the value of mutual aid groups for the person’s individual recovery goals. They should supportively explore the person’s experiences or views about mutual aid and provide accessible information about local groups. Information should include any meetings in languages other than English and for particular groups, for example LGBTQ+ people, women or people from particular minority ethnic groups.

Where the person agrees, the keyworker should also help the person to set goals to engage with mutual aid as part of their treatment and recovery plan (Timko and others, 2006).

2. Encouraging the person to engage with a mutual aid group

In the second stage, the keyworker discusses the information given in the previous session with the person and helps the person to talk through any concerns and find solutions to any barriers to attendance. The keyworker should aim to agree with the person which group they will try and when. It is often very helpful if a group member can accompany the person to their first group meeting and wherever possible, the keyworker should discuss this option with the person and organise it.

3. Taking an interest in the person’s experience of mutual aid

In the following sessions, the keyworker takes an active interest in the person’s attendance and engagement with mutual aid, helping them to overcome any difficulties they experience as they continue to attend meetings. Like most volunteer-led organisations, mutual aid groups do not have the same governance structures as public services. If for any reason the person does not feel comfortable in one group, the keyworker can encourage them to try other local groups or ask peers for recommendations. Once the person has attended a group for a while, the keyworker can encourage the person to become more involved with the activities of the group and eventually take on an active role.

For more detailed guidance and resources, see the Mutual aid toolkit for alcohol and drug misuse treatment.

The 3 stages set out above are based on an approach originally developed in the USA for referring people to 12-step groups (Timko, 2006) and adapted for a UK context in the ‘Facilitating access to mutual aid (FAMA)’ guidance in the toolkit. Current evidence for FAMA is based on facilitating access to AA and other 12-step fellowships (Kelly and others, 2020) but the guidance may also be useful for practitioners who are facilitating access to other forms of peer support.

Some people, particularly those with harmful drinking or mild dependence, may be less willing to engage in mutual aid groups like AA. But practitioners should still help them evaluate and find positive social and support networks. There are also emerging mutual aid groups and peer support options available in local areas and remotely, some of which may include support for people aiming at lower risk drinking.

Examples of interventions a keyworker can provide include:

mapping a person’s social network to identify people who could be supportive of recovery and making a plan to increase contact with these people
helping a person to identify other social, cultural or faith- based resources that could be supportive of recovery
facilitating access to mutual aid or peer support activities and groups
helping the person to get a peer mentor
helping the person to consider being a peer mentor themselves when they are ready

5.5.5 Self-efficacy and coping skills

Self-efficacy describes the person’s confidence in their ability to make or maintain changes to their alcohol use. Self-efficacy develops as people implement and observe change (McKellar and others, 2008).

Throughout treatment, keyworkers should emphasise any improvements and associated gains in confidence. Keyworkers can use techniques from several treatment approaches that build self-efficacy, such as motivational interviewing which identifies strengths and resources for change (McKellar and others, 2008).

Some treatment approaches more specifically target and develop self-efficacy (Kadden and Litt, 2011). For example, cognitive behavioural therapy (CBT) approaches to alcohol use focus on developing skills to increase a person’s ability to cope with high risk drinking situations and life stressors, to help increase their self-efficacy to avoid or control alcohol use.

CBT-based relapse prevention is a comprehensive package of interventions. Keyworkers can integrate elements of this formal psychological treatment within structured support.

Examples of interventions a keyworker can provide include:

promoting the use of drink diaries to identify high risk situations and to make proactive plans to cope with them
looking together at life stressors and working out how these can be reduced
teaching craving management strategies
teaching drink refusal skills
helping the person to manage low mood by encouraging good sleep hygiene and daily activity
helping the person to learn to manage anxiety by teaching relaxation techniques
developing an emergency plan to ensure an unintended drinking episode does not escalate to regular uncontrolled drinking
ensuring the person has a robust plan in place to support recovery when they are discharged from structured treatment, which anticipates future challenges and has a clear route back to getting professional support

5.5.6 Structured support and motivational interventions

Motivational interviewing (MI) and motivational enhancement therapy (MET, a form of MI) are evidence-based approaches to alcohol treatment. MI can be valuable in developing a strong therapeutic alliance and throughout treatment. But MI could be particularly important at a person’s initial assessment to build engagement and it can be combined with other effective interventions (Moyers and others, 2005). When practitioners provide structured support, they should use MI principles and techniques. MI also supports effective brief interventions (see chapter 3 on alcohol brief interventions) and can be used alongside psychological treatments including those listed in section 5.6.

Motivational interventions need a non-judgmental approach from the practitioner to help the person recognise the problems associated with their alcohol use and support their motivation to change their behaviour.

MI techniques focus on exploring why the person might be unsure or hesitant about changing their drinking or other behaviour that might be preventing recovery. The practitioner should elicit the person’s own reasons for change, to motivate them to make or strengthen their commitment to behaviour change. When using MI techniques, practitioners should use non-judgmental tone and language (Miller and Rolnick, 2023). Other MI specific skills include:

asking open questions
providing affirmations that support the change process
reflective listening to highlight the person’s desire and ability to change their behaviour (change talk)
summarising the ideas the person has expressed

MET is a structured approach that combines MI techniques with elements such as feedback on assessments or test results (normative feedback, for example highlighting discrepancy between typical alcohol use and the person’s use). MET can be used as a stand-alone treatment, or along with other psychosocial or pharmacological treatment modalities.

Developing MI skills can be difficult because they may go against the practitioner’s instincts to offer advice without considering whether the person is ready to act upon it. Keyworkers (usually alcohol workers) can deliver MI but it requires quality professional training and ongoing reflective practice supported by supervision in MI.

5.5.7 Structured support and support after treatment ends

An important part of structured support is preparing the person for the end of structured treatment and agreeing support after they leave. It is important that the end date leaves time and space to prepare the person for the end of their treatment and the next stage of their recovery journey. People can be at increased risk of relapse at transition or ending points without appropriate preparation and support.

Alcohol treatment services should work together with local recovery support services to help people sustain recovery after they leave treatment. Recovery support services can provide emotional and practical support for continuing abstinence (or low risk drinking where that is appropriate), daily structure and rewarding activities after the person has finished structured treatment.

The keyworker and the person can agree a recovery support plan for after they leave treatment that is proportionate to their level of recovery resources and need. Based on individual assessment, a recovery support plan for after treatment might include:

recovery goals for after treatment
recovery-oriented activities and recovery services they will engage with
appropriate support people
relapse prevention strategies following the end of structured treatment
arrangements for prescribing and collecting relapse prevention medication
arrangements for recovery check ups
a re-engagement plan

Monitoring people after they leave treatment can help them to manage early recovery. Recovery check-ups are an agreed series of scheduled in-person, online or phone appointments with the person after they leave a treatment service, generally carried out by the keyworker. Through recovery check-ups, the service can:

provide relapse prevention interventions
identify any extra support the person might need
where necessary, help the person to access the service again without delay

There is evidence to support recovery check-ups. You can find a summary in ‘Part 2: recovery support services - evidence and current provision’ in the guidance Recovery support services and lived experience initiatives.

You can read more about recovery check-ups in section 4.10.6 in chapter 4 on assessment and treatment and recovery planning.

5.6 Psychological treatments: selection and delivery

This section details several psychological treatments for people with problem alcohol use that are recommended by NICE in the guidelines Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (CG115) or are interventions with an emerging evidence-base that are supported by clinical consensus of the alcohol guidelines development group.

5.6.1 Selecting and using psychological treatments

Practitioners can use these psychological treatments in different settings, such as in community and residential settings.

You can find guidance on psychological therapies for people with co-occurring mental health conditions in chapter 18 on people with co-occurring mental health and alcohol use conditions.

Selecting a specific psychological treatment depends on:

assessment and formulation
the availability of suitably qualified staff
a supporting clinical supervision and governance structure for the treatment
use of relevant standardised outcome measurement tools

Practitioners can deliver these interventions one-to-one, and most can be adapted to be delivered to a group. Practitioners can also deliver some of these interventions using digital technologies like online video.

Elements of these interventions may be integrated into structured support under the oversight of a practitioner trained in the approach and with supporting supervision.

The psychological treatments below would normally be delivered by practitioners who have had specific training in the treatment. Services should provide clinical supervision by a professional clinical supervisor with training in the relevant treatment and appropriate clinical governance structures.

5.6.2 Using motivational interviewing alongside psychological treatments

You can use MI alongside the psychological treatments described in section 5.6.3 to 5.6.6 as they can be helpful in building the therapeutic alliance and engagement with treatment (Miller and Rollnick, 2023).

See section 5.5.6 for guidance on MI.

5.6.3 Behavioural approaches

Practitioners delivering behavioural treatments described in this section should be trained to deliver the specific treatment. Services should ensure that a clinical supervisor trained in the specific approach provides supervision for practitioners providing these treatments.

Behavioural approaches focus on changing the environmental or social circumstances to support a person to change their drinking. Based on the psychological concept of conditioning, behavioural approaches such as management aim to modify learned behaviours such as alcohol use.

Behavioural approaches include interventions that aim to unlearn (or ‘extinguish’) conditioned cues to drink alcohol. For example, ‘extinction-focused approaches’ include behavioural self-control training to reduce cravings to drink. Other behavioural interventions may help people develop recovery-supporting behaviours through support from others or specific rewards for positive behaviour. For example, a community reinforcement approach (CRA) or contingency management (CM) aim to reinforce abstinence and non-drinking behaviours.

CRA is based on the principle that addictive behaviours involve reinforcers (for example, learned environmental cues) that maintain the behaviour. Building motivation and engaging in alternative, rewarding activities shifts the person’s reinforcement cues towards recovery-oriented behaviours. Positive social activities are important reinforcement goals, and engaging in peer support, therapies or other suitable activities may also be valuable (Meyers and others, 2011).

Behavioural self-control training (or behavioural self-management training) involves developing strategies, including managing high-risk drinking situations. Examples of strategies include learning drink-refusal skills or setting clear drinking limits. Behavioural self-control training can be used for people who have a low risk drinking goal (Marlatt and Witkiewitz, 2002).

CM provides incentives such as monetary rewards for specific behaviours. This can include rewards for staying abstinent, attending treatment or other recovery-supporting activities. CM is typically used alongside other interventions and has some supporting evidence for alcohol specific outcomes (Petry and others, 2014; McDonell and others, 2020). CM requires well defined behaviour targets (for example, attendance at the service) and a clear monitoring system to ensure it is delivered consistently and ethically.

There is evidence that CM is effective and cost effective in improving adherence to acamprosate (Donaghue and others, 2023), so CM can be considered for people whose treatment and recovery plan includes acamprosate.

5.6.4 Cognitive behavioural therapy

Practitioners delivering cognitive behavioural treatments described in this section should be trained to deliver the specific treatment. Services should ensure that a clinical supervisor trained in the specific approach provides supervision for practitioners providing these treatments.

Cognitive behavioural therapy (CBT) approaches aim to change addictive behaviours by changing unhelpful cognitions (alcohol related thoughts and images) and behaviours that maintain or contribute to drinking. CBT enables people to recognise these thoughts and change the way they think and behave to support their recovery (Mitcheson and others, 2010; Liese and Tripp, 2018; Magill and others, 2019).

Relapse prevention

CBT-based relapse prevention, developed from Marlatt and Gordon’s model, is a widely delivered intervention for harmful drinking and dependence (Marlatt and Donovan, 2005). The approach identifies the main contributors to a return to problematic drinking (or relapse) and interventions, which include:

identifying high-risk drinking situations and learning how to manage them
coping with urges and cravings, and challenging expected positive outcomes from drinking
identifying and challenging personal permissions and justifications to drink, for example when a person says, “I deserve a treat” or “other people are drinking, why can’t I?”
drink-refusal skills training
identifying lifestyle factors such as stress and social networks that encourage drinking and seeking to manage these better
setting up self-reward systems for not drinking

Relapse prevention should be integral to treatment. Relapse prevention interventions are an important part of structured support (see section 5.5.5), enabling people to understand how to maintain changes in their behaviour and make progress in their recovery. Relapse prevention considers any returns to problematic alcohol use as a process rather than a stand-alone event. It focuses on developing strategies to reduce the likelihood of drinking, for example through coping skills or building self-efficacy and by attending to longer-term lifestyle stressors.

Relapse prevention also identifies how a ‘slip’ (a temporary or short return to problematic use) can be seen as a manageable event or even learning opportunity, rather than as a trigger for a full-blown relapse. It also helps people to change their thinking on how they see a slip.

Interventions for low risk drinking goals

NICE CG115 recommends that psychological interventions for abstinence broadly apply to low risk drinking goals. A formulation-based package of behavioural and cognitive interventions should form the basis of the approach.

Low risk drinking may be an appropriate goal for most people with mild dependence and people drinking at harmful (higher risk) levels who:

do not have significant physical or mental health conditions
have adequate social support

If the person meets the above criteria, a low risk drinking goal may be appropriate unless they prefer a goal of abstinence, or there is some other reason for abstinence.

The alcohol clinical guidelines development group recommend abstinence as the appropriate goal for most people with moderate or severe alcohol dependence. The guidelines development group also recommend abstinence as the appropriate goal for most people with mild dependence and for people drinking at harmful levels who have significant physical health or mental health conditions that can be made worse by alcohol use (for example, alcohol-related liver disease or clinical depression). Any person choosing a goal of abstinence should be supported to work towards that.

However, if the person makes an informed choice to opt for a low risk drinking goal, they should be supported in that goal. If there are considerable risks involved, the assessor should advise that abstinence is most appropriate and should support a negotiated approach where the person can consider abstinence if they do not achieve low risk drinking. People initially preferring a low risk drinking goal can switch to an abstinence treatment goal at a later point.

Low risk drinking in this guideline is defined in line with the UK chief medical officers’ low risk drinking guidelines. The guidelines recommend it is safest not to drink more than 14 units a week on a regular basis and if a person drinks as much as 14 units per week, it is best to spread drinking evenly over 3 or more days. For women who are pregnant or think they could become pregnant, the safest approach is not to drink alcohol at all, to keep risks to the baby to a minimum.

This definition of low risk applies to the general population. For some people, drinking any alcohol at all is a risk. For example, abstinence is crucial for the health of people with advanced liver disease, including cirrhosis.

A goal of low risk drinking is commonly known as controlled drinking (see definition of controlled drinking in the glossary). There is some evidence that tools such as the Impaired Control Scale may be appropriate for helping to identify the suitability of a controlled drinking goal (Heather and Dawe 2005). Low drinking goals should be regularly reviewed.

An initial period of abstinence may be valuable (where the person does not need medically assisted withdrawal) before beginning low risk drinking. A period of abstinence can allow the person to adjust a range of factors to support a low risk drinking goal. For example, recognising situations or feelings that lead to drinking, developing skills to manage these and adapting social behaviours and other daily habits to support low risk drinking.

People with mild dependence without additional complex needs and who have supportive social networks may only need a relatively brief period of treatment. However, this should be based on the individual assessment and formulation.

Several psychosocial approaches are particularly suited to low risk drinking goals. For example, exploring past and future motivations for a person’s drinking and evaluating these as part of a low risk drinking plan is likely to be important.

CBT and CBT-based relapse prevention interventions are suitable to support low risk drinking goals (Marlatt and Gordon, 1985). Additional strategies to support low risk drinking goals include:

setting clear limits for drinking
self-monitoring of alcohol consumption, for example keeping a drinks diary
methods to control the rate of drinking, for example alternating alcoholic drinks with soft drinks and not participating in buying rounds
analysing triggers for excessive drinking, for example the role of stress or anxiety

5.6.5 Third wave approaches and mindfulness

Practitioners providing the interventions in this section should be trained and certified in the specific treatment. Services should ensure that a clinical supervisor trained in the specific approach provides supervision for practitioners providing these treatments.

More recent developments of CBT (sometimes referred to as ‘third-wave CBT’ or ‘contextual CBT’) are based on mindfulness-oriented approaches and include:

acceptance and commitment therapy
mindfulness-based relapse prevention
dialectical behavioural therapy

Third wave approaches differ from traditional CBT as they focus on helping the person change their relationship to unhelpful thinking patterns (for example, believing “I cannot cope without a drink”) and emotions rather than changing thoughts directly. This is done using mindfulness and acceptance strategies to increase awareness of these unhelpful thoughts and feelings and to enable more flexible responses that support recovery.

Mindfulness encourages people to focus on their sensations (for example, cravings), thoughts and emotions in the present moment without judgement or reaction. Then, people can accept negative thoughts or feelings that they experience, rather than seeing them as something that needs to be fixed.

Research on the relationship between mindfulness and substance use behaviours (Karyadi and others, 2014) found that:

these practices were associated with a range of positive wellbeing measures
greater ability to be mindful was associated with better managing cravings among people with alcohol-related problems

Mindfulness-based relapse prevention brings together the practice of mindfulness within the relapse prevention model. There is emerging evidence that mindfulness-based relapse prevention leads to reduced negative emotions, stress and other potential internal triggers (Byrne and others, 2019; Bowen and others, 2014).

There is some evidence that mindfulness can reduce cravings and support abstinence (Karyadi and others, 2014; Korecki and others, 2020) and that acceptance and commitment therapy may be effective as a treatment for substance dependence (Byrne and others, 2019).

There is also evidence that dialectical behavioural therapy, which incorporates mindfulness techniques, is effective for people with emotional regulation difficulties who use substances (Maffei and others, 2018). As this intervention is for people with a mental health condition, it is included in chapter 18 on people with co-occurring mental health conditions.

The nature and extent of a person’s social network can influence their recovery outcomes and is an important part of structured support (see section 5.3.4).

Social network interventions are based on the principle that harmful drinking and alcohol dependence occur in a social context that can enhance or undermine behaviour change. These interventions aim to improve the quality of relationships and reduce stress by:

improving communication and problem-solving
reinforcing behaviour consistent with changing drinking and recovery
reducing unhelpful behaviours that may undermine efforts to change drinking

Improving how a person functions in a social network (family, friends, community) that supports abstinence or low risk drinking is an important recovery asset. NICE CG115 recommends involving families, partners and friends in treatment as long as the person in treatment has given consent.

It is important to review the support networks of any person with alcohol dependence as part of their assessment. The practitioner should ask what they think about each network member’s attitude to supporting them in their treatment and how willing they might be to be more formally involved. The keyworker can use mapping to help to review social networks (see also section 5.5.2 on support, structure and goal direction and 5.5.4 on social support and recovery-oriented networks).

Some people do not wish to involve their family members because they are unsupportive, or in some cases abusive. In these situations, it is particularly important to help the person to draw on or build alternative support networks. However, at the point of assessment, some people can be anxious about involving their family members, even if they think they are supportive. In these situations, it is helpful for practitioners to ask again at review whether the person would like to involve their family in their treatment as they may feel differently when they have started to engage in treatment.

Talking about social networks and the benefits of involving others in treatment provides an opportunity to ask the person if they think their family members or significant others are affected and might want support (see section 5.8 on interventions for adult family members, partners and friends).

Practitioners should establish the boundaries of confidentiality and consent to contact family members or significant others at an early stage of treatment. This can be helpful if the person in treatment drops out of contact with the service. This can be formalised as part of a re-engagement plan.

Effective family-focused interventions

There is evidence that several family-focused interventions are effective for treating problem alcohol use and can indirectly support and protect children affected by parental alcohol use (Templeton, 2010). These can broadly be grouped into 3 approaches:

Work with adult family members and significant others to help the person with problem alcohol use to enter and engage with treatment.
Involve both the person with problem alcohol use and their adult family members and significant others in the treatment intervention.
Interventions responding to the needs of the adult family members and significant others without the person drinking involved. This support should be available regardless of whether the person with problem alcohol use is engaged in treatment or not (Copello and others, 2005; Orford and others, 2013) (see section 5.8).

The following 2 sections focus on the first 2 approaches and describe the main interventions that involve the wider social network to support behaviour change in adults with problem alcohol use. Section 5.9 outlines an approach to supporting adult family members and significant others without the person with problem alcohol use being involved.

You can find details of interventions that involve the family to prevent or reduce substance use by children and young people in chapter 23 on young people.

Practitioners providing social behaviour and network therapy (SBNT) should be trained in this treatment. Services should ensure that a clinical supervisor trained in the specific approach provides supervision for practitioners providing these treatments.

NICE CG115 recommends social network and environment-based therapies that focus on alcohol related problems. SBNT is an example of these. It directly engages a person’s wider social network in the treatment process. The practitioner uses SBNT to support the person to explore and build social network support for changing their alcohol use and other problematic behaviour (Copello and others, 2002).

SBNT encourages a person to:

be open about their goals
be clear about their plans to cope if they return to problematic drinking at any stage
improve communication within their social network

These interventions aim to support the person with problem alcohol use through the treatment journey, and, where necessary, back into treatment. SBNT brings together elements of network therapy, social aspects of the community reinforcement approach, relapse prevention and approaches involving families and concerned others.

Practitioners can use SBNT to help the person pursue a goal of abstinence or low risk drinking. The coping strategies developed through SBNT are useful during and after completing treatment.

Behavioural couples therapy

Practitioners providing behavioural couples therapy (BCT) should be trained in this treatment. Services should ensure that a clinical supervisor trained in the specific approach provides supervision for practitioners providing these treatments.

NICE CG115 recommends using BCT for people who have a partner who is willing to participate in supporting the person to change their drinking. It is not recommended if the partner is also drinking problematically or the person is currently experiencing, or is a current perpetrator, of domestic abuse.

BCT is a structured approach that focuses on improving the quality of the relationship through improved communication and planned structured activities. It also includes aspects of CBT-based relapse prevention. BCT may be appropriate for either abstinence or low risk drinking goals, determined by assessment and formulation.

5.7 Modes of delivery

This section describes ways that you can deliver psychosocial interventions other than through individual (in-person) sessions.

You can find information on mutual aid groups and groups run by peer networks or LEROs in chapter 6 on recovery support services.

5.7.1 Psychosocial interventions delivered in groups

This section includes psychosocial interventions delivered in groups by trained alcohol practitioners.

There is evidence that several interventions for substance use disorders delivered on a one-to-one basis can also be effectively delivered in groups (Weiss and others, 2004).

Facilitating any group requires a high level of skill. Meeting the needs of multiple group members is more complex than one-to-one work. Services should ensure that therapeutic approaches to groupwork are evidence-based and that group facilitators are trained in groupwork and the specific group intervention they deliver. Facilitators should also receive clinical supervision by a supervisor trained in supervision and in groupwork and in the specific intervention they supervise, so that groups are safe and viable and achieve positive outcomes (Hill and Harris, 2011).

Group interventions can offer therapeutic opportunities that are not available in one-to-one sessions (Yalom and Leszcz, 2020). For example, groups can help people realise they are not alone in their experiences. This can reduce feelings of shame and create a sense of belonging. Support and challenges from peers in a safe environment can be powerful in motivating people to change, and group members can learn from one another’s experience. Groups can also help people learn to interact with others.

However, there are significant risks of attrition from groups in community treatment settings, so it’s important to have competent facilitation and a focus on maintaining engagement throughout.

Groups can be highly structured (for example, a mindfulness-based relapse prevention group). Alternatively, they could be less structured support groups where members share their experience of working towards their treatment and recovery goals.

The choice of specific group offered should be based on the setting, practitioner and supervisor competences, and the identified needs of the participants. Groups may aim to address the needs of any person in treatment assessed as appropriate or the needs of a particular group (for example, women or LGBTQ+ people).

Groups may include:

CBT groups such as relapse prevention (Wenzel and others, 2012) including coping skills training (see section 5.6.4 above) and mindfulness-based groups (see section 5.6.5 above)
interactional (also called interpersonal) groups
psychoeducational groups providing information on harmful drinking and alcohol dependence, health behaviours and recovery resources

There is little evidence on psychoeducational groups, but NICE CG115 recommends them as part of an intensive community programme and they provide practical help to reduce harm and build recovery resources.

Some services run groups focused on engagement and social or recreational activities. These can be an important part of supporting recovery, as identified in section 5.5.3 on rewarding activities and 5.5.4 on social support and recovery-oriented networks.

The parameters of a group intervention will vary according to its purpose and clinical leads will need to advise on:

therapeutic approach and target group membership
threshold of access (a closed group for one cohort only, cohorts joining at agreed points in a rolling schedule, or an open group that people can join at any time)
attendance at all sessions expected or optional drop ins
the length of time each group runs for and number of group sessions
ground rules describing boundaries and acceptable behaviour
adaptations for accessibility for individual members

The decision to offer a person a group intervention should be based on their assessment and formulation, and mutually agreed with the keyworker. There should be an explicit connection in the treatment and recovery plan between their goals and how the group can help to meet them.

Group interventions can be a valuable part of a person’s treatment. However, groups should not replace the offer of one-to-one interventions. These should always be available for people who do not want to engage in groups. The practitioner should assess any mental health conditions (for example, social phobia) and assess any risks the person might pose to others, and their suitability for a group intervention.

People are often anxious about groups and practitioners should address their concerns. Services offering group interventions should describe how groups can support recovery and have an induction process for newcomers to ensure they feel welcomed and supported.

The practitioner will need to share information on the purpose of the group, how it will run, and the ground rules. They should communicate information accessibly, considering group members’ language, literacy, sensory disability, cognitive disability and neurodiversity. It may be appropriate to introduce the new person to a peer who has experienced the group intervention and can share their experience of it, to help support engagement.

5.7.2 Intensive community and residential programmes

Intensive programmes consist of a range of groups and recovery-oriented activities to support people achieving their alcohol use goals (Orchowski and Johnson, 2012; Coco and others, 2019). These programmes provide support in the early weeks or months of abstinence, promote recovery, and strengthen social functioning.

Intensive programmes:

are usually delivered in residential settings
are generally abstinence based
include a focus on participation in communal activities

Intensive programmes can be delivered in community settings with sufficient capacity and staff competence. NICE CG115 recommends an intensive community programme after medically assisted withdrawal for people with complex needs who are mildly or moderately dependent, and for those who are severely dependent. It recommends that an intensive community programme should contain:

a drug regimen supported by psychological interventions including individual treatments
group treatments
psychoeducational interventions
help to attend self-help (peer support) groups
family and carer support and involvement
case management

Intensive community programmes usually require the person to attend for 4 to 5 days per week, and residential programmes require attendance for at least 5 days per week, with some requirements during weekends for a fixed period of time. There is no clear evidence about the best length of the programme. In the UK, intensive community programmes generally last between 4 and 12 weeks. The length of a programme should ideally be tailored to the individual’s needs. NICE CG115 recommends that a residential programme lasts up to 12 weeks.

You can find more guidance on intensive community and residential programmes in chapter 14 on residential and intensive structured day treatment.

Practitioners in community alcohol treatment services may have the opportunity to make referrals to an intensive community or residential based programme. Assessing whether such a referral is appropriate is a skilled job and there should be input from the MDT or a senior clinician. Intensive group programmes will usually be suitable for people who have engaged with standard treatment, but not appeared to benefit from it. However, there will be some people assessed as appropriate to move directly into an intensive programme.

Programmes are usually tailored to people with more severe dependence and with complex needs. These are usually orientated around the needs of people who need a high level of support to establish the foundations of their recovery and may require help in structuring their time and activities. However, some people with complex needs will require a more flexible, less intensive approach. Residential support may be most useful for people with little social support, including those experiencing homelessness.

There is wide variation in therapeutic approaches and programme requirements. It is important that the service and the practitioner are familiar with the approach and the requirements of the programme or programmes they are considering. The keyworker should communicate all relevant information to the person in an accessible way and should help the person to think through whether or not they want to engage in the treatment. If they do want to engage in the treatment, the keyworker should arrange visits.

The keyworker should ensure they have fully informed consent before making a referral. Where the referral is for residential treatment, the keyworker should find the results of the most recent inspection report (from the relevant inspection body) and only refer to services that are rated good quality or higher. They should share this information with the person so the person can make an informed decision. It’s important to prepare the person before they start the residential programme because it can help to reduce the risk of disengagement.

The keyworker should maintain contact with the person and with the staff of the structured group programme. The keyworker should arrange for early re-engagement with community treatment services for people who do not complete residential treatment and for those who need ongoing treatment and support after completing the programme.

5.7.3 Digital interventions

Definition of digital interventions

Services may offer digital and other remote interventions alongside in-person treatment to increase choice and accessibility for people with problem alcohol use. The term ‘digital interventions’ in alcohol treatment services covers a broad range of applications that enable remote support, which may combine both digital and in-person approaches as part of a person’s treatment and recovery plan. Or it could mean fully remote treatment provided using video or phone.

In these guidelines, ‘digital interventions’ refers to any interactive digital programme where there is contact between a practitioner and a person with problem alcohol use, to support them to change their behaviour. This can involve real time contact on video platforms like Microsoft Teams or Zoom, in place of in-person support. It can also involve contact using email or text chat, or phone-based support, where treatment is offered by a practitioner by phone to complement other methods, or for the entirety of the treatment.

This definition of digital interventions does not include digitally delivered information or screening tools that are offered in isolation, without any involvement from a practitioner.

Evidence of effectiveness

There is limited (but growing) evidence of the effectiveness of digital interventions in alcohol treatment and recovery (Kaner and others, 2017). There is emerging evidence to support the use of digital interventions to reduce alcohol health risk. For example, screening and alcohol brief interventions to reduce consumption. These interventions are appropriate for people drinking at increasing risk and at harmful levels (see glossary) who do not need specialist assessment or additional healthcare support.

There is currently less evidence for treatment of people with alcohol dependence, or people drinking at harmful levels who need specialist treatment. There is some evidence that online AUDIT based tools can support engagement in alcohol treatment interventions. Online tools such as the Alcohol Change UK’s Check your drinking quiz or TryDry app can be used to help people to reduce their drinking and can be considered as additional support alongside in-person structured treatment.

A systematic review of the effectiveness of remote and digital interventions in alcohol and drug treatment and recovery support found that remote interventions that supplement in-person alcohol and drug treatment appear to reduce relapse and the number of days people use drugs and alcohol (Kwan and others, 2025). The evidence is less conclusive for remote interventions that replace or partially replace in-person care due to a smaller body of evidence and uncertainty about how these interventions affect the number of days people use alcohol or drugs. The researchers noted that a high risk of bias means the findings should be interpreted with caution.

As more evidence on digital interventions emerges, these guidelines will be updated.

Offering digital interventions

Services can offer digital interventions to people seeking help for problem alcohol use if:

digital interventions are available
digital interventions are appropriate for the person after assessment and review
the person wants to use digital interventions

Services should continue to offer in-person support where the person prefers it, and especially where it will encourage ongoing engagement with treatment. Digital interventions should not replace the option of in-person treatment. Some people will not have access to digital technology or may not have digital skills, so services should ensure that these people can access all interventions in person.

For more information, see guidance on providing remote and in-person interventions for alcohol and drug treatment services.

Potential benefits and limitations

Digital interventions offer some potential benefits to services and to people who need treatment, including:

addressing geographical barriers, especially for people in rural communities or with limited transport options due to a lack of driving licence or public transport
providing flexibility, as well as cost and time efficiency, especially for people with caring responsibilities
enabling people with mobility issues to engage with treatment more easily
addressing stigma-related barriers, including those experienced by some faith groups

However, digital interventions also involve potential limitations and risks, including identifying:

alcohol and drug use by the person during the session
signs of urgent health crisis
undiagnosed physical and mental health conditions
poor self-care
general health issues

These limitations should be acknowledged in the assessment and in treatment planning. And from the start of treatment, practitioners should be aware of the need to manage risk in light of these.

Services can deliver in-person interventions in a way that minimises distractions and makes them more likely to be effective. But it’s difficult to guarantee that digital interventions will take place in a distraction-free environment, and this might reduce their effectiveness. Practitioners should take steps to reduce distractions. For example, they can encourage people to complete the intervention in a quiet room free of distractions, where this is possible.

Policies to support delivery of digital interventions

Practitioners can gather initial information for assessment remotely, but there should normally be an in-person assessment. This enables the practitioner to complete a comprehensive assessment, including:

the need for medically assisted withdrawal
physical and mental health
medical tests to be carried out, where indicated

Services using digital interventions should make sure that practitioners receive appropriate training so they are digitally competent. This includes understanding the ways that the therapeutic relationship can be established and maintained using digital interventions, as well being technically competent.

Services should maintain policies, and practitioners should receive training, in managing safeguarding and confidentiality when working remotely. For example, practitioners should always check whether the person is alone in the room. This will be particularly important where there are risks of domestic abuse. Services should also undertake a data protection impact assessment and maintain policies and procedures to protect confidentiality during remote interventions. And this should be discussed with the person.

Co-production, evaluation and sharing best practice are likely to be valuable in the future development of digital interventions to support alcohol treatment delivery. As services develop their digital interventions, they should seek feedback from people receiving and completing treatment to inform future developments.

5.8 Interventions for adult family members, partners and friends

Problem alcohol use can affect not only the person with the problem use, but also their partner, family and friends.

Members of the person’s family and social network can contribute to the treatment and recovery process, but they may also have support needs of their own. This section focuses specifically on providing support for adult family members, partners and friends. Services should offer support to partners, family and friends of a person with problem alcohol use even when the person with problem alcohol use is not in treatment.

For when and how to involve adult family members, partners or friends in psychosocial treatment interventions for the person with problem alcohol use, see section 5.6.6 of this chapter.

For guidance on considering adult family members, partners and friends as part of assessment for the person with problem alcohol use, see section 4.9.15 in chapter 4 on assessment and treatment and recovery planning.

For guidance on interventions to support children affected by problem parental alcohol use, see chapter 26.

Many family members, partners and friends experience stress as a result of living with a person with problem alcohol use. This stress can cause physical and psychological symptoms, affect their ability to cope, and affect the amount and quality of the social support they receive.

Services should offer families, partners and friends:

information on harmful drinking and alcohol dependence and how families, partners and friends can be affected
an appointment to provide support
an initial assessment of any urgent needs, where indicated

They should have clear, agreed arrangements covering confidentiality for both the person in treatment and the family member. Where a person does not agree to their personal information being shared with their family, partner or friends, the practitioner should provide general information about harmful drinking and alcohol dependence and how families can be affected, as well as information on treatment interventions. The service should still offer the family member a support intervention even if they are not involved in the person’s treatment.

The ‘stress-strain-coping-support model’ has been shown to reduce family members’ signs of strain (physical and psychological symptoms) and improve their coping mechanisms (Copello and others, 2000). This involves a 5-step approach:

Give the family member the opportunity to talk about the problem.
Provide them with relevant information.
Explore how the family member responds to and copes with their relative’s problem substance use.
Explore and enhance social support for the family member.
Discuss the possibilities of being referred for further support.

Practitioners should assess risks such as domestic abuse, suicidality and safeguarding concerns. Where these risks are indicated, they should produce an initial safety plan and refer to appropriate services.

Practitioners delivering the 5-step approach need to be trained in the approach and regularly supervised by suitably qualified supervisors.

Providing this support to a family member can also help the person in treatment to recognise the extent of their problem alcohol use, while enhancing engagement and treatment outcomes. However, this is an indirect secondary effect of the intervention and not its primary objective.

Family members or friends who spend a significant amount of time caring for a person with problem alcohol use are entitled to a formal carer’s assessment to see if they are eligible for social care and support services. Each of the UK nations has legislation and guidance covering carer’s support entitlement. You can find the relevant laws and guidance in annex 1.

Practitioners should discuss the carer’s assessment with adult family members and carers and have established pathways with local services responsible for providing carers’ assessments so they can make referrals as appropriate.

There are self-help groups which provide support for families, including:

Evidence has shown these groups to be beneficial (Miller and others, 1999). Practitioners should encourage family members to use local resources that support affected family members and carers.

5.9 References

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5. Psychosocial interventions

5.1 Main points

5.2 Introduction

5.2.1 Aims of psychosocial interventions

5.2.2 Principles of care

5.3 A framework for delivering psychosocial interventions

5.3.1 Framework overview for delivering psychosocial interventions

5.3.2 Delivering psychosocial interventions in a recovery-oriented system of care

5.3.3 Treatment phases

5.3.4 Assessment, formulation, and engagement

5.3.5 Severity of dependence and complexity

5.3.6 Duration of interventions or treatment episodes

5.3.7 Alcohol use goals

Identifying appropriate alcohol use goals

Using psychosocial interventions with different alcohol use goals

5.3.8 Psychosocial interventions: what they are

5.3.9 Structured support

Providing structured support

Structured support and recovery-oriented care

5.4 Clinical formulation

5.4.1 Clinical formulation: aims and objectives

5.4.2 Formulation framework

Predisposing factors

Precipitating factors

Perpetuating factors

Protective factors

5.5 Structured support: common factors in effective treatment

5.5.1 Therapeutic alliance

5.5.2 Support, structure and goal direction

5.5.3 Rewards and rewarding activities

5.5.4 Social support and recovery-oriented networks

Peer support and mutual aid

Facilitating access to mutual aid

5.5.5 Self-efficacy and coping skills

5.5.6 Structured support and motivational interventions

5.5.7 Structured support and support after treatment ends

5.6 Psychological treatments: selection and delivery

5.6.1 Selecting and using psychological treatments

5.6.2 Using motivational interviewing alongside psychological treatments

5.6.3 Behavioural approaches

5.6.4 Cognitive behavioural therapy

Relapse prevention

Interventions for low risk drinking goals

5.6.5 Third wave approaches and mindfulness

5.6.6 Interventions supported by family or social networks

Involving family, friends and social networks in treatment

Effective family-focused interventions

Social behaviour and network therapy

Behavioural couples therapy

5.7 Modes of delivery

5.7.1 Psychosocial interventions delivered in groups

5.7.2 Intensive community and residential programmes

5.7.3 Digital interventions

Definition of digital interventions

Evidence of effectiveness

Offering digital interventions

Potential benefits and limitations

Policies to support delivery of digital interventions

5.8 Interventions for adult family members, partners and friends

5.9 References

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