Liver transplantation (LT) has increased the survival for participants with end-stage alcoholic liver disease (ALD), however more than 50% of ALD transplant patients return to alcohol use after LT. Despite medical referral and a number of clinical trials of standard alcohol interventions, participants who are ALD transplant patients are reluctant to use specialist alcohol programs to support their required abstinence. The aim of this study was to identify those factors contributing to treatment reluctance by participants who are ALD transplant patients. The authors conducted a prospective case-control study comparing 40 ALD transplant patients matched for age and sex with 40 alcohol treatment seekers on a number of demographic and clinical predictors associated with treatment seeking. The authors found that lengthy abstinence and a progressive stage of change profile by participants who are ALD transplant patients contributed toward alcohol treatment being perceived as unwarranted or not needed. Furthermore, the ALD group differed significantly to those who would typically utilize alcohol treatment on a number of other clinical variables suggesting that standard alcohol interventions are not well tailored to the ALD transplant population. Two major barriers to help seeking among ALD transplant patients included the potential for stigma and limited access to alcohol services. Based on these findings, an individualized stepped-care alcohol treatment approach taking into account the clinical characteristics and needs of ALD transplant participants is required. Alcohol treatment needs to be integrated with the medical transplant program and is recommended for responsiveness to the ongoing psychological and social needs of those at risk of relapsing.