This week Alcohol Action Ireland convened a panel of experts with voices from those in recovery, service providers and research to discuss the significant gap between alcohol treatment provision and need and the barriers that people face in accessing what is available.
To say there is a gap is a very diplomatic way of highlighting what in fact is a huge chasm between what’s required and what is currently in place. Studies by the Health Research Board have found 14.8% of the population in Ireland – 578,000 people, show evidence of an alcohol use disorder, with 90,000 of those having a severe problem. International evidence suggests that at any one time, 10% of those in need might seek treatment. Yet data for 2020 shows there were only 3,319 new presentations gaining access to alcohol treatment. Is it any wonder really that people face problems accessing assistance when they need it?
Barriers to treatment
These barriers are on a spectrum from simply not knowing what’s available in terms of help and how to access it, to the lack of timely provision of services across all stages of recovery such as detox facilities and aftercare. For women there are also very specific issues such as childcare and the fear of having children taken away because of their alcohol problem. On top of all of this, they may be experiencing issues such as domestic abuse, financial struggles and grief, not to mention stigma for having the problem in the first place. Research shows that women with a drug or alcohol dependence disorder report significantly higher levels of stigma than men. Indeed, fear of stigmatising experiences is one of the most reported factors hindering women from accessing substance use treatment. As Prof Jo-Hanna Ivers, co-author of the excellent SWAAT report, put it: there are so many women with the potential to recover but they don’t get the opportunity because of the layers of barriers in their way.
One size does not fit all
The issue of mental health and trauma was one that permeated all of the talks. As is now well known, people don’t fall into addiction because of personal weakness or because they are enjoying themselves too much, but because they are attempting to self sooth, to numb themselves from trauma or pain.
The research now is clear that almost everyone accessing treatment services has experienced significant trauma at some point in their lives. Such issues include domestic violence, abuse, parental problem substance use, poverty and bereavement/ loss.
Services must be equipped to respond to these needs in a timely and holistic manner. If they can’t, people will not be able to recover fully and the likelihood of relapse is higher.
This was explained very well by a service user of Coolmine TC, who spoke at the event.
Emma said that she began using alcohol as a coping mechanism for underlying childhood trauma that she never told anyone about. On the outside she looked fine – she had a good job, a partner, she was a ‘functioning alcoholic’. Alcohol gave her a break from dark thoughts and her drinking eventually spiralled out of control to the point where she lost her partner and child. Today she is well into her recovery, but is clear that her mental health needs had to be treated in conjunction with her drinking.
“When a person presents for addiction treatment there will almost always be mental health issues (whether diagnosed or not) in the mix. There are so many moving parts, so many complex needs that all need to be met, in order for a person to embark on a journey of recovery,” she said.
It’s a theme that Amy Roche, CEO of Finglas Addiction Support Team (FAST), picked up on.
“We make people fit into models rather than the other way around. When people’s need are identified, we need to be able to respond in a coordinated integrated way,” she said.
“Treatment and recovery is not a linear model, no one size fits all and people are seeking treatment and recovery in many ways. We need to respond, and in line with Sláintecare’s commitment we need to develop initiatives that will offer the right care, in the right place at the right time.”
Unfortunately, this does not always happen and for those who do manage to access the system, they are likely the ones in crisis – in most need. That’s not good enough and we need to get to people before their lives have spiralled out of control. Of course the lack of treatment placements seriously hinders this, but if we did mange to get to people long before they required intensive treatment, we’d offset the need for costly and scant residential treatment placements.
One way to do this would be to ensure that all frontline professionals, for example GPs, who have so much contact with people, are well equipped to recognise the signs and to signpost people to community counselling and support.
A qualitative research paper carried out by Dr Sharon Lambert and Andrea McSweeney of the School of Applied Psychology, University College Cork, looked at the roles and experiences of professionals in supporting individuals who require treatment for alcohol dependence. Interviews with professionals working in addiction were carried out. Issues highlighted included long waiting lists, a lack of structured treatment pathways and the lack of trauma informed services to properly assist people.
The report states:
In Ireland, it is prevalent that there are long waiting times and lists for those wishing to access treatment. The issue of waiting for treatment was frequently mentioned by participants throughout the interview process: “To get into treatment there are big waiting lists… I suppose if they’re waiting to get into treatment centres and then they have a relapse, that sets them back.”
Trying to get people into treatment was also difficult because of a lack of clearly defined pathways within the system.
The report noted:
“A lack of set referral pathways … there’s also a lack of awareness of what kind of addiction services there are and what the workers do.” It appears that the referral process is quite ambiguous and lacking in solid guidelines: “I come up dependent in an alcohol assessment, what do I use as a tool or evidence to decide whether you go for residential or whether you stay in the community? You know, so that to me is left to the choice, really, maybe of the counsellor. I don’t think that’s appropriate… I also think though we need something that will tell us the pathway.”
The suggestion of introducing guidelines for those key professionals involved in referring clients was prevalent among participants.
It is very concerning to hear that frontline professionals working with people every day in a country where alcohol harm is so common have such trouble getting people help. In terms of community supports it is heartening that currently the HSE is investing in more frontline community-based drug & alcohol treatment interventions. What we need as a matter of urgency is a comprehensive directory of all the resources and support services available across the country.
It is astonishing to think that this information is not readily available in a modern accessible way that shows what’s available in each CHO area, what the capacity of the service is and what exactly is being offered – ie individual counselling, a group programme, residential treatment and so on. People should know if the service is trauma-informed, gender sensitive, has a religious ethos etc. If we are serious that addiction treatment is part of our healthcare services, accessible information is a vital tool, not just for people but for GPs, social workers, mental health professionals, probation officers – anyone who might look to refer people for help.
Alcohol Action advocates that a national strategy for treatment services should set out the types of interventions that constitute best practice and develop national standards to which all services should adhere. Person-centred trauma-informed services would ensure that people’s rights are at the centre of policies and practices and it is vital that services are evaluated and monitored for effectiveness. We also need to normalise the concept of getting help. Heavy drinking is normalised in Ireland, so we should expect there will be a significant fallout from this – as indeed the HRB figures cited at the outset show. There shouldn’t be a shame and stigma in seeking assistance if a problem develops.
On top of all of these issues there is also the question of how to pay for the treatment which is vitally needed. Addiction services are currently funded at a level of around €103 million annually while the wider costs of alcohol to the State are estimated at least at €3.6 billion. We have allowed our society to be awash in alcohol marketing that sends a message that alcohol is a product that brings happiness, success and sporting achievement. When it leads to addiction, health problems and family destruction perhaps we should be looking to the alcohol industry to pick up the tab.
A recording of the event is available here.
