Liver damage is one of the most well-known and common health problems associated with drinking too much alcohol. The most severe type of alcohol-related liver damage is called alcohol-related cirrhosis. This is when the liver becomes scarred to a point when the scarring cannot be repaired. Patients with alcohol-related cirrhosis are at risk of liver failure, liver cancer and death. Fortunately, even for patients with cirrhosis, becoming abstinent from alcohol dramatically improves their chances of long term survival. Despite this, about 50% of patients with cirrhosis are actively drinking alcohol1. Nearly two thirds of patients who are admitted to hospital with alcohol-related cirrhosis will be drinking alcohol again within 3 months2. As few as 1% of these patients access optimal relapse prevention support, combining talking therapies and medications3.
To understand why relapse is so common and engagement with relapse prevention support so poor, we interviewed patients with alcohol-related cirrhosis during an admission to hospital4. We interviewed 33 patients across two hospitals in East Anglia. There was a wide age range and a mix of male and female patients. About half of the patients were interviewed during their first admission with advanced liver disease. Most were drinking alcohol at the time of their admission to hospital, but some had achieved abstinence and we felt it was important to learn from their experiences.
This time has to be different
We discovered that patients were very motivated to remain abstinent after their hospital admission. The patients we spoke with understood that they had severe liver damage due to alcohol and that they should not drink again in the future. As one participant stated:
Luke (48 years old): “This time has to be different. If I keep on going down this route, I’m going to die.”
This renewed motivation made patients confident that they would be able to be completely abstinent after being discharged from hospital. In fact, they felt that they could do this on their own, without the need for additional help. In addition to the fear of future health problems, patients would rely on their own determination and willpower to make sure they did not go back to drinking alcohol:
Matthew (57 years old): “You can have all the support you want in the world but the only person that’s going to stop you drinking is yourself. You know, you’ve got to make a decision.”
We might think that being highly motivated to change, and having a belief in your own determination would be a positive attribute for someone trying to give up alcohol. However, these same factors make patients reluctant to accept any support because they don’t view it as necessary for them. Motivation and determination are very likely to fade in the weeks and months after a hospital admission, especially once the patient starts to feel physically better. Indeed, we know that relapse into alcohol use is common.
It’s not like I’m a bad drinker
Another reason why patients did not feel they needed relapse prevention support was that they did not see themselves as a ‘bad drinker’. Although all of the patients interviewed had advanced alcohol-related liver damage, most rejected the label of “alcoholic” and therefore felt that they were not part of a group which needed treatment.
Jennifer (36 years old): “It’s not like I’m a bad drinker. I drink for like relaxation, so it would just be with my friend, sit there and have a laugh and stuff. It’s not like we’re going to go out and be like hooligans or something like that. Or I’m making like risky choices, things like that.”
Oliver (43 years old): “But the one thing I will say—and it’s gospel—is I’ve never been what I’d put down to be (an alcoholic)—I’ve never drank in the morning; I’ve never finished off a bottle of whisky.”
It was clear that the term “alcoholic” was prominent in the minds of our patients and was associated with stigma and shame. Engaging with any kind of support for alcohol use would therefore mean accepting that they had a problem with alcohol themselves, and that they might be one of those “bad drinkers”. We think that patients do this to protect their existing identity and avoid taking on one with negative connotations and stigma.
We know that for many people who struggle with alcohol, accepting that they have a problem and even adopting the label “alcoholic” can be an important part of the road to recovery. However, that label is also associated with stigma, identifies the patient as having a problem, and challenges the patient’s idea of who they are.
Conclusion
Motivation, confidence in your own abilities, and the alcoholic identity are double-edged swords for patients with alcohol-related cirrhosis who are trying to remain abstinent. While they may be useful attributes for some patients, they can also create barriers to engagement with relapse prevention support.
A way forward?
One way to address these barriers might be to include relapse prevention support as part of the normal, routine care of patients with alcohol-related cirrhosis. We might consider delivering that support in the liver clinics, which patients might be more likely to attend and where the only label they would need to adopt is of someone with liver damage. Another way is for all of us to consider how we can reduce the stigma around alcohol problems and make it more acceptable for patients to seek help and support.
Note: names attributed to the quotes in this article have been changed.
Written by Dr Christopher Oldroyd, Clinical Research Fellow at Cambridge University Hospitals NHS Foundation Trust.
All IAS Blogposts are published with the permission of the author. The views expressed are solely the author’s own and do not necessarily represent the views of the Institute of Alcohol Studies.
1. Lim WH, Tay P, Ng CH, et al. Meta-analysis: Prevalence and impact of alcohol abstinence in alcohol-associated cirrhosis. Aliment Pharmacol Ther. Mar 2024;59(6):730-741. doi:10.1111/apt.17888
2. Oldroyd C, Pan S, Patel J, et al. P2 A regional evaluation of outcomes at three months for patients admitted to hospital with decompensated alcohol related cirrhosis. Gut. 2024;73(Suppl 3):A12. doi:10.1136/gutjnl-2024-BASL.15
3. Rogal S, Youk A, Zhang H, et al. Impact of Alcohol Use Disorder Treatment on Clinical Outcomes Among Patients With Cirrhosis. Hepatology. 06 2020;71(6):2080-2092. doi:10.1002/hep.31042
4. Oldroyd C, Avades T, Martin GP, Notley C, Allison MED. Motivation, self-efficacy, and identity-double-edged swords for relapse prevention in patients with alcohol related cirrhosis. Alcohol Alcohol. May 14 2025;60(4)doi:10.1093/alcalc/agaf027