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‘What happened to the survivors?
A mixed-methods study of ‘Treatment’ and
‘Recovery’ - seeking alcohol patients’
Andrew James Philip MacDonald
A Dissertation submitted in partial fulfilment of the requirements for the
Degree of Masters in Science in Public Health
School of Health and Social Sciences
Liverpool John Moore’s University
Submitted on April 2nd
2013

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Table of Contents
List of Tables
Table 1 Structured Interview Data Extracts Page 97
Table 2 Services Used By Residents in Structured Interview Sample Page 98
List of Figures in Appendices
Figure 1 Total ‘Top 200’ Cohort Deaths in Treatment at Salford Royal Page 91
Figure 2 Cohort ‘Liver Disease’ Prevalence at Salford Royal Page 92
Figure 3 Cohort Christo Inventory of Substance Misuse Services (CISS) Median
Scores at Salford Royal Alcohol Assertive Outreach Service Page 93
Figure 4 NVivo 10 Framework Analysis – Participant Node Extracts Page 94
Figure 5 NVivo Recovery Matrix Page 100
Figure 6 NVivo 10 Recovery References Page 102
Figure 7 NVivo 10 Framework Analysis – Participant Node Extracts Page 106
List of Photographs
Front cover of this study – ‘Big Sur’ and beyond
Acknowledgements page - front cover of Courtwright’s study (Sheila Hart)
List of Graphs
Graph 1 Trends Per capita Alcohol Consumption and Alcohol-related Deaths per
100,000 Population United Kingdom 1984-2008 Page 10
Graph 2 International Classification of Disease (ICD10) Liver Disease, Liver
Cirrhosis, Mental & Behavioural Disorder 1984-2008 Page 10
Graph 3 Salford Royal Hospital Admissions (Hughes et al 2012) Page 91

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List of Diagrams
Diagram 1 Complexity, Severity, Motivation and Assets Matrix Page 13, 97
1. Introduction and Aims and Objectives Page 9
1.1. Alcohol as a Public Health Issue Page 9
1.2. The Epidemiology of Alcohol in the United Kingdom Page 9
1.3. National alcohol ‘treatment’ approaches Page 11
1.4. Why conduct this study in Salford? Page 11
1.5. Why conduct this study now? Page 14
1.6. What is the personal interest of the author? Page 15
1.7. Structure and Content of the Study Report Page 16
1.7.1. Literature Review Page 16
1.7.2. Methodology Page 17
1.7.3. Results Page 17
1.7.4. Discussion and Conclusions Page 18
1.8. Aims and Objectives Page 18
2. Review of the Literature Page 20
2.1. Why was this study inspired by an earlier US study from 1989? Page 20
2.2. The ‘paradigm shift’ between ‘treatment’ and ‘recovery’ Page 20
2.3. What is ‘dependent’ alcohol use? Page 21
2.4 What is ‘recovery’? Page 22
2.5. The history of alcohol ‘treatment’ and ‘recovery’ in the literature Page 23
2.6. Literature review search methodology Page 29
2.7. Why we must ultimately exclude Quantitative Studies Page 32
2.8. Conclusion Page 34
3. Methodology Page 36
3.1. Research Design Page 36
3.2. Collection method - Quantitative data Page 36
3.3. Collection method - Qualitative data Page 36
3.4. Structured Questionnaire and Semi Structured Questions Page 38
3.5. Data Analysis – Quantitative Data Page 39
3.6. Data Analysis – Qualitative Data - Framework Analysis Page 40
3.6.1. Stage 1: Familiarization Page 40
3.6.2. Stage 2: Thematic Analysis Page 41
3.6.3. Stage 3: Indexing Page 41
3.6.4. Stage 4: Charting Page 41
3.6.5. Stage 5: Mapping and Interpretation Page 42
3.7. Strengths of the ‘Mixed Methods’ Approach Page 42
3.8. Possible sources of bias Page 43
3.9. Ethical or Political Considerations Page 44

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3.10. Limitations Page 45
4. Results Page 46
4.1 Were the right participants drawn down from the larger patient cohort? Page 46
4.2. Does the fractured data align with the literature and evidence base? Page 47
4.2.1. Complexity Page 47
4.2.2. Severity Page 48
4.2.3. Motivation Page 48
4.2.4. Assets Page 49
4.3. Where does this lead us? Page 50
4.3.1. Damascene Recovery Page 52
4.3.2. Relationships Page 53
4.3.3. Religion Page 54
4.3.4. Survival Page 55
4.3.5. The Treatment and Recovery Paradigm Debate Page 56
4.4. Has the study met the overall aims and objectives? Page 57
5. Discussion Page 59
5.1. Introduction and Summary Page 59
5.2. A critical appraisal of the study in the context of other relevant work Page 61
5.3. The wider relevance and implications of the findings Page 63
6. Conclusion and Recommendations Page 66
6.1. Conclusions Page 66
6.2. Recommendations for further investigation and public health action flowing from
the results and discussion Page 67
6.3. The strengths and limitations of the study Page 69
7. References Page 77
6. Appendices Pages 82-113
Appendix 1 Questionnaire Page 83
Appendix 2 Ethical Approval Page 85
Appendix 3 Interview Schedules Page 86
Appendix 4 Consent Forms Page 87
Appendix 5 Participant Information Page 88

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Appendix 6 Mixed Methods Study Data Pages 90-113
6.1. Salford Royal Alcohol Assertive Outreach Phase 1-2 Page 90
6.2. Salford Royal Alcohol Assertive Outreach Phase 1-3 Page 92
6.3. NVivo 10 Framework Analysis – Participant Node Extracts Page 94
6.4. Structured Matrix: ‘Complexity’ / ‘Severity’ / ‘Motivation’ / ‘Assets’ Page 96
6.5. Structured Interview Data Extracts Page 97
6.6. Services Used By Residents in Structured Interview Sample Page 98
6.7. NVivo Recovery Matrix - Distribution in Participant Statements Page 100
6.8. NVivo 10 Recovery References Page 101
6.9. NVivo 10 Framework Analysis – Participant Node Extracts Page 106
6.10. Example of Participant Transcript – Highlighting ‘Damascene’ Recovery and
the Existential Journey Page 108
Appendix 7: In the Garden – Van Morrison Page 113

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Abstract
Rationale: Despite years of research into the clinical effectiveness of alcohol
treatment, less is known about survival and recovery after treatment. This is a major
public health issue and is the subject of this study.
Aims and Objectives: The main research question of this mixed methods study was
to find out how and why dependent drinkers leaving treatment decided to engage
with long term recovery.
Methods: An extreme sample of 5 patients was recruited from a cohort of 200
patients from an earlier study. All had received treatment for acute alcohol related
problems at a hospital in the North West of England between 2008 and 2012. All 5
had then been discharged into a residential recovery facility. A purposive sample of 6
members of staff from that facility (all of whom had been in recovery for many years)
was also recruited. A structured questionnaire and semi structured interview was
administered to all 11. Using NVivo 10 software, data was extracted from the
transcripts and matched against a ‘Framework Analysis’, aligned to the evidence
base. This process identified material highlighting known recovery themes, but also
material which revealed gaps in knowledge.
Key findings: The experience of treatment for alcohol use does not in itself prepare
people for sustained recovery. The transition process is marked for all patients by
traumatic events, and for some is followed by a quasi religious and spiritual ‘tipping
point’. ‘Damascene Recovery’ or a conversion on the way into a new world is not a
novel idea entirely, but more research is required to describe the phenomenon.
Policy implications: Public Health England needs to draw more people into
recovery from alcohol dependency. Health professionals could learn much from
recovery professionals, and vice versa, about the transition between treatment and
recovery; major workforce and training issues arise from this.
Abstract Word Count: 300
Study Word Count: 16, 394 (15,000 +/- 10%: 13,500 minimum, 16,500 maximum)
Key Words: Drugs, Alcohol, Treatment, Recovery, Damascene Recovery

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Acknowledgements
- To Courtwright, Joseph and Des Jarlais for their elegant study of the survivors
- To Dr Conan Leavy and to Dr Lorna Porcaletto for their encouragement
- To Dr Colin Wisely for his inspiration over recent years
- To Dr Neill Hughes, Dr Martin Smith, Dr Richard Warner, Dr Haitham
Nadeem, and last but not least, Dr Ahmed Al-Rifai who now carry the torch
first lit by Dr Griffith Edwards
- To Mark Knight, Gordon Adams, Liza Scanlon, Jack Sharp, Melanie Walters,
and last but not least Suzanne McDonald, for helping with quantitative
statistics and qualitative data
- To all at the residential recovery centre who gave their time and shared their
experiences of ‘treatment’ and ‘recovery’
- And last - but not least - to Kate and all of my family.

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Declaration
‘The results presented in this dissertation are based on my own research in the
Faculty of Health and Applied Social Sciences, Liverpool John Moore’s University.
All assistance received from other individuals and organisations has been
acknowledged and full reference is made to all published and unpublished sources
used. This dissertation has not been previously submitted for a degree at any other
institution.’
Signed: A.J.P. MacDonald
Date: 2nd
April 2013

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1. Introduction: Aims and Objectives
1.1. Alcohol as a Public Health Issue
Patterns of alcohol consumption in the UK have changed dramatically over the last
50 years. Alcohol is now 45% more affordable than in 1980 and yet accounts for only
5.2% of household spending. There has been a major rise in home drinking and a
decline in the amount of alcohol consumed in pubs and bars. Supermarkets are the
leading providers of alcohol for home consumption. There is therefore easy access
to cheap high strength alcohol for the whole population; this has had an impact upon
those most vulnerable to abusing alcohol, leading to an earlier and greater onset of
alcohol related disease (LGA, 2013).
1.2. The Epidemiology of Alcohol in the United Kingdom
Over 10 million adults in England now drink more alcohol than the recommended
daily limit and 2.6 million drink more than twice this. The cost of alcohol-related harm
to the NHS is estimated at around £2.7 billion per year (ONS, 2012). The rate of
increase in alcohol-related deaths has risen most steeply among those in their
thirties, forties and fifties (Plant et al., 2009). The serious nature of alcohol as a
public health issue is reflected in national and international strategies (WHO, 2007).
Alcohol consumption has a clear impact on public health. In 2010-11 there were
198,900 hospital admissions directly attributable to alcohol, an increase of 40% since
2002-3. Furthermore, in 2010 6,669 deaths were directly attributable to alcohol, a
rise of 22% on the 2001 figure (ONS, 2012).

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Graph 1 Trends Per capita Alcohol Consumption and Alcohol-related Deaths per 100,000 Population UK 1984-2008
On the one hand, as above, the population level alcohol consumption is falling
accompanied by fewer deaths, as is often seen in times of recession (Pacula,
2011)1
. On the other hand, as below, alcohol related liver disease, liver cirrhosis and
mental and behavioural hospital discharges rose from 1992-20082
.
Graph 2 (ICD10) Liver Disease, Liver Cirrhosis, Mental & Behavioural Disorder 1984-2008
1
ONS UK, Scottish Government, Northern Ireland Department of Health, Beer and Pub Association Trends Per capita Alcohol
Consumption and Alcohol-related Deaths per 100,000 population United Kingdom 1984 – 2008 (2008)
2
ICD10 Liver Disease, Liver Cirrhosis, Mental & Behavioural Disorder 1984-2008 English Information Centre for Health and
Social Care, Health Solutions Wales, the Scottish Government, the Northern Ireland Government (2008)
-1.5
-1
-0.5
0
0.5
1
1.5
2
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Years
Z-Scores
z - consumption z - mortality
Sources
Mortality: UK Office of National statistics, the Scottish Government and the Northern Ireland Department of Health.
Consumption: The British Beer and Pub Association 2008.
0
50
100
150
200
250
300
350
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Year
Alcoholic liver disease per 100,000 in England
Alcoholic liver disease per 100,000 in Northern
Ireland
Cirrhosis per 100,000 hospital discharges in
Wales
Mental and Behavioural disorders per 100,000
in England
SOURCES: English Information Centre for Health and Social Care, Health Solutions Wales, the Scottish Government, the Northern Ireland Government

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1.3. National alcohol ‘treatment’ approaches
This study is concerned with the treatment of and long term recovery from alcohol
abuse. In the United Kingdom patients at risk are targeted through screening
programmes. Patients are then offered a variety of treatment options depending on
the complexity and severity of their alcohol use. Their longer term recovery is a
matter of balancing clinical treatment, support in the community, and patient
motivation to change (NICE, 2010, 2011).
The transition, from ‘treatment’ to ‘recovery’ is described in a series of publications
by the National Treatment Agency, which deals with drug and alcohol misuse (NTA
2010, 2011, 2012). The United Kingdom Government in the last three years
published drug, alcohol and mental health strategies. Drug, alcohol and mental
health problems may be contemporaneous and this further complicates the delivery
of both ‘treatment’ and ‘recovery’ (Home Office, 2010, 2012, Department of Health,
2011). Advances in thinking as to how to best make the transition from ‘treatment’ to
‘recovery’ include ‘personalized treatment’ and ‘personalized recovery’ (National
Treatment Agency, 2012). This reflects an international search for a better
understanding of the means to draw people away from ‘treatment’ and towards
‘recovery’. This is the focal point of this study.
1.4. Why conduct this study in Salford?
Salford is one of the more extreme alcohol research sites in the United Kingdom.
Salford has one of the highest rates of alcohol related morbidity and mortality and

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amongst the highest rates of alcohol related hospital admissions in the country
(LAPE, 2013). Salford also has one of the most progressive acute hospitals in the
country which faces huge scale alcohol problems on a daily basis: around one in
three people in Salford are artificially estimated to have some form of alcohol
problem (Department of Health, 2004).
It will assist the reader at this point to appreciate that the battle ground for public
health is ultimately in the acute hospital – i.e. preventing as many people as possible
from going there. On the front line are the Consultants. This study is possible
because of the interest of the local hospital Emergency Medicine Consultants who
first worked with the research team, on a study of their own, for British Medical
Journal publications, of which I am cited as joint author, and now on this study
(Hughes et al, 2012).
This earlier study looked at the impact of working intensively with the acute and
chronic drinkers who populate the emergency room on a typical weekend night. The
quantitative data for this concerned a cohort of 200 patients in 2008, tracked for four
years, which provided an extreme sample for the current study, four years later. As a
by product this new study refreshes the data on the original patients pre and post
treatment as detailed in the Appendix (Appendix 6: 1, 2, 3).
It will further assist readers to understand, that as a result of this local work
commissioners in Salford have developed an evidence based ‘matrix’ by which we
assess the individual patient, describe the care they require, and also judge the

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clinical and other risks, as to the optimum timing and conditions for their recovery.
This is described by Diagram 1 below.
Diagram 1 Complexity, Severity, Motivation and Assets Matrix
So that the reader understands this obtuse notion clearly, a few words of explanation
are required. The ‘matrix’, as it will be referred to in the study, comprises of
‘complexity’ and ‘severity’. That describes the incidence and prevalence of alcohol
dependence and related co-morbidities, such as mental health problems. The
‘matrix’ is also comprised of ‘motivation’ and ‘assets’. That concerns the
psychological preparedness of the patient, and the strength of family ties, and social
networks.
This tool is entirely consistent with the evidence base, which it helpfully distils for
clinical, commissioning and research purposes (Best et al., 2012, Strang et al.,
2012). Patient flow analysis in Salford has subsequently confirmed that the ‘matrix’
captures the decision processes for clinicians and recovery providers, and is a
relevant tool for the segmentation and analysis of patient experience. This is detailed
in the appendices – a key example is the Salford ‘alcohol assertive outreach’

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approach which tests the model to the extreme (Hughes et al., 2012). Salford is
therefore an ideal place to study things getting worse, but is also to study how things
might get better. If that is accepted, a further question is why now?
1.5. Why conduct this study now?
There are many reasons for undertaking this study: humanitarian, health, community
cohesion, community safety, political, financial and academic:
Firstly, the study was feasible because there is a stable ‘community’ of ex addicts in
Salford. As the internationally renowned commentator, William White describes, this
‘community’ acts as a ‘...healing forest...’, ensuring ex users in ‘recovery’ stay close
to each other, so that if and when one stumbles, none fall (White & Kurtz, 2006). The
study sees this community in action.
Secondly, as mentioned, this study updates vanguard research in Salford started
some four years ago, at a local acute hospital. Knowing why patients made the
transition from ‘treatment’ into ‘recovery’ will add an important layer of knowledge to
the evidence base.
Thirdly, the study is contemporaneous with recent ‘recovery’ focused national drug
and alcohol strategies (Home Office, 2010, 2012). These are aligned to major
capacity building in ‘treatment’ and ‘recovery’ by the National Treatment Agency
‘Building recovery in Communities’ (National Treatment Agency, 2012). This is an
interesting moment simply because experts now acknowledge that ‘treatment’ alone

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can only lay the foundations of long term ‘recovery’, and that ‘recovery’ is essentially
a different entity to ‘treatment’ (Strang et al., 2012).
Fourthly, drugs and alcohol make up over 25% of the public health budget within the
new Local Authority framework. The money sits alongside monies from the Police
and Crime Commissioners and the new Clinical Commissioning Groups. The public
health budget will be under local political control for the first time since the early
1970s. There is no guarantee that the priorities of the NHS will be those of local
councillors; an interesting political ‘fin de siècle’ moment;
Fifth, and finally, there is a limited understanding of the mechanism by which people
move from ‘treatment’ into ‘recovery’. Such an extreme, but well resourced – and
well evaluated test site – with four years of data - provided a unique opportunity to go
towards addressing that deficit. ‘Treatment’ and ‘recovery’ are a focus of the
literature review, as these concepts are clearly important to this study and given
detailed definitions to assist the reader.
1.6. What is the personal interest of the author?
The author commissions a major hospital and a residential recovery service in the
North West which form the quantitative and qualitative sites. This raises questions of
influence and bias (which the study will address), but also opportunities for unique
insights.

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1.7. Structure and content of the study report
Individual chapters in the study will concern:
- A literature review of evidence underpinning the study
- The methodology of the study
- The results of the study
- The discussion arising from the study
- The conclusions and recommendations arising from the study
These are briefly outlined below.
1.7.1. Literature Review
The study is framed around a methodology originally used in a classic 1989 US drug
user study which is fully described in the introduction to the literature review
(Courtwright 1989). The current study will then review the relevant classic alcohol
studies of the last 50 years. These fall into four key phases:
Firstly: a disease typology of progressive and irreversible ‘alcoholism’, which
reached an academic pinnacle internationally in 1960;
Secondly: over the next 30 years a growing recognition over that some ‘alcoholics’
regain ‘control’ over their drinking, but these are mainly those with more social
assets such as housing, relationships, work and families;

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Thirdly: towards the end of that period, a recognition that ‘addicts’ may ‘naturally
recover’ regardless of the offer of ‘treatment’ and ‘mature out’ of addiction;
Fourthly: that ‘recovery’ may take many attempts over many years to reach this
stage – with numerous calls on psychological, pharmacological and social support.
1.7.2. Methodology
As highlighted in the previous section, the study utilised a methodology from a
classic 1989 US study which is fully described in the literature review. The current
study subjects started as patients of the emergency department at weekends.
Having established their ‘treatment profile’, the study followed them through the
system. The study details interviews with an extreme sample of these patients
discharged to a residential facility we will call ‘St Paul’s House’, and also a purposive
sample of staff at St Paul’s. Participants were asked about how they had survived
and why they sought long term ‘recovery’ post ‘treatment’ and this data was
analysed using a ‘framework analysis’ which is detailed fully in the methodology
section (Green & Thorogood 2010).
1.7.3. Results
The results showed a complex picture of ‘recovery’. The study demonstrates both
the pains ‘treatment’ and the revelation of ‘recovery’, and reveals further layers of
existential experience - these concern spiritual growth.

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1.7.4. Discussion and Conclusions
What becomes obvious is that ‘recovery’ is not solely intellectual – but also spiritual.
The enervating moment of ‘recovery’ cannot be mapped into ‘treatment’ guidelines,
or clinical guidance. What cannot be described in words needs to be experienced –
more people need to ‘see’ and ‘hear’ from those who know. Those who know are
rarely doctors and are always people who know both ‘treatment’ and ‘recovery’
paradigms.
1.8. Aims and Objectives
This study was inspired by one of the consultants at my local hospital who wanted to
know how best to get across the idea of ‘recovery’ to his patients once ‘treatment’
had deferred their early mortality, from dependent alcohol use. It is critical that the
reader fully appreciates the Bacchanalian scenes in the average emergency
department at the weekends. All in the field acknowledge that most doctors simply
do not have these words which seem to emit from somewhere beyond clinical
understanding. This study will try to answer the doctor’s questions. The aims and
objectives of the study follow on from that.
The aim of this study was:
- To gain a better understanding of how dependent drinkers enter ‘recovery’
The objectives of this study were:

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- To establish ‘recovery’ characteristics amongst alcohol ‘treatment’ survivors
and;
- To explore notions of ‘recovery’ as described by alcohol ‘treatment’ survivors3
.
3
See Appendices 6:1, 6:2, and 6:3 for details of the original Salford Royal study (Hughes et al, 2012)
and Appendices 6:4, 6:5. 6:6, 6:7, 6:8, 6:9 and 6:10 for the details of the current qualitative and
quantitative mixed methods study.

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2. Review of the Literature
2.1. Why was this study inspired by an earlier US study from 1989?
It will assist the reader to understand that this present study is based upon
Courtwright’s highly regarded study in the US into the history of drug addiction.
Courtwright detailed the rise of ‘the asylum’, of ‘psychiatry’ and the ‘medical’ model’
in treatment; this work is thus of both historical and symbolic significance to the
present study, which looks at a new world where this status quo ante has ended.
Courtwright adopted an elegant study design - using a structured questionnaire he
gained a sense that his participants were indeed from the extreme end of drug
misuse - and then asked a series of brief semi-structured questions to gain a deeper
sense of their forays into ‘recovery’. This present study pays homage to Courtwright
in adopting much of that original design and the content of his questionnaires. We
will return to look at Courtwright’s study in detail after setting out the key parameters
of the debate and definitions.
2.2. The ‘paradigm shift’ between ‘treatment’ and ‘recovery’
There is a ‘fin de siècle’ feel to current events in this field. For the non-cognoscenti
reader it is crucial to gain an appreciation of the recent work of two key figures. The
first, representing the medical establishment, is Professor John Strang - the second
William White, representing ‘recovery’: together they wrote ‘Medications in Recovery’

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(Strang et al., 2012). Strang and White acknowledge the Rubicon between
‘treatment’ and ‘recovery’.
The report advises clinicians to deliver balanced psychological, pharmacological and
social support for those in treatment to encourage more to enter long term recovery
(Strang et al., 2012). The paper marks a power or ‘paradigm’ shift. A ‘scientific
paradigm’ concerns the practices that define a scientific discipline in a particular
period (Kuhn, 1962). The ‘paradigm shift’ put simply is that the hegemony of
‘treatment’ and all its panoply, which as we shall detail, has lasted for fifty years, is
over, and ‘treatment’ now pays obeisance to ‘recovery’. It is important that the
general reader next gains a sense of what these perhaps somewhat nebulous terms
– ‘treatment’ (for ‘dependent alcohol use’) and ‘recovery’ mean in the field.
2.3. What is ‘dependent’ alcohol use?
It is important that the reader clearly understands what type of drinker the subjects
are. The aim of the study is to focus on the heaviest level of alcohol consumption
known in the population; ‘dependent drinking’.
What this means in lay terms is that because alcohol is both physically and
psychologically addictive these patients have reached a point where they are unable
to prevent medical emergencies occurring as a result of ‘dependent’ drinking. As the
National Institute of Clinical Excellence describe being dependent on alcohol is;
‘...being unable to function without alcohol, that consumption of alcohol becomes the
focal point of one’s life...’ (NICE, 2011)

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In this state, withdrawal symptoms may well follow sudden cessation of drinking
alcohol; both physical and psychological (NICE, 2011). In short, once in this state, it
becomes hard to stop and sustain this, and mortality looms.
2.4. What is ‘recovery’?
It is also important that the reader gets a clear sense of an important term for this
study – that of ‘recovery’, within the drug and alcohol treatment field. ‘Recovery’ now
has an internationally agreed definition, subsumed into UK policy:
‘...a voluntarily maintained lifestyle characterised by sobriety, personal health and
citizenship...’ (McClellan et al., 2010, Best et al., 2012)
So what is different about ‘treatment’ and ‘recovery’? Is the travel from one to the
other linear? A major debate has taken place in the world of ‘recovery’ – centred on
the work of Alcoholics Anonymous – and related credo. This concerns whether
‘moderated’, ‘medicated’ and ‘abstinent’ iterations are all ‘recovery’, or phases of
‘treatment’ (White & Kurtz, 2006).
The ‘treatment’ of ‘dependent’ drinking as defined in NICE guidance rests on
substantial international evidence over the last 50 years (NICE, 2011). This whole
‘body of scientific knowledge’ (and importantly, the power and status which go with) it
are what Kuhn called a ‘scientific paradigm’ (Kuhn 1962). That is - definitions of
‘health’ and ‘wellbeing’ are made by scientific experts which state when one is ‘not
well’ and requiring ‘treatment’ and in what form. As we will see ‘recovery’ comes from
a wholly different body of knowledge - a different world – a different ‘paradigm’.

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The study explores facets of this debate from the ‘participant’ viewpoint. As we shall
see, doctors and patients now see ‘recovery’ as another state one aspires to, tries
out, and then moves to. This leads to tensions in the evidence base as attempts
have been made over 50 years to pin down the journey from ‘treatment’ to ‘recovery’.
This as we shall also see is reflected in the lives and statements of the ‘patients’ and
‘participants’ in this study. The study will attempt to show what this ‘journey’ looks
like and what marks out those who seek to make the change. Further, what is the
history of this in the literature?
2.5. The history of alcohol ‘treatment’ and ‘recovery’ in the literature
The proposition up to the 1960s was that alcoholism may be fitted within a
predictable, progressive typology towards an advanced disease state (Jellinek,
1960). This notion was challenged by work at the Maudsley Hospital. This suggested
that some more stable and better resourced alcoholics may recover spontaneously
and do better still if offered structured support (Davies, 1962).
The early promise of this lasted for a period; when it seemed that alcoholism was a
state from which better supported alcoholics might mature out (Winnick 1962, 1974).
However during the 1980s and 1990s the complexities of this emerged just as
psychiatry, behavioural psychology and medicine wrestled to take the ‘treatment’
high ground (Edwards, 1985, Heather, 2006).

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What was clear by the 1990s was that ‘recovery’ from alcoholism was feasible, but
only for those with appropriate social support and alternative occupations to drinking
– be they temporal, vocational or spiritual (Vaillant, 1995). It was also emerging that
alcoholism needed to be understood as a ‘chronic relapsing’ condition for some, but
also as a ‘social construct’ (Brown, 1998). What did the latter mean?
It was self evident that alcohol dependency was a condition which was serious and
long term, and came to be located as an emergency – an acute condition to be dealt
with in hospitals – and in more serious case, psychiatric wards. However, by the
1980s alcohol dependency was becoming less regarded as a chronic condition
requiring long stays in psychiatric institutions. The reason for this is that the
mechanisms by which patients moved from ‘treatment’ to ‘recovery’ were better
understood. It became fashionable to describe the potential for patients to regain
‘control’ – it thus seemed alcoholism resulted from social circumstances – or what
might be called ‘social assets’. It became crucial to understand the perceptions of
patients at critical moments (Heather, 2006).
The leading clinician at the Maudesely of the 1980s and 1990s Griffith Edwards went
so far as to try to apply quantitative methods and early textual analysis to try to better
understand these statements (Edwards 1987, 1992). Others went so far as to make
the extraordinary claim that if one managed to fully understand the social mechanism
then the patient would have no need for ‘treatment’ or Alcoholics Anonymous (Booth
Davies, 1997). This has as we shall see, has become the touchstone for the
‘recovery’ movement. As yet, it has not been achieved.

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After the millennium, the debate honed in on ‘evidence based treatment’ largely
clustered around criminal justice imperatives, and finally became focussed on
‘quality’ (Best, 2010 and Wardle, 2013). What became clear was that while the drug
demographics were changing via an epidemiological transition away from opiate and
cocaine use, the demand for alcohol fuelled by lax availability and price control
continued to mushroom into a disease burden ‘time bomb’, notably in burgeoning
liver disease (Home Office, 2010, 2012, NWPHO et al., 2012). What did ‘recovery’
have to offer in these developing circumstances?
Overall, studies on ‘recovery’ over the last 50 years offer the following insights:
First, the journey from ‘treatment’ to ‘recovery’ requires follow up by ‘assertive’
approaches (White, 1994);
Second, this is partly because there are different levels of recovery: ‘medicated’,
‘moderated’ or ‘abstinent’ (White and Kurtz, 2006);
Third, ‘recovery’ has three core dimensions of change: remission of the substance
use disorder; enhancement in global health (physical, emotional, relational,
occupational and spiritual); and positive community inclusion (White, 2007);
Fourth, the current treatment system lacks a recovery orientation (White, 2008) and
needs to shift to a long term assertive ‘chronic care’ model (White and Kelly, 2010);

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Fifth, follow up after ‘treatment’, needs to be centred on ‘mutual aid in the
community’ (Best et al., 2012);
Sixth, individuals will discover their own path and for alcohol users this will typically
take 4 to 5 years (Best et al., 2012);
Seventh, the best predictors of effective recovery are the personal and social
resources that a person has to call on (Best et al., 2012 and Strang et al., 2012);
Eighth, barriers to recovery include early onset and increased complexity of
problems, as well as co-morbid physical and mental health problems, including
ongoing alcohol and prescription drug use (Strang et al., 2012).
So, while ‘treatment’ clearly has a key role to play in ‘recovery’, overall the evidence
is that success will rely on effective co-ordination of professional treatment and
sustained community support:
‘...Although the UK evidence base is limited...much of the evidence is based
on alcohol research, there are increasing grounds for believing that recovery
is a viable and empirically established phenomenon...’ (Best et al., 2012)
So what is the theoretical underpinning of recovery? Moos locates these features of
‘recovery’ in theories of ‘social learning’ (imitation of alcohol free family and peers)
and ‘stress management’ (self knowledge, efficacy and control), and ‘behavioural
economics’ (alcohol free activities) (Moos, 2010). The debate around how this fits
into a pathway from ‘treatment’ to ‘recovery’ gathered momentum and overtook
governments on both sides of the Atlantic.

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The international evidence base moved away from quantitative to qualitative studies
of what drives the transition between ‘treatment’ and ‘recovery’. The ‘paradigm shift’
came with the publication by the National Treatment Agency of ‘Medicines in
Recovery’ jointly written by Strang and White (Strang et al 2012).
It is important that the reader, as highlighted earlier, fully understands the nuance of
this. John Strang is seen in the field as carrying the torch at the Maudsley Hospital
previously lit by D.L. Davies in 1962, and carried into the 1990s by Griffith Edwards.
Davies study was at one point the most cited article on alcohol worldwide... The
Maudsley team noticed that a small number of former ‘alcoholics’ had seemingly
‘recovered’ (Davies, 1962). This raised huge questions, examined by Brown and
others, as to whether ‘alcoholism’ could be properly be described as a ‘disease’ and
whether it was ‘socially’ or ‘psychologically’ determined in some way (Brown, 1998).
This study will return to these questions.
Griffith Edwards followed this work up over the following 30 years. This baton then
passed to John Strang. Strang was formerly director of the National Addiction Centre
and was widely regarded as the national lead on addiction studies. Strang jointly
authored a paper commissioned by the UK Government with a former patient from
the US, William White, whose expertise lies in describing ‘recovery’. In the days of
D.L. Davies – this had been the preserve of psychiatrists and psychologists and
physicians – this signalled that the world has truly changed.
Putting it plainly, the reason for this is that ‘recovery’ is not understood by and nor is
it the proper preserve of doctors. What also became apparent is that the quantitative

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evidence base had not delivered definitive answers on alcohol. It is important to
briefly review the seminal US studies which followed D.L. Davies and explore the
achievements of the addict, starting with an equally seminal study of opiate users by
Courtwright (Courtwright, 1989).
As we highlighted at the very beginning of this chapter, Courtwright described the
history of drug addiction in the US. This details the rise of the ‘asylum’ and ‘medical’
model’ in treatment. Courtwright looked at the so called ‘classic period’ of drug
treatment in the USA, ending with the Kennedy era, in large institutions, such the
Lexington Hospital (Courtwright et al., 1989).
The study is best known for the monologues from forty ‘addicts’ in later life. The
study revealed that some participants had avoided a linear progression to chronic
disease. These ageing ex users described ‘moments of reprieve’ – what we would
now call ‘moderated recovery’. These ‘super-addicts’ had taken a leap into a new life
paradigm – ‘recovery’ – which was fleeting and fragile – but real nonetheless. In this
state many did ‘normal’ and creative activities – such as writing an international best
seller in the case of one well known participant, William Burroughs, who is the author
of ‘Junkie’ (Courtwright, 1989).
Courwright’s study is a good example of why a quantitative approach alone struggles
to explain the complex transition from ‘treatment’ to ‘recovery’. It also supports the
argument that only via qualitative work do we get a true in depth sense of how and
why people seek recovery. This is why ‘recovery’ is only adequately described by
newer qualitative US studies of William White and associates. Those studies help to

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relocate medical care for drug and alcohol patients within a chronic longer term care
system instead of a short term emergency driven acute care system. This chronic
approach makes more sense as anticipates the likelihood of relapse. The model
flexes to allow ‘recovery’ iterations, be that: ‘moderated’ (controlled use), ‘medicated’
(treatment supported) or ‘abstinent’ (drug and alcohol free). In this sense, ‘recovery;
is not set in the concrete typologies of the ‘disease model’.
The approach also reveals new ideas about what comes after ‘treatment’ - notably
‘self help’ and ‘mutual aid’ (White & Kurtz, 2006, White & Kelly, 2010, McClellan,
2010). The quality of this US evidence gave rise to a demand for UK based studies
to review the transferability of such ideas. The most prominent spokesman here has
been David Best who recently led an internationally respected review of the evidence
(Best et al, 2012). This describes the limits of the ‘medical model’ and heralds ‘asset
based recovery’ based on timely provision of social contact, social membership,
housing, and employment. However, the key point remains that ‘recovery’ takes
many years to cement, whether medicated, moderated or abstinent, and these
benefits build over time (Hibbert & Best: 2011).
2.6. Literature review search methodology
The study requires a focus on evidence describing the crossing point between
‘treatment’ and ‘recovery’. The literature review search began by establishing the
most commonly used key words around ‘treatment’ and ‘recovery’. These were:
Drugs, Alcohol, Treatment, Recovery, Recovery Community, Recovery Mutual Aid,
Culture of Recovery, Recovery Paradigm, Continuing Care, Remission, Addiction,

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Motivation, Processes, and Quality of Life, Stress and Coping and Resilience. The
best combination for this study of ‘survival’ was found to be: Drugs, Alcohol,
Treatment, and Recovery.
An electronic search was duly undertaken on the 1st
of January, February and March
2013 using Liverpool John Moore’s University ‘Discovery’ software, and this yielded
783 sources. This search was refined by ‘Peer Review’, ‘English’, ‘Print online full
text’ and ‘Date Published 2006-2013’ to 78 journal articles and book reviews. 2006 is
the start point because this marked the publication of Duncan Raistrick’s erudite
review of the effectiveness of alcohol treatment for the UK (Raistrick et al 2006). The
intervening years then become a proper focus up to the publication of John Strang’s
even more seminal paper (Strang et al., 2012.
These studies were then further examined within an ‘evidence matrix’ underpinned
by an international academic consensus (Strang et al., 2012). As stated in the
introduction, this ‘matrix’ has been the basis of commissioning work in Salford for the
last four years. The matrix comprises of two axes: ‘complexity’ and ‘severity’, of
clinical presentations, and ‘motivation’ and ‘assets’ presented by participants, such
as clear statements of action, and development of personal resources which sustain
those actions.
The ‘matrix’ was used to refine the evidence down to that explaining ‘complexity’,
‘severity’, ‘assets’, and ‘motivation’. It was then possible to see the best fitting
evidence about ‘treatment’ to ‘recovery’ by researchers from both paradigms. Given
the amount of historical quantitative literature on ‘treatment’ (the ‘complexity’ and

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‘severity’ axes), a decision was taken to focus on the axes best served by qualitative
research i.e. what is meant by ‘motivation and ‘assets’. Of these 78 studies, 24
highlighted ‘religion’ and related issues of the ‘higher power’ and ‘spirituality’ but
none did so comprehensively. Increasingly the key message was that quantitative
research had limits unless aided by qualitative analysis.
This is a conclusion many seminal figures have long reached (Edwards et al 1992,
White, 2009). An early attempt to assess textual references made by patients
researched by Edward’s Maudsley team outlined a means of measuring what they
called the ‘Damascus event’ (Edwards et al., 1992). This came to be a central theme
of the study – the different ways in which participants describe a conversion on a
journey – like ‘Saul of Tarsus’ in the New Testament of the Bible, whose life
experience included a ‘conversion on the road to Damascus’ to become ‘St Paul’: a
‘paradigm shift’ from literally one belief system to another. This ‘Pauline conversion’
or ‘Damascene recovery’ is not confined to ‘religious’ experience however, and it is
more accurate to describe a ‘spiritual’ and ‘quasi-religious’ experience for most.
A further ‘Google Scholar’ search using the key words ‘Damascene’ and ‘Recovery’
was undertaken - and based on relevance. This yielded 18 further references
examined using ‘Google Scholar’. These references highlighted classic works in the
field.
This was followed up by a final desk search of related commonly cited classic works
on ‘treatment’ and ‘recovery’ and ‘public health’ and ‘health and wellbeing’ over the
last fifty years for completeness. These are fully referenced.

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2.7. Why we must ultimately exclude Quantitative Studies
While 50 years of quantitative literature defines effective ‘treatment’ for ‘alcoholics’
the evidence base is more limited in describing ‘recovery’ despite seminal UK and
Scottish Government commissioned reviews by Raistrick and Best and Strang
respectively (Raistrick et al., 2006; Best et al., 2010). This is why our enquiry is
balanced by qualitative research to understand ‘motivation and ‘assets’.
A key clue to the ‘bridge’ between ‘treatment’ and ‘recovery’ is that of ‘spirituality’.
The notion of ‘spirituality’ is hard to define and tends to be used interchangeably in
the literature, perhaps because it lies easily across the notion of ‘higher power’, in
Alcoholics Anonymous, spiritual development – ranging from transcendental
meditation – to formal religion instruction, to the following of formal religion.
It is however clear that one does not have to go as far as formal religion to
experience ‘recovery’. It is also clear that going some of the way will ‘feel’ like a
spiritual journey. As we will see in the study, one of the participants captures this
continuum best, with the notion of a ‘bridge of willingness’ – but this is not to say that
via religious observance will one cross completely – it is more ‘quality’ than ‘quantity’
of experience. This is overall an ill defined area of work; as clearly some form of
epiphany, conversion, occurs for those entering ‘recovery’. As Best explains, the
qualitative evidence base is not comprehensive:
‘...The story of recovery remains an incomplete one with a need for considerable
translation and interpretation to apply the existing evidence base...’ Best et al., 2010

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Around 30% of studies searched referred to ‘religion’ and related issues of the
‘higher power’ and ‘spirituality’. One of the internationally most quoted studies
elegantly describes how users get ‘tired’ of the lifestyle and highlights religious or
spiritual factors as a turning point (Winnick, 1974). The problem for researchers is
the wide variety of these studies (Cheney et al., 2009). Some studies look at notions
of suffering and an ‘act of surrender’ (Chen, 2010). Others look at spiritual work,
such as ‘mindfulness’ training (Garland et al., 2010). Others look at spiritual training
within cognitive behavioural programmes (Hodge, 2011). Most critical of all however
is that exactly how Alcoholics Anonymous (AA) achieves beneficial outcomes is less
well understood. As Kelly states, there is:
‘...little research or support was found for AA’s specific practices or spiritual
mechanisms...’ Kelly et al., 2009
It is true that further large scale empirical research may improve our understanding
(Kelly et al., 2009). However as Edwards neatly states, the research problem with
AA, is that AA itself is not a random grouping; and this precludes a randomized
control trial. That is, people decide to join AA for one reason; they do not follow the
dictum of Groucho Marx. That is, they do recognize themselves as members; there
is no random grouping of the membership which can thus be established – they are
there for the same reason – they form one group. Research is thus confined to
qualitative studies which are frequently criticised for having a hermetically sealed in
internal bias from being exclusively about AA members and for AA members
(Edwards, 2000). However, as Edwards helpfully concludes:

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‘...Up to the present, science has not found a research approach to overcome
the...conundrum...but on the basis of the available research it is not unreasonable to
conjecture that AA probably works, in some way or other, for not less than 50% of
the troubled drinkers who make contact with it...’
Edwards, 2000
William White’s tries to describe religion’s purpose as ‘ontological’ – that is giving ‘life
meaning and purpose’ via the broader church concept of ‘higher power’ in AA;
(White, 2009). The literature review showed that only qualitative methods are likely
to give us an insight into the spiritual elements of recovery. This is sensitive material
and Best emphasizes the importance of this approach:
‘...As William White has argued...this work will shed light on some of the ‘hypotheses’
about recovery...it’s significance is much more likely to revolve around it’s charting of
the optimism and drive that characterizes recovery...’
Best, 2010
This exercise may get us closer to White’s description of ‘spiritual awakening;
‘...spiritual awakening...convey(s) a vision of recovery...transformation in character,
identity and inter-personal relationships...AA ‘promises’ speak...the acquisition
of...serenity...and authentic connection to others...’
White on Kelly et al., 2010
2.8. Conclusion
The international evidence base shows the need for better understanding of the
‘bridge’ between ‘treatment’ and ‘recovery’. What is the character of the light on the

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other side? Quite simply, other than references to religion, and spirituality, and the
AA concept of a ‘Higher Power’, the literature on drugs and alcohol ‘recovery’ has
only limited and general references to ‘survival’. The material is too diverse and there
is almost no material on ‘Damascene Recovery’ which appears a stable element of
studies which have focused on recovery. Given this is essentially the key ‘rite of
passage for many in the ‘recovery movement’, at least those within Alcoholics
Anonymous, there is a huge gap in our knowledge.
Ultimately, our search leads back to the research question and hypothesis
developed from Courtwright’s original study – how did these individuals survive?
Courtwright’s observations about ‘super addicts’ resonates within this present study.
The language and experiences of the purposive sample i.e. those who were more
experienced in ‘recovery’ stands out above the more recent ‘survivors’. As Best
concludes, there is much to know and understand:
‘...recovery...creates a massive agenda for researchers...we...need...a new language
and in a new series of research methods...ways of developing quantitative as well as
qualitative approaches to action research that is owned by the people in recovery...’
Best, 2010
We will return to what this means later in our discussion.

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3. Methodology
3.1. Research Design
This is a mixed methods study. This is detailed in Section 3.6 below.
3.2. Collection method - Quantitative Data
The quantitative data, as explained in the introduction, is derived from a cohort of
200 patients who have sought acute hospital care as a result of dependent drinking
of alcohol. The purpose of using this cohort is to ensure that participants in the
smaller extreme sample who have been discharged into a third sector ‘recovery’
service, St Paul, had this type of history. This type of history means that they will be
more likely to produce testimony about ‘acute’ ‘treatment’. The qualitative data, is
derived from structured and semi structured interviews with the extreme sample in St
Paul4
and a purposive sample of staff at St Paul, who have been ‘in recovery’ for
many years.
3.3. Collection method - Qualitative data
Practically then, the quantitative data established the sample for the qualitative
analysis. This narrowing approach is justified because, as argued in the literature
review, purely quantitative ‘treatment’ research is too ‘high level’ to see fleeting
moments between individual patients and their clinicians. The qualitative arm, here,
4
The name of the recovery centre has been changed to protect the anonymity of the participants

37. 37 | P a g e
as Cresswell describes, seeks to explore the ‘essence of human experience’
(Cresswell, 2003). The study will thus focus on the meaning behind ‘low level’ terms
like ‘healing forest’ and ‘recovery communities’ and ‘mutual aid’ (White, 2005, 2012).
Participants in the qualitative arm of the study all met entry criteria of moving down a
pathway whereby they had been seen by the Salford Royal Alcohol Assertive
Outreach Service or Alcohol Nurses and established as a dependent drinker,
meeting the WHO classifications (ICD 10) on more than one previous admission,
and had been discharged successfully into ‘recovery’ services, and then been in
‘abstinent recovery’ from alcohol, and finally, had expressed motivation to freely
engage with the study.
St Paul House is the residential rehabilitation centre where this further element of the
study took place. The ‘purposive’ sample of St Paul participants seen post discharge
was identified by ‘matching’ unique Identifier Numbers assigned to real NHS
Numbers using a device to match the confidential data cohort for the earlier study;
these numbers were matched with ‘recovery’ patients to ensure that those
interviewed had come from the original ‘Top 200’.
An ‘extreme sample’ of 6 ‘survivors’ was identified from those who had been
discharged from Salford Royal and who have moved from ‘treatment’ to ‘recovery’
within the last 12 months. This was supplemented by a ‘purposive sample’ of a
further 5 ‘volunteer’ staff members who were ‘old’ survivors, with years, not months
of experience. There was a good level of matching between the ‘extreme’ and
‘purposive’ groups – with e.g. similarities in range of ages of first drug and alcohol
use.

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The potential participants were then approached by the Principal Researcher via a
therapeutic meeting and invited to take part. Participants were fully briefed as to the
content of the survey and semi structured interviews. Participants of both the
‘extreme’ and ‘purposive’ samples were made aware that they could exit the study
without obligation at any stage. All participants were offered a £10 gift as a token of
thanks for their time and efforts.
3.4. Structured Questionnaire and Semi Structured Questions
The original Courtwright study was marginally amended from a drug to an alcohol
bias, and was administered in the form of a questionnaire for all sections other than
that on ‘Recovery’ on which more detailed responses were sought, essentially
focussing on the key questions of ‘rock bottom’ and ‘Damascene Recovery’ and
related subjects. Kvale (1996) stresses the importance of moving the participant
gently away from well rehearsed scripts about their lives, to address ‘How’ and ‘Why’
questions.
The structured questionnaire principally gained basic demographic details - notably
the level of social and family stability addicts grew up in (providing a sense of ‘social
assets’ and early using ‘motivations’), and the age at which they first used
substances (providing clinical ‘markers’ of ‘complexity’ and ‘severity’). The ‘matrix’
approach is extensively detailed and explained in the introduction and literature
review and is not repeated verbatim here.

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The study then asked a short series of semi structured questions which got to the
heart of his enquiries. The questionnaire was administered 1:1 and recorded by the
Lead Researcher in comfortable surroundings at St Paul House.
3.5. Data Analysis – Quantitative Data
The data team was made of analysts from the Salford Drug and Alcohol Action
Team, NHS Salford Public Health Team and Salford Royal Acute NHS Foundation
Trust. The same analysts had also undertaken work on the earlier quantitative study
(Hughes et al., 2012). The team ‘cleaned’ the Hospital data of miscoded patients,
and analysed the burden of liver disease and mortality in the ‘Top 200’ cohort. Other
data was also collected: data on engagement, levels of take up of detoxification, and
services to which patients were discharged. This is not reported as it merely confirms
the anticipated complexity and severity of medical problems the cohort have (see
Appendix 6:1, 6:2, and 6:3).
Of interest to this present study were the overall functioning levels of patients
attending the study: levels of functioning and health and wellbeing were established
using the ‘Christo Inventory of Substance Misuse Services’ or ‘CISS’ (Christo et al.,
2002). This data was tested for statistical significance using a Wilcoxon Test for a P
Value on 30th January 2013 and Median values are reported. The ‘medians’ in the
acute admissions are quoted. A comparison was drawn between the CISS Scores
for this present study and the earlier study in which the author was co-author - this is
detailed in Appendix 6:1, 6:2, and 6:3 Hughes et al., 2012).

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3.6. Data Analysis – Qualitative Data – Framework Analysis
A list of coded responses and a verbatim transcript of the semi- structured responses
were then analysed using NVIVO 10 software. A total of 11 participants were
interviewed. This is seen as the ideal for a small case study (Cresswell and Plano
Clark, 2007). A code book was maintained which detailed extracts of interviews and
fragments of emergent ideas – notably about the boundary between ‘treatment’ and
‘recovery’.
The Primary Researcher established a codebook, organised documents, transcribed
the interviews and prepared the text for computer analysis via NVIVO 10. The data
from the 11 interviews was analysed using a ‘Framework Analysis’ approach (Green
& Thorogood, 2010).
The method lends itself to the Salford ‘evidence matrix’ approach and locates the
study from the outset alongside the literature. Framework analysis has 5 stages:
‘familiarization’, ‘thematic analysis’, ‘indexing’, ‘charting’, and finally ‘mapping and
interpretation’ (Green & Thorogood, 2010). We will look at each in turn. The ‘matrix’
approach is extensively detailed and explained in the introduction and literature
review and is not repeated verbatim here.
3.6.1. Stage 1: Familiarization
This stage involved using Sony Sound Organizer software to listen to the tapes and
transcribe the participant responses to the semi structured interview questions. This

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activity immersed the principal researcher in the participant data. All 11 transcripts
were read through using NVivo 10 and quotations were highlighted; paragraphs in
each transcript were numbered to allow for referencing during the analysis process.
3.6.2. Stage 2: Thematic Analysis
A ‘coding scheme’ was used based on the ‘matrix’ used in Salford for the last 4 years
and closely aligned with the emergent national and international evidence base. The
‘Treatment’ Axis is ‘Complexity’ and ‘Severity’. The ‘Recovery’ Axis is ‘Motivation’
and ‘Assets’. The ‘evidence matrix’ achieved what Kvale terms ‘condensation’ and
‘categorization’ – that is ‘structuring’ of the data (Ibid: 190).
3.6.3. Stage 3: Indexing
The whole data set was then indexed systematically into portions which fitted the
matrix axes of ‘Complexity’ and ‘Severity’, and ‘Motivation’ and ‘Assets’. This
involved levels of cross over and duplication – where a fragment of code fitted
several labels. The data was then indexed into sub-themes of: ‘Damascene
Recovery’, ‘Recovery Relationships’, ‘Religion and ‘Spirituality’, ‘Survival’ and
‘Treatment’ in accordance with the evidence base.
3.6.4. Stage 4: Charting
The literature pointed to a need to look further into the experience of crossing from
the paradigm of ‘treatment’ into the paradigm of ‘recovery’. This was facilitated by a

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fourth step which involves rearranging the data by thematic content. This exercise
enabled the researcher to read across themes. Summary examples were referenced
back to the original transcript. The original data was retrieved using NVivo 10 which
automated this referencing process.
3.6.5. Stage 5: Mapping and Interpretation
The final stage was looking at the relationships between the codes. Tables were
used to physically explore the relationships between the concepts. As Green and
Thorogood describe, ‘Fracturing’ the data in this systematic way firmly located the
study material within the evidence base (Green and Thorogood 2010).
3.7. Strengths of the ‘Mixed Methods’ Approach
There was largely a strong fit and concurrence between evidence in the literature
and what participants said. The interviews were coded using a detailed matrix
‘framework’ analysis which closely matches the current evidence base, and neatly
bifurcates the data, exposing the themes of ‘Survival’ and ‘Damascene Recovery’ –
the conversion on the road to some latter day ‘Damascus’.
Reflecting on what has been achieved; a stable data set and a stable team over four
years has bred a level of confidence in the research – the earlier quantitative data
analysis has already passed peer review for the BMJ article (Hughes et al., 2012).
The third cohort and samples have provided further rich data indicating that the
methodology was sound and that there were enough of the right participants. The

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judgement to replicate a questionnaire based on a well known, validated study,
which had been subjected to numerous peer reviews seems to have been vindicated
(Courtwright et al., 1989).
As stated, the participants were a mixture of an extreme sample of people recently in
recovery and a purposive sample of people more stable in their recovery who were
more practiced in therapeutic assessment and dialogue. There is therefore a strong
level of confidence that both arms of the study are robust, and that the conclusions
will be equally valid, and replicable.
3.8. Possible sources of bias
The sources of bias in the quantitative data were reduced by removing outliers from
the data and conducting the second statistical significance tests on the same cohort
in four years – with similar results.
As Principal Researcher the author accepts that as a non ex-user various types of
‘bias’ may affect the qualitative data. It was made explicit that while acting as
university researcher, the author was also commissioner of both services studied.
While in some ways a potential disadvantage, such as eliciting overly positive
responses, this was discounted, and seen as a potential advantage – the fact that
close relationships might elicit more candid responses.
Courtwright’s questionnaire was strengthened by what Kvale calls the ‘Thousand
Word Questions’ – a question which cuts to the quick (Kvale, 1996). In this study that

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question was ‘How did you survive?’ see Appendix 1. The deliberate design feature
was that the structured questionnaire would ‘funnel’ the participant into the semi-
structured in depth narrative ending to each interview, and set aside ’learned’
responses to a non addict interviewer, e.g. to mitigate what they perceive as ‘bad’
acts, and to be spontaneous (Green & Thorogood, 2010).
It is important that the reader gains and understanding of these underlying biases in
more detail. Booth Davies (1987) explains that this way; people drink alcohol largely
for pleasure, but also to manage emotional pain. Booth Davies describes various
types of bias arising from an understanding of ‘Attribution Theory’ that is, simply, the
complex ways in which people explain why things happen, often independent of
reality. These ‘systematic biases’ lead addicts to adduce causal links in statements
where none exist (Ibid: 115). Thus for Booth Davies bias exists whoever the
researcher is; an addict may as likely mislead an ex-user researcher, as a non ex-
user researcher. Addicts seek to reframe experiences, in positive and negative ways,
lay off blame on others, and away from themselves, or onto their circumstances.
Indeed, this is why Best et al (2012) encourage the recruitment of peer interviewers
for some studies. We will return to this in the final sections as to future work.
3.9. Ethical or Political Considerations
NHS Ethics Approval was not required for this study as it fulfilled the criteria for
service audit and evaluation. The study was supported by Salford Royal NHS
Foundation Trust and St Paul and was given ethical approvals by Liverpool John
Moore’s University (See Appendix 2).

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Participants were asked to take part and given informed consent to be interviewed in
comfortable and familiar and confidential surroundings and were clearly advised that
they may exit the study at any stage (See Appendices 3, 4 and 5). No harm was
done by the study; indeed, the study had a therapeutic purpose for the participants –
a chance to tell and share their stories in a safe environment – and to ‘make a
difference for others’. Participants were given transcripts of their individual interviews
and briefings on the overall progress of the study. All participants were invited to a
private presentation and discussion of the findings. Participants were all offered
independent support and counselling e.g. extra sessions with key workers to express
therapeutic issues which arose.
3.10. Limitations
The simplicity of Courtwright’s work has generated ‘stories’ and images. However,
while the study data shows overlaps between different elements of the ‘matrix’ it is
less sensitive in distinguishing between them. However, it remains fair to say that
this Framework Analysis meets the explicit aim of this study to generate insights
useful for the guidance for clinicians and services to support the ‘Medication in
Recovery’ work (Strang et al., 2012). In fairness, no attempt has been made to
further ‘fracture’ the data, save to locate the material and align it with the evidence.
What did became clear was that, as Mildred Blaxter notes, is that this framework
provides a much richer series of potential supplementary questions (Blaxter, 2002).
There is as we shall discuss later, scope for further study of this.

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4. Results
4.1. Were the right participants drawn down from the larger patient cohort?
The proof of this simple but important question comes from whether or not the
supporting evidence confirms key eligibility features of the patients / participants
within the study. This is fully outlined and demonstrated in a series of linked graphs
and tables and explanatory notes in the Appendix 6:1, 6:2, 6:3, 6:4, 6:5, and 6:6.
These quantitative and qualitative findings show that the right participants drawn
down from the larger patient cohort; notably - most of the ‘new’ survivors and many
of the ‘old’ survivors have a ‘complex’ risk profile (Appendix 6:5) and almost 25% of
the patients have some form of ‘liver disease’(See Appendix 6:1- Figure 2).
Christo Inventory data taken from patients at Salford Royal confirms that the
Assertive Outreach Model performs at or better than previously validated study
levels of performance for a non residential alcohol service with some of the most
challenging patients in the system (See Appendix 6:2).
Further, NVivo analysis confirms participants are part of a larger cohort who moved
from primary, through secondary, to acute and chronic services (See Appendix 6:6).
Further, ‘participants’ had markers from early childhood of ‘pathology’ (See Appendix
6:5). Finally, ‘participants’ exhibit clear ‘markers’ of continued ‘pathology’ up until the
moment of seeking ‘recovery’ (See Appendix 6:6). A reasonably equitable spread of

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references made by participants within the expected ‘matrix’ described in the
evidence base (See Appendix 6:3).
4.2. Does the fractured data align with the literature and evidence base?
The first phase of data extraction aligned with the evidence ‘matrix’ developed by Dr
Colin Wisely and the author in Salford over the last four years. The data ‘fractured’
equitably provided a good range of extracts which are cited here. More raw data is
cited in the Appendix, including a full transcript most typical of the sample overall
(Appendix 6:7- 6:10).
4.2.1. Complexity
The following data extract represent ‘complexity’ issues.
Participant 9
...I am under the mental health team. The psychiatrist wants me to go. He thinks I am as
mad as a bag of cats...from the Army ‘Post Traumatic Stress Disorder’ – self harming,
suicidal thought... a man in a car with a big long chain said ‘alright dickhead’ and I thought I
would twat them – they followed me round three times – paranoid – probably they were just
lost...
Overall ‘complexity’ issues typically concern ‘co-morbidities’ of Alcohol Dependency
Syndrome, e.g. cravings and physical withdrawal symptoms, contemporaneous with
severe physical damage due to alcohol e.g. Wernick’s Encephalopathy (‘wet brain’),
liver de-compensation, severe and enduring psychiatric conditions e.g. paranoia, as

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well as psychological features e.g. Post Traumatic Stress Syndrome. There is a
degree of overlap with the nodes concerning ‘severity’, ‘motivation’, ‘survival’, and
‘treatment’. The data extract is distinctively focussed on ‘complexity’.
4.2.2. Severity
The following data describes the frequency of presentations, progression of disease,
and setbacks in ‘motivation’. There is a degree of overlap with the nodes concerning
‘complexity’, ‘motivation’, ‘survival’, and ‘treatment’, as well as the following section
as to ‘recovery’, ‘survival’, and ‘treatment’. This data is distinctively focussed on
‘severity’.
Participant 4
‘...I don’t know how I have survived. I don’t understand. Many a time I have thought I would
be dead next morning. I have drunk surgical spirits and aftershave because that has alcohol
in it – any substance – that I could get hold of I have drunk. But then I had a burst ulcer in
1996 and lost 2 ½ pints of blood in the process, then I am thinking there must be ‘something
there’ I am still walking...’
4.2.3. Motivation
The following data describe the cycle of 'preparation', 'action', 'lapse' and' 'relapse' in
‘treatment’ and in ‘recovery’ (Prochaska & DiClemente, 1986, and Marlatt & Gordon,
1987). What we see are examples of ‘self talk’ as participants with poor historical self
esteem gain experience and confidence through trying out what they are learning
about ‘recovery’, how the pros and cons are weighed e.g. gaining family, losing the
pleasure of using, but overall recognising a clear direction for the future, and
identifying within themselves the means to move forwards.

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Participant 3
‘...There are lots of people who don’t survive... I also believe that my path is already set out
for me. That’s what I believe. Not everyone would believe that. But that’s what I like to
believe that. You know. It allows me to make sense of the direction that I took. I also think
that I am quite a strong character. People who have been in addiction are quite resilient and
kind of have an inner strength if you like. They don’t always believe that or see it. But I think
you have to have something about you to survive on the streets...’
Participant 7
‘...Well I always thought I would never drink again. Now I say ‘I don’t know if I will drink
again, but just not for today’...wiser this time: I see new people coming in after years of
addiction. The character weaknesses with addiction; the self centred, the lying, closed
mindedness. All this has to be removed: if I am to change and not drink again...’
This data is focussed on developing self knowledge, awareness and efficacy -
bundled as ‘motivation’. This aligns the selections align to the evidence base on both
‘attribution theory’ and ‘social labelling theory’ as explained in the Methodology
Chapter (Booth Davies, 1992, Becker, 1963, Goffman, 1974). This is because these
participants have reached a point where they see their recovery as being something
to do with their actions, and are beginning to see themselves as ‘in recovery’ as
opposed to being ‘addicts’ - the label society places on them (and which they place
on themselves). There is therefore a degree of overlap with the nodes in the
following section as to ‘Damascene recovery’ and ‘relationships’ in recovery.
4.2.4. Assets
The following data represents the sort of social and family ‘assets’ that ‘Medicines in
Recovery’ and the Scottish Government review sees as vital for recovery (Strang et
al., 2012, Best et al., 2012). There is a degree of crossover between node extracts

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on ‘personal assets’ with ‘recovery relationships’ and the statements on ‘survival’
which follow in the next section.
Participant 2
‘...Oh yeah. I mean, yeah, we go on holiday, I have a tight bunch of 8 adults and 15 kids and
we do things together every weekend, or holidays, round at my friends at the weekend
there was about 15 of us there, Sunday Dinner, all the kids playing, and all the adults in the
kitchen talking, it’s nice that stuff, that’s what life’s about (LAUGHS)...’
‘...I have NVQ Level 1-4 and I want to go on and do a degree. But I also have internal
questions ‘...why do I have to do that...’ (LAUGHS) so it’s like a...I should have done it a while
ago...somewhere inside is always this non conformist (LAUGHS). I have decided now in my
mind I need to do things for my child to move up in earning potential...’
There was limited emphasis on the long term importance of education, training and
employment, and past times. This is more a feature of ‘new’ survivors. The ‘old’
survivors generally recognised the early role these social assets play. As years go
by, with more embedded recovery these seem to recede in importance, as we will
see in the next section; they are skills which once learned may confidently be
replicated (White, 2009).
What becomes more important is the thinking and belief underpinning recovery.
What remains vital as to ‘social assets’ are the relationships developed in the
transition from ‘treatment’ to ‘recovery’ – there is a very strong overlap here with the
next section and the nodes as to ‘Damascene Recovery’, ‘recovery relationships’,
‘survival’ and indeed the debate about the ‘treatment’ and ‘recovery’ paradigms
which the study concludes with.

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4.3. Where does this lead us?
The second phase of semi structured interviews makes a deeper inroad into a
section of the ‘matrix’. This explored notions about ‘treatment’, ‘control’ and
‘recovery’ – also explored by Courtwright - and focuses on the moment of revelation
and supporting features which then sustain ‘recovery’.
The evidence base strongly directs the reader towards more promising areas of
discovery. These studies as detailed below show that quantitative evidence does not
adequately describe why one individual recovers and another not. Further, that how
the addict views their internal and external worlds is important but that this process is
little understood. In studies over the last 25 years, qualitative research has tried to
unlock this world: the following themes emerge from the literature:
- ‘Damascene Recovery’ - a life changing moment (Booth Davies 1997,
Edwards, 1985, 1987, 1992, 2000, White & Kurtz, 2006);
- ‘Recovery Relationships’ – family, friends, and mutual aid relationships (Best
et al., 2012, Strang et al., 2012, White & Kurtz, 2006);
- ‘Religious and Spiritual’ experiences –experiences of a ‘higher power’ external
to the self, or an ‘internal power’(Edwards, 2000);
- ‘Survival’ experiences – the range of real ‘near misses’ and hardships
statistics never adequately describe (Best et al., 2012);

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- ‘Treatment and recovery paradigm debate’ whereby participants rehearse the
arguments through lived experience (Edwards, 2000, Best & Laudet, 2011,
Strang et al., 2012, White & Kelly, 2010)
The final step was to use NVivo 10 to ‘fracture’ the transcripts, after the initial ‘matrix’
analysis. This revealed why these experiences are central to understanding
‘Damascene Recovery’ and underlying existential and spiritual experience as
survivors move from ‘treatment’ into ‘recovery’ (Edwards 1987, 1994).
4.3.1. Damascene Recovery
The following data represents the sort of ‘Damascene Recovery’ issues that
‘Medicines in Recovery’ and the Scottish Government review of the ‘recovery’
evidence base anticipate for alcohol users (Strang et al., 2012). These are the
moments: before and immediately after ‘recovery’ - and as ‘recovery’ grows.
Participant 3
‘...It was for me ‘tell me what I need to do to move away from that life’. I call it ‘The Bridge
of Willingness’. Now some people can see the bridge, some people are at the foot of the
bridge willing to walk across, and there are people like me; who are already half way across.
That was how it was for me; I was so willing to change my life...’
‘...I think there are people. I have been abstinent 5 ½ years and there are very few. I got
recovery in a prison...and originally 13 of us started the course and 4 of us finished the
course which was a 12 week programme. 2 of us are still standing today. The rest have
relapsed...So what I have learned is that you cannot predict who will get recovery and who
will not get recovery...’
‘...I think for the first two years in recovery that is really vital. I think as you move on you
become more responsible for your own life and rely on that support less and less. If that
makes sense...Emotionally you don’t grow at all. Ultimately that is what ‘recovery’ is about
is ‘about growing up’ and I really feel that...’

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Participant 11
‘...Someone said to me you can either carry on being a victim or be a
Warrior; I had been a victim to my past for that long. It was like a little coin dropping...’
4.3.2. Relationships
The following data represent the sort of ‘relationship’ issues that the Scottish
Government review of the ‘recovery’ evidence base anticipates for alcohol users.
This, put simply relates to whom addicts spend their ‘recovery time’ with and how
they spend that time (Best et al., 2012). That is, to be clear, the absolutely central
relationships to recovery.
These people would be proximate to the source in ‘node mapping’ of social
connections probably within 1-2 degrees of separation (Best et al 2012). There is a
degree of overlap with the nodes concerning ‘Damascene Recovery’, as well as
‘religion’, and ‘survival’. The participants also talk warmly of people who have helped
them professionally who know from experience what ‘recovery’ is all about. The
participants also talk about family relationships, previously affected by their
addiction, and how important these become as signs of their enduring ‘recovery’.
This data is distinctively focussed on these ‘relationships’.
Participant 1
Yeah, I suppose it came in my relapse, I had friends in NA that I consider close friends but
when they found out about the relapse I felt ‘dropped’ to an extent and it’s when I found
out who my real friends were – the ones I didn’t really expect – came together for me and
helped me and they are the ones I have kept close to ever since. Yeah that’s exactly it. And

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these people have been in the same places. There is only so much you can learn sometimes
from a book but when you have been there you are not bothered about picking that phone
up. It’s helping someone else get through another day. Kind passed on I suppose. There are
people who have been there for me, so why shouldn’t I be there for someone else.
But having a baby as well it gives that much more responsibility to give something my other
kids didn’t get or so this one’s going to get to know a sober dad who works hard. Floating
Support got me through that first 2 years. The people back then I class as a ‘family’. The fact
they got paid was a bonus to them. And they were non addict people. I still go and see
them. Three still work for XXXXXX. I go on holiday and to concerts with two of them.
4.3.3. Religion and Spirituality
The following data represents the sort of ‘religion and spirituality’ issues that the
‘recovery’ evidence base anticipates for alcohol users. As White and Kurtz argue,
‘recovery’ requires either a ‘religious’, ‘spiritual’ or ‘secular’ framework (White &
Kurtz, 2006). What we see are overlaps with references to ‘complexity’, and ‘severity’
– the stages before change - ‘motivation’ and ‘assets’ - the stages of early
‘recovery’, the bridging experiences of ‘Damascene Recovery’, ‘relationships’,
survival’ and the ‘treatment and recovery’ paradigm debate. The data cited is
distinctively focussed on ‘religion’ and ‘spirituality’ and less so on ‘secular’
frameworks, such as employment. Further, the data describes the anchoring of
‘recovery’ via charitable acts in a ‘new world’ – so that positive associations develop
(Marlatt & Gordon, 1987). Over time, addicts mature and ‘recovery’ comes into view
(Winnick, 1962, Vaillant, 1995).
Participant 2
‘...No, I think that’s how they define ‘spiritual experience’ isn’t it? ‘Something good has
come from something bad’. Do you know what I mean?..’
‘...I have faith. I believe things will turn out how they are meant to turn out. The most
important thing I have learned in recovery is that I don’t know much about stuff. Things that

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seem good sometimes turn out bad so I have given up dealing with things and deal with
things as they come. That’s it...’
Participant 6
‘...It’s that man in the sky: must be...Just for today, for the grace of God...’
Participant 8
‘...I don’t know if God is there but I don’t always have an answer to that question. But
something has definitely been there. My best pal still says your mum is looking after you. It’s
lucky. It’s unbelievable. I have had so many things happened where I should have been
dead. I don’t know but someone has been looking out for me. Definitely...’
‘...I have faith things will turn out alright. It’s just my perception sometimes isn’t quite right
and I need to ring somebody up and they turn my thinking around so I can see the light
again and don’t have tunnel vision...’
4.3.4. Survival
The following data represents the sort of ‘survival’ issues that the ‘recovery’ evidence
base anticipates for alcohol users as some progress to ‘moderated recovery’, some
to ‘medicated recovery’ and a small number to ‘abstinent recovery’, and a smaller
number yet who sustain this long term (White & Kurtz, 2006).
There is some degree of overlap into the ‘treatment’ and ‘recovery’ paradigm debate
in the sense of addicts being patched up to regain the field of battle with their
addiction. There are also overlaps with ‘Damascene Recovery’, and ‘recovery
relationships, but the focus here is on ‘survival’ – even as far as Darwinian overtones
of ‘survival of the fittest’ (Darwin, 1859).

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Participant 2
‘...Yes - at 19 I had seen more of life than your 40 old man. I had been in HMP and lived on
the street and I knew these people these people had the answer for me. I knew when I
walked into doctors and treatment agencies that these people did not have the answer for
me. I knew they didn’t know what to do with me. I think so they are like two ends. I know
what we are trying to do now in treatment which is provide recovery. And you cannot buy it.
Yes I think so Andrew. It’s two worlds...’
Participant 3
‘...I think for me it was a point in my life where I had had enough and wanted to change and
my alcohol and drug use had taken me to a point where I had nothing left externally. So
family, relationships, that kind of thing, possessions, but also internally, spiritually, as a
human being, you know, I was an empty shell if you like, a very lonely place to be, a very
frightening place to be. I was without hope, if you like. Drugs and alcohol had drained my life
force from me. There was nothing left. A real clarity of thought I have in my head is me
looking at the mirror and seeing nothing in my own eyes they were like ‘shark eyes’, there
was nothing behind...’
4.3.5. The Treatment and Recovery Paradigm Debate
The final set of data represents the sort of ‘treatment and recovery paradigm’ debate
issues that ‘Medicines in Recovery’ and the Scottish Government review of the
‘recovery’ evidence base anticipates for alcohol users (Strang et al., 2012, Best et
al., 2012). The greatest parallels are with ‘Damascene Recovery’ and ‘survival’.
This then leads us into the debate as to the need for a longitudinal ‘Chronic Care
System’ as alcoholism is largely a chronic and pathological state, not suitable for
‘treatment’ by Primary Care, Specialist Secondary Care, and Acute Care, (Edwards,
2000, White, 2009, White & Kelly, 2010, Strang et al., 2012, Best et al., 2012).
The data focuses on the ‘treatment and recovery paradigm’ debate; the benefits and
dis-benefits of ‘treatment’, and the new world of ‘recovery’ and why the twain shall

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never meet, as outlined in the Literature Review and Methodology (Edwards, 1987,
1992, 1994, Booth Davies, 1997).
Participant 2
‘...No, I had felt RULED ‘...you will come and do this or else I will take your script...’ I felt ruled
like a second class citizen. I mean there’s a saying ‘...If you prod an angry dog a number of
times he’ll bite you...’ you know and I think that’s what happened (LAUGHS...’
‘...I have experienced things – the way the government do things – I have seen good points
and mistakes since we started recovery and have had an experiential involvement. The world
of treatment is a world where you get better in some ways but not in all places and you
described very clearly the limitations of treatment. Whenever you came out of HMP
treatment is part of a world that wasn’t really offering you a future....’
‘...Treatment could be more recovery based and focussed. That’s what we need to be aiming
for. That’s just my opinion. The main point is that recovery is recovery. It cannot be owned or
it break; a stepping stone into a lifetime of recovery. Not part of anything but recovery.
These are the questions... the first place you go if you are setting up selling. Let’s go to the
local Probation (LAUGHS)... I can remember going into the DTTO and smoking Crack in the
toilets...’
Participant 11
‘...I had a whole load of psychologists who got me drawing pictures when I was a kid but I
wasn’t ready and it was forced on me, but when I was ready, I asked for a counsellor...’
4.4. Has the study met the overall aims and objectives?
The study has added to the growing body of qualitative research on ‘recovery’ and
explained this via a ‘framework analysis’ which aligns closely to the international
evidence base (Best et al., 2012, Strang et al., 2012). The study has added to the
limited body of qualitative research on ‘survival’ and confirms the well established
evidence on ‘Rock Bottom’, to which it is well aligned.

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The study then went onto a less explored theme of ‘Damascene Recovery’ that is –
the moment after ‘Rock Bottom’ when another existence is visible and is referred to
by existential motifs such as ‘another world’ and ‘the bridge of opportunity’. The
study at this point aligns strongly with the sociological and psychological evidence
base as to ‘attribution theory’ and ‘social labelling theory’ (Booth Davies, 1987,
Becker, 1963, Goffman, 1974).
By way of example, for the reader, Becker’s essential notion refers to the tendency
of the majority to ‘label’ minorities as deviant to cultural norms. This then becomes a
self fulfilling prophecy as the labelled live up to the label effectively. Thus it followed
that Participant 11 did not care to engage with ‘experts’ until ready. Participant 2 felt
‘ruled’ by treatment. As Participant 3 states, he felt drained of his humanity. As he
says, the transition to better self esteem probably happens in the first 2 years into
recovery.
Most importantly, as we shall argue, this means that the study aligns with White and
Kurtz seminal notion of a phased and iterative transition from moderated drug and
alcohol use, to medical support for managed detoxification and onto abstinence as
well as notions of a continuum of ‘solo’, treatment’ and ‘peer’ initiated treatment
episodes (White & Kurtz, 2006).
Perhaps what it does not capture, is the sense of grief and loss of childhood and
adulthood the participants allude to but never detail. Former addicts often describe
this phenomenon, but perhaps surprisingly the study did not generate this type of
material.

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5. Discussion
5.1. Introduction and Summary
To recap, the ‘classic’ alcohol studies of the last 50 off years concern four phases:
- Firstly, a notion before 1962, that the world of addictive drinking is explained
by a model of progressive and irreversible alcoholism;
- Secondly, a growing recognition that some ‘alcoholics’ regain ‘control’ over
their drinking, but mainly those with more social assets such as housing,
relationships, work and families;
- Thirdly, a recognition that ‘addicts’ may ‘naturally recover’ regardless of the
offer of ‘treatment’ and ‘mature out’ of addiction;
- Fourthly that ‘recovery’ may take many attempts and over many years to
reach this stage – with numerous calls on psychological, pharmacological and
social support before ‘recovery’ is achieved.
Great progress was made as alcohol treatment moved from ‘asylum’ into specialist
services, into general hospitals, and finally into general practice. The approaches in
these settings became more and more sophisticated. What is however clear that

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despite huge progress in ‘treatment’ there remains a clear parallel between the lives
of many of the ‘survivors’ of Lexington and their modern contemporaries (Drummond
& Ashton, 1999). The reason for this impasse is that the ‘treatment’ paradigm does
not have an evidence base which adequately describes ‘recovery’ – nor indeed
‘lived’ experience of ‘treatment’.
These are fundamental gaps – while the National Treatment Agency continued to try
to locate alcohol treatment within the national frameworks of psychiatry and mental
illness, there was no real prospect of progress; NICE evidence is largely quantitative
and ‘treatment’ oriented and not ‘recovery’ oriented. The factor of time is also critical
to understanding change; over time, the ups and downs of the average addict
feature several major life changing events. Until very recently, once cases were
discharged they were out of sight until the next crisis. This allowed for the inevitable
relapses as one would anticipate in the life of the average addict. As the then doyen
of the ‘treatment’ world, Edwards, reminded us as long ago as 1999;
‘...Good luck to the specific therapies, psychological and pharmacological,
let’s not put them down, but at the centre is still the...little understood core of
the change process... ’ (Drummond & Ashton, 1999)
Best concludes from this that ‘recovery’ remains a huge research challenge (Best et
al., 2012). The clarion call, as we shall see, from the 1990s onwards, from both
‘treatment’ and ‘recovery’ researchers, was that we needed to hear more from those
who know most (Edwards, 2000, White, 2009). It is submitted that a richer
understanding of how the evidence based ‘matrix’ would help clinicians and patients
alike to better understand the balance between aggravating and mitigating risks and
needs, and building recovery, by intense support for those in treatment, and in their

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inevitable relapses, over time, and when to take risks, and how best to make
recovery visible. This is the question Strang and White asks without fully articulating
(Strang et al., 2012).
The typology of recovery involves a transition from moderated attempts, to
medicated support, to abstinence – a transition few fully make, (White & Kurtz 2006).
Given this, while communications about recovery may come from clinicians, in
extremis, those who have made that descent themselves are best placed to mount a
rescue; and rescue it often is -in the early hours when ‘treatment’ largely sleeps –
unless we are talking of Accident and Emergency. As the study shows, this a hugely
important location for building pathways to ‘recovery’, as Hughes study shows, and
this study now further confirms (Hughes et al., 2012).
5.2. A critical appraisal of the study in the context of other relevant work
As we have seen, this study sits at the centre of the ‘treatment and recovery
paradigm debate’ as evidenced by the close match between the literature and the
data. What is plain from looking at the literature is that the ‘treatment’ paradigm has
not delivered ‘recovery’ to enough patients. There is something in this to do with the
observation that non medical notions like ‘recovery’ has not been easily understood
by doctors - as Strang acknowledged (Strang et al., 2012).
The synthesis of the study is that the ‘evidence matrix’ from Salford has many
advantages for practice, and for theory. The matrix concerns the key domains of the
‘treatment and recovery paradigm debate’. The study shows the matrix to be simple,

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based in real experiences, related to patient and clinician views. The matrix offers
commissioner, provider, practitioner, patient, and researcher an opportunity for
dialogue on those brief opportunities. It follows that a richer understanding the
dialogue within the ‘matrix’ for each patient would help bring clinicians and patients
closer. As stated, previous attempts at this have been made with ‘relapse prevention’
and ‘motivational in interviewing’ training (Prochaska & Diclemente, 1986, Marlatt &
Gordon, 1987). The ‘matrix’ is also the key to unlocking the shifting locus across the
‘treatment and recovery paradigm’.
The ‘matrix’ firmly locates the data and synthesis of the study alongside the existing
evidence base of the last fifty years. The study supports the notions proposed by
Winnick and Vaillant that those with better social assets are more likely to recover
(Winnick, 1962, Vaillant, 1995). While the study would also support the notion of
periods of helplessness and despair, it does not go so far as to support the
deterministic ‘disease’ model of alcoholism proposed by Jellinek (Jellinek, 1960).
The study resonates powerfully with the work of Edwards and White which
acknowledges the gap in our knowledge around why people seek recovery and what
this process is about (Drummond & Ashton, 1999, White, 1999).
Overall, the study shows via the ‘matrix’ that the typology of recovery is almost a
direct reversal of the Jellinek ‘curve’. The pathway is in fact a transition from
moderated attempts, to medicated support, to abstinence. As the study shows – this
is a transition few fully make – but we still need to better understand how to stick with
the many who do try than we do currently (White & Kurtz, 2006).

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5.3. The wider relevance and implications of the findings
This study and debate around the ‘treatment and recovery paradigm’, as Best
recently acknowledged, take us to the edges of what is known about ‘recovery’ (Best
et al., 2010). It is no surprise that David Best has recently established two new
research cohorts in Glasgow and Birmingham to:
- Map out how support groups help ‘recovery’,
- Collate the experiences of people in recovery journeys, and
- Assess the role different elements play, at the different stages of recovery
The present findings drawn from the NVivo extracts show the complexity of individual
belief systems at any given point. The ‘cross cutting’ references demonstrate the
complexity of how users define their worlds and their behaviour. This is critical given
‘treatment’ and ‘recovery’ will only follow if these thoughts and behaviours are in
steady state. To be clear, every drinker has to weigh the balance of how they see
their own individual ‘complexity’, ‘severity’ ‘motivation’ and ‘asset’ levels. The
balance of these thoughts is then seen in their behaviours daily; indeed, other
related work has recently highlighted the importance of a ‘systems’ approach to
understanding ‘recovery’ (Daddow & Broome, 2010).
This shows the huge challenge of getting this complexity across in population level
communications; clearly one may better convey this from an individual level. This is
a problem for public health which instinctively believes that public pronouncement
shifts these beliefs thoughts and behaviours so that the user comes to believe that

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change is something to do with them, and within their gift. However, as Petersen &
Lupton (1996) argue, public health fails to recognise the needs of the ‘pathological’
user who has fewer social assets and so is less able to exercise ‘citizenship’, given
their constrained choices (Petersen & Lupton, 1996). In the struggle to be ‘normal’
many users fall by the wayside.
Further as the French philosopher Canguilhem would argue, health, and public
health here, seems to lack a keen sense of who in the population are ‘normal’
drinkers, and who are the ‘pathological’ – the future alcoholics (Canguilhem, 1989).
For the latter, one needs to regard the markers of future problems early in life – as
we see in the present study – those who get into such deep problems with alcohol
tend to start drinking and taking drugs early (Shedler and Block 1990)
Much of this knowledge has been around for decades (Prochaska & Diclemente,
1986, Marlatt & Gordon, 1987). As Drummond and Ashton have commented –
‘treatment’ has come out of the asylum to the Acute Hospital, the Specialist
Secondary Service, and now to General Practice (Ibid: 1999). However, Strang and
White now set the bar higher for General Practitioners, Specialist Generalists and
Consultants, to weigh aggravating and mitigating risks and needs, to build ‘recovery’
(Strang et al., 2012). For the ‘pathological’ case, the forum for this is clearly a ‘multi-
disciplinary’ case management approach involving the patient.
The study strongly confirms that the issues in Strang’s paper which lack clarity are
precisely when to take risks, and how best to make recovery visible (Strang et al.,
2012). The study powerfully differentiates emphases made by the ‘new’ survivor,