Background and rationale: This thesis explores the impact of attendance and participation at an ex-service user led project in Leeds for alcohol dependency. This thesis is important for two reasons. First, in the last few years, UK drug and alcohol policy has implemented a strategy that aims to facilitate full recovery from drug and alcohol dependency. Further research is needed to explore and understand the issues surrounding addiction recovery. Second, a scoping review of the literature found a significant lack of UK based studies exploring the impact of attendance and involvement at self-help groups for addiction recovery. Methodology and Methods: A qualitative, ethnographic methodology was used to gain a holistic understanding of the Learning to Live Again project (hereafter LTLA). A convenience sample of service users, mentors and professional staff who attended or were involved with the project was recruited. Participant observation was conducted at the project in order to gain greater familiarity with the project, followed by semi-structured interviews with those involved with the project. Data were analysed through a thematic framework approach. The data were interpreted and explained based on the theoretical assumptions of symbolic interactionism. Findings: The main finding was that the LTLA project provides service users with a recovery project that facilitates recovery on both an individual and collective level. The culture of abstinence and the peer support service users had access to, appeared to facilitate recovery by providing service users with a recovery project that is built on firsthand experience of addiction recovery. However, the data also demonstrated that some service users remain connected to their addiction through their ‘over-involvement’ with the LTLA project. Conclusions: This thesis contributes to the understanding of how and why attendance at an ex-service user led project for alcohol dependency impacts on recovery, and contributes to the UK evidence base on research in this area. The themes identified in this thesis lay the foundation for future research and further contributes to the understanding of recovery in UK drug and alcohol policy.

Ongoing pairing of alcohol consumption and alcohol related cues in the environment, through a process of classical conditioning, result in the development of alcohol attention bias (AAB) which reaches automaticity with ongoing alcohol use. AAB may co-occur alongside alcohol expectancies and physiological responses contributing to misuse (Robinson & Berridge, 1993). Understanding AAB is an important step in understanding addiction aetiology. The following series of studies employs the novel approach of eye tracking to examine AAB more directly, expanding current understanding which to date has relied on indirect methods. Inclusion of adolescent participants provides insight into earlier stages of AAB, an area where there is currently a dearth of research. Results indicate differences between drinking groups and age groups in AAB strength; older drinkers and heavy drinkers demonstrate the strongest bias. Employment of eye tracking provides novel insight into the efficacy of a modified dot probe task differentiating automatic and controlled processes. These studies provide insights regarding the early stages of AAB manifestation and the studies included in this thesis begin to address gaps in the current literature. Inferences from the cross sectional analysis and retraining task suggest the bias is not static and may change over time, approaching automaticity as alcohol use continues. Whilst AAB appeared to be associated with alcohol use, as evidenced across age groups, additional factors also appear to influence attentional processing as indicated by findings in non-drinkers. Inconsistent relationships between AAB, expectancies and physiological response are reported and possible explanations for this are outlined in the thesis. The clinical utility of these findings in understanding AAB and the role of interventions in reducing it are considered and recommendations for future work to further understand AAB' s development and its role in substance misuse are outlined.

Recovery occurs in a complex, emergent manner. It is a worldly process, shot through with the nuances and imperatives of an equally complex, emergent and imperfect world. Encountering recovery, therefore, entails thinking through the complex, mutually informed relationship between recovery-oriented organisations and the contexts in which they arise. This thesis presents and compares different attempts to address the social problem of addiction in Sarajevo. At its heart, it is a study of the ways in which members of two primary fieldsites—a therapeutic community and an NGO—try to achieve recovery from addiction, which gives equal weight and attention to the roles and voices of the addicts whose recovery is at stake, and to the roles and voices of the professionals involved in recovery processes. Positioning my study within both the city of Sarajevo, and within historical and contemporary manifestations of addiction problems in the city, I pursue a comparative explication of the ways in which addicts and professionals come together to ‘make’ recovery. I trace and compare the manifestations of a productive tension in these contexts between idealised and programmatic recovery on the one hand, and the imperatives of sociality on the other. If recovery is ‘made’ through such tension, it can also be ‘unmade’ in this way. As such, I ground my observations of the ‘unmaking’ of recovery processes in a discussion of the factors inherent to, and externally acting upon these institutions which undermine both the recovered state and the recovery process. In so doing I seek to generate insight into the complex, emergent nature of change in these contexts, which will be discussed in terms of (ab)normality, capricious simultaneity and possibility.

Harmful drinking adversely affects the drinkers’ health, social, and occupational functioning, leads to immense societal costs, and causes a significant burden on global health. Despite this, policy makers, and consequently health systems, are disproportionately focused on providing care for dependent drinking, the more severe end of the alcohol use disorders spectrum. Consequently there is a large treatment gap for harmful drinking, especially in lowS and middleSincome countries where only a small proportion of those with harmful drinking receive appropriate psychosocial care. Two major barriers to providing care for harmful drinking are the shortage of adequately skilled specialist human resources and the lack of contextually appropriate psychosocial treatments suitable for low resource settings. The aim of my thesis is to describe the systematic process used to develop Counselling for Alcohol Problems (CAP), a brief psychosocial intervention for delivery by lay counsellors in routine primary care settings to men with harmful drinking in India. In my thesis I have described each step of the intervention development process which is broadly divided three sequential stages viz (i) identifying potential psychosocial intervention strategiesZ (ii) developing a theoretical framework for the new interventionZ and (iii) evaluating the acceptability, feasibility, and preliminary impact of the new intervention. These three stages have nine steps that utilise a range of quantitative and qualitative participatory research methods to achieve the aims of the study. The outcome of the intervention development process is CAP a threeSphase treatment delivered over one to four sessions based on a Motivational Interviewing stance and includes other strategies as follows: assessment and personalised feedback, family engagement, drink refusal skills, skills to address drinking urges, problemSsolving skills and handling difficult emotions, and relapse prevention and management. To conclude, the outputs of the intervention development process were a) a contextually appropriate brief psychosocial intervention for harmful drinking designed to overcome specialist manpower shortages as it can be delivered by lay counsellors in primary care, and b) a structured framework to guide the development of contextually appropriate psychosocial interventions in low resource settings.

Different kinds of alcoholic drink have different connotations for drinkers in terms of their potential to produce intoxication and their effects on health. These connotations are likely to be important influences on drinking behaviour. This mixed methods study examined how young people (18 to 24 years old) in two countries with different drinking cultures (France and the UK) perceive the costs and benefits of consuming particular kinds of alcoholic beverage, specifically contrasting beers (blonde and dark), wines (red and white) and spirits (clear and dark). More broadly, the project evaluated young people's beliefs about the different beverage types, and the factors that influence their choices of beverage, including, peer influence, beliefs about drink-specific effects and how different kinds of drink affect body weight. A pilot study of online drinking diaries was conducted to establish drinking trends among young adults in the two countries. A number of key difference were found between the two countries which informed areas of discussion in the focus groups, including beverage preferences, the difference in levels of preloading and mixing drinks, as well as the relationship between alcohol and food. The qualitative part consisted of sixteen structured focus groups (8 in each country), which examined participants’ understanding and beliefs about the health consequences of consuming different kinds of alcoholic beverage. They also explored how different drinks are related to drinking styles. In both countries, participants highlighted ‘getting drunk’ as a reason for drinking, and they adopted similar justifications for their drinking behaviours. UK participants tended to view all drinks (except wine) as equally problematic for health, whereas French participants had more diverse beliefs about the health effects of different beverages. The quantitative phase consisted of a large survey distributed across the two countries (UK= 555 participants and France= 401), which looked further into people’s health beliefs about different beverage types. The notion that wine is healthier than other beverages was widely held in both countries, but was stronger in France than the UK and it had different determinants in the two countries. Also, in France, spirits were identified as particularly problematic for health, much more so than in the UK. In the UK, apart from wine, all beverages were considered to have a similar potential for causing health problems. Liver damage was identified as a key problem linked to chronic alcohol consumption; in France, it was most strongly associated with drinking dark spirits, whereas in the UK it was not linked to any particular beverage type(s). In both countries, the acute effects on health were more salient than the chronic effects, and the primary concern relating to long-term consumption was addiction rather than damage to physical health. Lastly, 14 semi-structured interviews were conducted in the two countries (7 in each country) exploring the impacts of public information, media reports and peer influence on beliefs about different beverage types. Across the two countries the participants believed that there was a lack of information about the long-term health effects of alcohol, and expressed a lack of trust in the media (i.e. newspapers and television advertising). They believed that information should be more accessible through the internet, i.e. social media sites, and they also suggested the use of images to illustrate the major health impacts of alcohol consumption. To conclude: drinking practices and views about alcohol’s health effects appear to be converging across the two countries. Participants showed a limited understanding of (and concern about) long-term health problems associated with different drinks, and their views were confounded with stereotypes about typical consumers and beliefs about the “naturalness” or “authenticity” of different drink types.

By theoretically framing sportspeople’s drinking within a social identity perspective, this thesis aims to elucidate the social psychological processes underpinning the link between sport group membership and alcohol use. It is argued that focusing on these group-level processes provides theoretically grounded foundations for applied practice. The thesis utilised both quantitative and qualitative methods. Secondary data analyses in Study 1 indicate that athletic identification plays a significant role in shaping alcohol consumption in different sporting contexts. Study 2 examined longitudinally personal and group-based social identities. Results indicated that alcohol consumption increased sports group identification over time, and this identification positively related to wellbeing. In contrast, a personal athletic identity was weakly associated with alcohol behaviours, indicating that there may be utility in harnessing these dual identities when addressing health in sport. Qualitative explorations in Study 3 exposed sport-related drinking as strategic and functional practices that served to provide a positive sport experience at the group-level. To achieve this, the sports group exhibited self-monitoring and regulating influences, whereby members’ alcohol behaviours could both be encouraged or deterred by the wider group. Experimental manipulations in Study 4 sought to examine effects of alcohol consumption and social identity processes between sporting and non-sporting participants. Findings indicate that intoxication exaggerates in-group biases for those highly identified with their group, pointing to a hitherto unexamined interplay between the psychopharmacological effects of alcohol and intergroup behaviour. Overall, the thesis highlights the central role of sport-related identities in defining alcohol behaviours. Its contributions outline how a number of social identity processes (identification, wellbeing, self- and social control) may be drawn upon to address risky drinking among student sportspeople.

Drinking behaviour in the UK population continues to be of topical interest with ongoing references to a drinking culture consistent in the British media. This is despite an overall fall in drinking patterns across the UK reported by public health sources in recent years. ‘Heavy drinking’1 in universities has been suggested as a normative social behaviour and there are a number of studies that describe this in large scale descriptive studies of patterns of drinking and trends in morbidity and mortality. However, longitudinal, qualitative case studies which explore the interpretations of drinking in the social context of a university across different courses are limited. Design and methodology. This is a longitudinal, instrumental case study which followed a cohort of undergraduate students through their time at university with multiple data collection points across three years from 2012 to 2015. In depth interviews with a variety of stakeholders and other methods were triangulated to explore the nature of drinking behaviour over time at one university. Participants from a range of courses were recruited and individual and focus group interviews were conducted, recorded and transcribed. QSR NVivo software was used to collect, organise and code data and thematic analysis was utilised to explore the findings Key Findings:  There is an enduring perception at the Case University that heavy drinking is an expected student behaviour. Participants felt ‘safe’ at the Case University to drink heavily because it was transient and they said they would not continue with that behaviour once they started work (the ‘bubble’ effect).  For younger students, (18-24-year-olds), the motivation for drinking alcohol changed over three years from ‘having fun’ and ‘partying’ in the first year to ‘relieving stress’ and ‘relaxing’ in the third year.  The Student Union (SU) body and some academic staff appeared complicit in the normalisation of drinking at the Case University.  Some young people ‘pretended’ to drink in order to achieve a sense of belonging to their peer group.  Non-drinkers felt uncomfortable in the SU bar and avoided that social space, reporting that there was particular pressure to drink in that environment. Key Recommendations  There needs to be a move towards changing the cultural expectations that heavy drinking is a key feature of student life at the Case University.  A culture of inclusivity at the Case University is needed to accommodate those who choose not to drink or drink in moderation.  Considerations of how the Case University promotes drinking in the setting and how risk is managed is important.

This thesis explores patterns of time use among university students to further understand their leisure time as an aspect of their day-to day lives, especially with regard to their time spent drinking alcohol. Attending university can be viewed as a key aspect in the prolongation of the youth life-stage for some young people, and a key influence on how they develop their own identities and spend their leisure time. In this regard, research suggests that far from being a homogeneous group, there can be a marked difference between sub-groups of students. Residence, for example, has been shown to be a particularly significant factor influencing how students report their university experience. Furthermore, a number of studies report that rather than being fixed, young people’s leisure lives, including their time spent drinking, tend to be dynamic, context-dependent and develop in some significant ways during their university careers. However, studies that have focused on university students have tended to study aspects of their leisure in isolation. This study aimed to address this limitation by studying students’ lives ‘in the round’ in order to more adequately understand the contextual complexity of their lives and how this might shape patterns of time use on leisure in general and drinking alcohol in particular.

Background Alcohol-related deaths and hospital admissions have risen steeply in the United Kingdom and little is known about whether there are opportunities for preventive interventions or opportunities for the earlier detection of alcohol misuse. The purpose of this research was to investigate and describe patterns of healthcare utilisation in the pre-diagnosis period of alcoholic cirrhosis and alcoholic psychosis, two alcohol-related disorders which contribute significantly to alcohol related morbidity and mortality. This information is important as it could greatly facilitate a better understanding of opportunities for the earlier detection of alcohol misuse, and could also potentially encourage and assist practitioners in the timely identification of those who are at high risk of developing significant alcohol-related illnesses. Specific research objectives 1)To estimate rates of primary and secondary healthcare contacts before the diagnosis of alcoholic cirrhosis/psychosis and assess whether this differs from rates in the general population 2)To characterise the healthcare contacts and establish whether such consultations were for other conditions known to be related to alcohol. 3)As a secondary objective, to establish whether prior healthcare contacts led to recognition of alcohol problems and consequent interventions. Methods UK general practice and hospital admissions data were used for this research. A population of patients diagnosed with alcoholic cirrhosis and subsequently, a population of patients with alcoholic psychosis were identified. For each case, 10 patients without the disease who were of similar age and from the same general practice were selected as controls. For each disease group, a case-control study design was used to compare rates of primary care contacts and hospital admissions in cases to that of the control population. Further, the reasons for primary care visits and hospital admissions were assessed to describe the frequency of other alcohol-attributable morbidities in cases and controls, and to assess whether there were any morbidities which were strongly associated with the later development of alcoholic cirrhosis and psychosis. Finally, the proportions of patients who had a record of their alcohol use status or a record of an offer of brief alcohol intervention/referral were estimated. Results Alcoholic cirrhosis 2,479 patients with alcoholic cirrhosis and 24,790 controls matched on age and GP practice were available for analysis. Assessment of healthcare utilisation showed that people with alcoholic cirrhosis had 50% higher rate of GP visits and twice as many hospital admissions compared to the control population. This excess healthcare use was apparent as far as 10 years pre-diagnosis of alcoholic cirrhosis, but greater excesses were seen within 5 years of diagnosis. Cases of alcoholic cirrhosis did have a higher frequency of other conditions that are partly alcohol-attributable, especially diabetes, epileptic seizures, hypertensive diseases, injuries and digestive diseases. Of all these conditions, injuries, seizures and digestive diseases had the strongest association with the development of alcoholic cirrhosis. Overall, a high proportion of patients with alcoholic cirrhosis (84%) had their alcohol use documented on an average of 4 years before diagnosis and 58% of these records indicated harmful/hazardous drinking. However, only 1 in 5 patients (22%) had any record of a brief alcohol intervention or an alcohol referral. Alcoholic psychosis 1,731 patients with alcoholic psychosis and 17,310 matched controls were included in the study. As with alcoholic cirrhosis, there was a substantially higher rate of primary and secondary care use in cases which was apparent up to 10 years prior to disease diagnosis. Cases of alcoholic psychosis also had a higher frequency of partly alcohol attributable morbidities. However, the strongest associations were seen for intentional and unintentional injuries and seizures. 78% of cases of alcoholic psychosis did have their alcohol use recorded, 50% had a harmful/hazardous drinking record but only 1 in 5 (19%) had any intervention record. Conclusion and Implications: This research has shown that patients who misuse alcohol make frequent contacts with both primary and secondary care, suggesting that there are high number of opportunities within these healthcare settings to improve the early identification and treatment of alcohol use. Relatively few patients were identified to have received brief alcohol interventions/referral despite the large proportion of people with documented drinking problems, suggesting potential inadequacy in the treatment of alcohol problems. However, this may also partly be an artefact of recording biases. Considering that alcohol is one of the leading preventable causes of morbidity and mortality in the UK, these findings should encourage healthcare professionals to, at the very least, screen for alcohol misuse in patients presenting with any alcohol-attributable condition, and for policy makers to consider directing more effort towards integrating alcohol screening and brief intervention into routine clinical practice.

The present study aimed to map out how members of Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) construct themselves, in talk, as being in recovery. This study adopted a social constructionist epistemology and a Foucauldian discourse analytic research methodology. A total of nineteen adults in self-reported AA and/or NA recovery were interviewed. Four individual interviews and three discussion groups were held. Analysis found that, on the whole, participants drew on AA/NA discourse in ways that were contradictory, subversive, pragmatic, dilemmatic and aligned with agency. Analysis generated four main themes: difference; possession; powerlessness-agency; and transformation. Participants tended to construct themselves not as objectivised subjects, but as exercising agency to knowingly draw on AA/NA discourse to practice care of the self and ethical selfgovernance. Other recent psychological studies have arrived at similar findings. AA/NA may, then, possess values that are more closely aligned with the humanistic ethic that informs counselling psychology and psychotherapy than is sometimes supposed. This is significant, because some authors have argued that the low rate of practitioner referral into AA/NA is caused by an ideological tension between the humanistic privileging of subjectivity and the perception that AA/NA subjects its members. Given the inexorable expansion of the addiction concept to most forms of human experience, it is likely that practitioners will be increasingly likely to work with addiction presentations in their clinical practice. It is therefore hoped that this study will challenge practitioners to reflect on why they don't work in partnership with 12- step programmes more often. More qualitative research in this important area will help to develop our understandings of subjectivity in AA/NA and other forms of 12-step recovery.