Alcohol and drug services have been patient centred for years

Editor—Stewart's summary of and enthusiasm for a patient centred approach is most welcome.¹ I believe that one additional feature of this approach should be added—namely, that it acknowledges the reality of patients accepting or rejecting our advice or treatment. Clinicians working with patients with alcohol and other drug problems, particularly those working in the harm reduction model, have known this for years.

The work of W R Miller, for example, has shown that the more confrontational (non-empathic, non-patient centred) the clinician the poorer the outcome. Previously, poor outcomes were taken as a sign of the patient's denial or unwillingness to change—now most clinicians (those working in the field of alcohol and other drug problems, at least) accept that these problems usually represent failure on the part of the therapist. The increasing evidence that most humans do not always “comply” with our treatments must surely make us as doctors more keen to enter our patients' world and mindset as a clinical priority, at least if we wish to achieve good health outcomes. Stewart's point, that the fact that some may not prefer a patient centred approach constitutes a false objection, is most important, since any clinician who rigidly adheres to any model as taught is, by definition, model centred, not patient centred.

Working with patients with alcohol and other drug problems, we often meet people who are very sick and who occasionally die from violence, overdose, or organ failure over the ensuing days or weeks. With respect to outcomes, it is a discipline as serious as any other. But we do not delude ourselves that we can do much more than attempt briefly to enter another person's world and possibly help make some positive changes if they wish. All health training and undergraduate programmes should incorporate significant exposure to the management of people who have problems with alcohol and other drugs, as a means to understand the person centred approach.