Drinking-up time

A problem drinker who has a relapse will probably not be
treated as sympathetically at work as someone with a recurrence of, say,
hypertension or diabetes. But in the armed services, where retaining trained
personnel is vital, every effort is made to help, by A Kingscote, B Coldwell, and
C Mackin

Many conditions that have a behavioural component, such as diabetes,
hypertension and asthma, often reoccur. Similarly, problem drinkers are known
to relapse.

While a review of outcome research demonstrates that the treatment of
alcohol problems, diabetes, hypertension and asthma are comparable1, the
potential occupational consequences are often more severe for the problem

Employers frequently regard relapse as a continuation of the original
problem, even when people have been successful in moderating their behaviour
for some time. The employee may be dealt with as having ‘used up’ his or her
‘last chance’.

This poses a dilemma for those working in occupational health. Dismissal for
the problem drinker following a period of success may seem harsh and this view
is compounded by the fact that relapse in other conditions that have a similar
rate of recurrence are likely to be dealt with much more sympathetically.

This dilemma is particularly acute in situation such as that in the military
services, where recruitment and retention of personnel are areas of great

Does rehabilitation work?

In a recent presentation at the International Conference for the Treatment
of Addictive Behaviours, Cape Town, 2000, McLellan1 suggested the question:
"Does rehabilitation of problem drinkers work?", should be placed in
the context of a second question: "Compared to what?"

A review of the research clearly demonstrated that the outcome of alcohol
rehabilitation is comparable to other conditions.

Relapse through non-compliance with treatment leading to a further episode
of incapacity is common in many conditions, yet, as most workers with an
alcohol problem are aware, the attitudes of employers and healthcare
professionals are likely to be much more subjective in their case.

A recurrence of asthma or hypertension as a result of failure to comply with
treatment is usually dealt with as another episode of the original problem.
With this approach in mind, a pathway of care was formulated by the substance
misuse team at the Duchess of Kent Psychiatric Hospital, which is part of the
occupational health services for the Royal Navy, British Army, and Royal

Pathway of care

It can be seen from the figure above that the pathway of care is also
applicable to other conditions with a behavioural component. It also meets the
needs of both employer and employee.

The pathway of care consists of

– Planning reviews

– Ongoing treatment and support

– Treatment for relapse with alternatives for future treatment/discharge
within a two-year period

– Plans for relapse following a two-year period of success

This provides the clinician, the client/employee and the employer with a
clear agenda. Setting out the pathway of care in this way may help those
considering continuation or termination of service to make decisions regarding
servicemen or women treated for alcohol misuse. Decisions made in this way will
be the same as those made for clients treated for other conditions that are
subject to recurrence.

Alcohol misuse has serious implications for fitness for duty in a
professional military organisation but the loss of highly trained personnel is
also taken seriously.

Referral, assessment and treatment procedures are largely similar to those
operating elsewhere. However the consideration of ‘fitness to serve on’ within
a military service is critical.

Fortunately, in the services, it is possible in some cases to reduce the person’s
responsibilities by organising reassignment to less sensitive areas or
relocation to settings more conducive to long-term success.

Review, ongoing support and re-assessment are essential. Extra help from the
substance misuse team is available to clients either by attending the unit or
through the support and consultative advice it can give to community services.

Treatment and rehabilitation

Initial treatment following assessment offers a rehabilitation programme
that includes attending a three-day cognitive behavioural group that uses
motivational interviewing techniques with added individual sessions Using the
cycle of change2, relapse prevention and dealing with relapse are integral
components of treatment. At follow up, slips and relapse are dealt with as
learning experiences, with the aim of attaining long-term success.

Accepting the cycle of change, clinicians are able to justify long-term
treatment of clients. However, employers have wider responsibilities than to
the person alone. Occupational health staff have responsibilities to individual
employees, the workforce as a whole and the employer. They need to apply the
cycle of change within their particular context.

These responsibilities are particularly pertinent for the substance abuse
team working in the military setting. So, the development of a clear pathway of
care is essential. While review of ‘safety and suitability to serving on’ is an
ongoing process built into the ‘trial of duty’, the pathway developed builds in
the pathway of success.

Following a period of two years or longer of abstinence or unproblematic
drinking, relapse is dealt with as a new problem, as the precipitating
contingencies may well differ from the original referral. So, the relapse of an
alcohol problem is dealt with in much the same way as a recurrence or further
episode of conditions such as asthma or hypertension.

It would seem that this approach is consistent with research findings and
with meeting the needs of the military services in retaining skilled personnel.
Defining the pathway clearly to the employer and the employee gives all
concerned a clear understanding of the treatment approach and fulfils the
responsibilities of the occupational health department.

Removing the sword of Damocles that hangs over people being treated for a
relapse of alcohol abuse is likely to result in more people seeking help, and
being re-referred more quickly. It may be considered that development of
similar pathways may be useful in other settings catering to the particular
needs of specific organisations.

Dr A Kingscote is Consultant Psychiatrist, Ms B Coldwell, Consultant
Clinical Psychologist and Mr C Mackin, Clinical Nurse Specialist at the
Substance Misuse Team, Duchess of Kent Psychiatric Hospital, Catterick, N.


1. McLellan AT (2000) Does Alcohol Treatment Work? Presentation at the
International Conference on Treatment of Addictive Behaviours, Cape Town, South

2. Prochaska J, DiClemente C (1998) Comments, criteria and creating better
models; in response to Davidson. In: Miller WR, Heather N (eds) Treating
Addictive Behaviours. New York: Plenum.

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