British Journal of Addiction 79 (1984) 129-130© 1984 Society for the Study of Addiction to Alcohol and other Drugs.

EditorialWhat Future for the Multidisciplinary Approach to Alcohol Prohlems?

'It is a disorder that is unsurpassed for the variety of itsmanifestations . . . there is no organ in the body, nor anytissue in the organs which is not affected . . . it is almostimpossible to describe its clinical symptoms withoutmentioning almost every symptom of every diseaseknown' [1]. This description of tuberculosis, publishedover .half a century ago, might well be applied to alcoholproblems today. With the striking increase in theirincidence in most parts of the world, alcohol problemshave become the multidisciplinary 'disorder' par excellenceof the latter part of the twentieth century. The spectrumof presentations is probably unique, even exceeding thatof the multi-system diseases of yesteryear. Patients mayseek help from a gastroenterologist because of jaundiceor abdominal pain, from a psychiatrist because of de-pression or symptoms of alcohol dependence, or from aneurologist because of a failing memory. Financial ordomestic difficulties may lead an individual to the socialwork department, and the police or probation servicewill be involved in cases of recurrent drunkenness orviolence. The common element in these diverse presen-tations is the alcohol problem, and recognition of thisand appropriate therapy is of primary importance. Thatis asking for no more than a display of professionalcompetence.

How effectively do various professional groupsidentify and manage alcohol problems? Comparativedata are hard to find, but my personal experienceworking in general hospitals, psychiatric hospitals andcommunity services leads me to conclude that there aremajor deficiencies in diagnosis and management. It isstill all too common for a physician in charge of the careof a patient with alcoholic cirrhosis to attend only to the'medical' aspects of management and to ignore theunderlying alcohol dependency and any co-existingpsychiatric disorders [2] which, left unheeded, wouldrender the patient more liable to relapse and thus lead toexacerbations of his liver disease. Perhaps equallycommon is for a psychiatrist to initiate a complexpsycho-therapeutic programme without fully establish-ing the extent of cognitive impairment, or to prescribepsyehotropic drugs without acknowledging the presenceof cirrhosis or heart disease which may be a contra-indication to such treatment. The presence of physicalcomplications such as these need to be borne in mindwhen the treatment programme is being devised andshould rule out any strategy based on controlled drinking.

Increasingly we are realising that our management mustextend beyond that of the presenting problem and musttake note of these other factors. The need for a multi-disciplinary approach to alcohol problems seems obvious.

I will forgive you if, by now, you are wonderingwhat is original or perspicacious in this article. It isn't anew theme. The need for a multidisciplinary approachhas been emphasized for some years. Witness Sir CyrilClarke's comment: 'If ever there was a subject that ismultidisciplinary it is alcoholism' [3]. And yet when onesurveys the horizon one finds remarkably few multi-disciplinary teams in operation.

'It is generally agreed that co-operation is essentialin the overall management of the alcoholic patient,particularly with a somatic disturbance. Indeed, everynew paper on the treatment of alcoholism stresses theneed for management by a team. However, in the U.K.apart from isolated instances in various parts of thecountry, this theory of co-operation has not been trans-lated into working practice' [4].

Why should this be so? The reasons will vary fromcountry to country. In the United Kingdom the policy ofestablishing regional alcoholism units in psychiatrichospitals that were often deep in the country and farremoved from major centres of population and generalhospitals, had the unfortunate effect of concentratingexpertise away from the places where it was mostneeded. Furthermore the in-patient psycho-therapeuticprogramme that was the basis of treatment in many ofthese units was not one that readily allowed the par-ticipation of non-psychiatrically-trained therapists. Withthe swing in fashion against such programmes over thelast decade there has evolved a more eclectic approach totreatment with contributions from psychiatrists, clinicalpsychologists, counsellors, nurses, occupational thera-pists and social workers.

However, the divide between internal medicine andpsychiatry and its allied disciplines remains, in mostinstances, as wide as ever and few of the vast number ofpatients admitted to general hospitals because of analcohol-related problem are fortunate to be assessed bysuch a team. Indeed in many hospitals the patient maynot receive any advice about his alcohol consumption ormay simply be told to stop drinking without beingoffered any practical help to do so. In a limited numberof cases multidisciplinary teams which include physicianshave been established to serve the needs of problem

130 Editorial

drinkers in general hospitals, psychiatric hospitals andcounselling services, but these remain the exception.

Will broadly based multidisciplinary teams emergewith the passage of time? This is possible, but is madeless likely by the lack of interest of many physicians inalcohol problems, and the corresponding lack of interestof many psychiatrists and others in the physical con-sequences of excessive alcohol consumption. This iscompounded by the fact that the post-graduate trainingprogrammes in psychiatry and in the internal medicinespecialties have virtually no common ground. Post-grad-uate medical training in most countries in the English-speaking world has become increasingly formalized andrigid. This is commendable in certain respects, forexample in maintainng clinical and procedural stan-dards, but has the disadvantage of discouraging interestsand experience outside the strict curriculum of thespecialty. It is extremely difficult for physicians to gainappropriate training in the management of alcohol prob-lems, or even to have an appreciation of the methods ofassessment and therapy used by those from other disci-plines. Likewise, advances in physical investigation, inclinical pharmacology and in our understanding of thepathogenesis of alcohol-related disorders may not evenbe recognised by trainees in other disciplines. An ad-ditional problem is that many professional societies seemuninterested in receiving communications about multi-disciplinary studies. Pity the research fellow who submitsa paper on alcohol dependence in patients with alcoholiccirrhosis to a gastroenterological society. 'Stick to yourwork on magnesium flux in experimental cirrhosis,young man.'

Progress towards the multidisciplinary approachwill only be made if this is encouraged by seniormembers of our respective professions and if there issome support to do so by government health and socialservice departments, so that post-graduate medicaltraineees and those seeking qualifications in other dis-ciplines will be encouraged to take an interest in alcoholproblems. This has been the case in parts of Canada andin Australia, and it is perhaps no coincidence that I ampenning this editorial from Australia. The cost need notbe great. Some new posts will need to be established buta reorganization of existing commitments will oftensuffice. Provision should be made in the medical post-graduate training programmes for experience in otherdisciplines, and a knowledge of the spectrum of alcohol-related disorders should be an essential part of thetraining of all those who are likely to deal with alcoholproblems, including counsellors and social workers.More than this, there must be a willingness to learn fromeach other. It takes an effort of will for someone highly

specialized and highly regarded in his own field toacknowledge ignorance in another discipline and to takesteps to remedy that.

The B.J.A. is concerned to promote this under-standing. From this issue in the centenary year of theJournal, we shall be publishing a series of reviews ofmedical disorders that occur in problem drinkers. Wehave asked the authors to highlight recent advances inour knowledge and to place them in the context of thewhole spectrum of alcohol problems. On pages 139-145Dr Hans Kristenson and Professor Bertil Hood reviewtheir extensive experience of screening for alcoholproblems in Malmo, a city that is renowned for the majorcontributions that have been made in the epidemiologyof many of the major health problems of today. In theSeptember issue we shall be publishing an authoritativereview on alcohol-related brain damage by Dr RogerTuck and colleagues of the Regional Brain Damage Unitin Sydney, and in subsequent issues there will be articleson alcohol and hypertension, alcoholic liver disease, and,of major importance nowadays given the increase inalcohol consumption among young women, the effect ofalcohol on pregnancy and the development of the foetus.

We hope that these reviews will be of interest to allreaders, irrespective of whether they have a medical,sociological, or psychological background. We hope thatan increasing number of physicians will be attracted tothe Journal and will iearn of the many developments inour understanding of the basis of alcohol problems, theirsocial context and their management. We hope that theinterests of the different disciplines will gradually con-verge and that a multidisciplinary approach to alcoholproblems will have a firmer foundation than hitherto, afoundation based on a common language and commongoals.

John SaundersStaff Specialist Physician, Drug & Alcohol Services,

Royal Prince Alfred Hospital, Sydney, Australia

References1 Osier, W., McCrae, T. and Funk, E. H. (1925). Modem

Medicine: Its Theory and Practice, Vol 1. Lea and Febiger,Philadelphia, 430-442.

2 Ewusi-Mensah, I., Saunders, J. B., Wodak, A. D., Murray,R. M. and Williams, R. (1983). Psychiatric morbidity inpatients with alcoholic liver disease. British Medical Joumal,287, 1417-1419.

3 Clarke, C. A. (1980). Foreword in: Madden, J. S., Walker,R. J. and Kenyon, W. H. (eds) Aspects of Alcohol and DrugDependence. Pitman Medical, London.

4 Krasner, N. (1977). The reality of medical-psychiatriccooperation. In: Edwards, G. and Grant, M. (eds) Alcohol-ism: New Knowledge and New Responses. Groom Helm, London,p.335.