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14 The Treatment of Special Populations: Overview and Definitions Over the past 20 years, a number of subgroups have been identified as special populations for the purposes of planning and evaluating the national system of treatment for alcohol problems. Through the years, barriers to accessing and successfully completing treatment were identified for a variety of such groups. Efforts were initiated to provide funding for separate programs or to make sure that generic, or mainstream, programs were structured so as to provide appropriate outreach and treatment (USDHEW, 1974; Gunnerson and Feldman, 1978; USDHHS, 1981, 1983, 1986; Saxe et al., 1983; McGough and Hindman, 1984~. Emphasis has been placed on developing treatment strategies that would be delivered through separate treatment programs employing clinical and administrative staff from the affected group whenever possible or with special training for staff of mainstream programs in understanding the normative environment in which the persons that they are treating have functioned and developed alcohol problems. Throughout the history of its funding of specialty programming for the treatment of alcohol problems, the federal government has emphasized that there are certain populations or subgroups that must receive special attention because of their unique characteristics and their inability to receive appropriate treatment within what might be called "generics treatment programs (e.g., USDHEW, 1974; USDHHS, 1986~. These special populations have been defined in terms of either their apparently greater risk for alcohol-related problems, whether the reasons are primarily biological or sociocultural (e.g., American Indians, children of alcoholics) or legal or political (e.g., public inebriates, drinking drivers, the homeless). From the perspective of general health care, people with alcohol problems are themselves seen as a special population whose needs have not been adequately met within the overall health care system nor within the specialty mental health system (e.g., Plaut, 1967; Heckler, 1985~. Just as there is still debate over whether a separate specialty alcohol problems treatment sector is necessary or whether integration and mainstreaming are possible, there is still debate over whether specialty alcohol problems treatment programs are needed for the various special populations that have been identified. The term special popul~iorls takes in a wide range of categories, many of which do not truly make up a self-identified group (Diesenhaus, 1982~. Yet, the concept is still seen by those in the field as instructive for designing and implementing treatment programs in instances in which there is information on commonly shared characteristics that are thought to have relevance for treatment attraction, retention, and maintenance. The concept has remained important at the state and local service delivery level. The states report that they are continuing to provide services targeted toward a variety of special populations (ADAMHA, 1984, 1986), even though the federal government no longer requires such targeting (other than to women and American Indians) as a condition of receiving federal block grant funds (see Chapter 18~. Legislators, clinicians, and researchers recognize the need not only to define but also to provide culturally relevant treatment of alcohol problems for individuals who belong to special populations. Yet there is little consensus about what such treatment entails, for whom it is specifically designed, and what the term special populations actually means. The purpose of Section IV is to review some of the history and issues involved in the delineation of treatment programming for special populations, to review selected research and practice, and to make recommendations regarding future research and programming needs. 344

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THE TREATMENT OF SPECIAL POPUIATIONS: OVERVIEW AND DEFINITIONS 345 Defining Special Populations: A Historical Perspective Alcoholic beverages have been a part of the heritage and culture of the United States since the first Spanish colonists arrived in this country in 1565. All of the European groups that established colonies imported alcoholic beverages and rapidly developed local production as an early priority. Each group of settlers brought over its unique views of the positive and negative aspects of alcohol use, as well as its own alcoholic beverage of choice. Early on, this country's ambivalent relationship toward alcohol use led to economic, medical, and social support for drinking on the one hand and to control and prohibition of alcohol use for some population groups on the other. Those leading religious and moral/social movements directed toward all drinkers of alcoholic beverages began to describe subpopulations that they considered to have unique problems associated with alcohol ingestion. These initial efforts at control were directed mainly toward Indians, blacks, and Irish and Scottish immigrants all of whom were singled out as special subgroups that consumed alcohol at levels far above nnormal" and had a higher rate of problems associated with drinking. Since those early times, efforts have continued to classify those individuals who misuse alcohol into categories as a way to facilitate assessment and treatment, but it was not until the establishment of NIAAA in the early 1970s that using the concept of special populations as a categorizing strategy (both for funding and for the development of treatment programs) became prominent. Historical perspective on the changing or progressive definition of what constitutes a special population represents progress in recognizing the complexity of treatment for alcohol problems. Gomberg (1982) notes that the Third Special Report to Congress on Alcohol arid Health (USDHEW, 1978) refers to special populations as groups defined in terms of demographic variables: age, gender, and race. The groups discussed in that report were young people, women, the elderly, American Indians, Spanish-speaking persons, and blacks. These groupings were seen as very different from those described in the 1940s, when the focus was on grouping by differences in social class and psychiatric symptoms. Gomberg further noted that the fourth report, published in 1981, had added Native Alaskans, Asian Americans, and gays to this list (USDHHS, 1981~. Although she questioned why the special populations discussed did not include such white ethnic groups as Irish-Americans or Polish-Americans or those groups at higher risk for alcohol problems by virtue of their socioeconomic status, she concluded that the definition of special populations then current represented real progress in recognizing the complexities of alcohol problems. As Gomberg noted, The term has come to mean those groups who have special treatment needs and who have been underserved (Gomberg, 1982:351~." A major arena in which there has been an effort to define special populations for the treatment of alcohol problems has been legislative activity at the federal level. Special populations first began to be identified legislatively in the mid 1960s when the Alcohol Countermeasures program was established within the National Highway Safety Administration; this effort ultimately led to the funding by NIAAA of categorical grants for the treatment of drinking drivers (Diesenhaus, 1982~. Public inebriates were singled out for state and federal legislative attention as a result of federal court decisions that the chronic alcoholic could not be held criminally liable for public inebriety. The establishment of the National Center for the Prevention and Control of Alcoholism and of NIAAA, in the early 1970s, also drew attention to special populations (Plaut, 1967; Gunnerson and Feldman, 1978~. Alcohol problems among the poor were seen by many as an area of particular need. Efforts to provide targeted service were initiated through grants made for outreach, advocacy, and outpatient counseling as part of the Model Cities Act and the Antipoverty Act in the late 1960s; in 1972 these so-called poverty grants were transferred from the Office of Economic Opportunity to NIAAA and became its largest special population grant

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346 BROADENING THE BASE OF I:REAIMENT FOR ALCOHOL PROBLEMS category (Gunnerson and Feldman, 1978; DeVita, 1988~. Another piece of legislation targeting special populations was the 1970 Hughes Act (Public Law 91-616~. The Hughes Act authorized a formula grant to the states which required them to identify needs and services for women and youth under 18 years of age. These two groups were also included in the legislation authorizing NIAAA to provide categorical grants for community-based services. Parallel to the federal effort, a number of states had also begun focusing on the need for differentiating treatment to meet the needs of identified subgroups (e.g., Minnesota's programming for American Indians; California's funding of commissions to focus on the needs of women and Hispanic Americans). Yet despite this apparent interest, the term special populations does not appear in the First Specu~l Report to the U.S. Congress on Alcohol and Health from the secretary of health, education, and welfare (USDHEW, 1971~. The chapter, Treatment of Alcoholism,n in the report was organized around the multiple interacting systems that must be taken into account in developing treatment strategies (biological, biochemical, organ, intrapsychic, interpersonal, social, small group, and large group). However, several population subgroups were singled out in this discussion of treatment as requiring specialized programming: skid row alcoholics, alcoholic employees, persons arrested for driving while intoxicated, and those who have suffered injuries to the central nervous system. The report also identified six priority areas for the development of research and services programs. Three of these areas were related to special populations: (1) rehabilitating the public inebriate; (2) providing help to alcoholic employees, and (3) identifying and treating drunken drivers. The priorities also served to introduce a fourth subgroup: American Indians. The priority involved was to reduce alcoholism among them. Adolescents were also discussed but as part of prevention programming; the report singled out for attention those adolescents "who exhibit delinquent behavior or personality traits of incipient alcohol abuse." The term specu~l populafion programs was finally introduced in the Second Special Report to the [J.S. Car~gress on Alcohol and Health (USDHEW, 1974) in describing NIAAA's efforts to carry out these priorities: Recently the NIAAA has also launched a series of special-population programs in addition to those already functioning for American Indians and Alaskan natives. They include projects to bring aid and rehabilitation to alcoholic people in certain hitherto neglected segments of our society: blacks, Spanish-speaking Americans, migrant farm workers, women, and persons caught up in the criminal justice system. (p. xviii) To increase resources to meet the needs of the ethnic groups noted above, the NIAAA has developed separate program guidelines that encourage the recognition and use of each group's unique cultural characteristics in developing treatment services and has supported these services through the award of project grants. (p. 113) The Third Special Report (USDHEW, 1978) continued this emphasis on services to specially designated populations, including both a separate chapter on special popula- tions and a discussion of the research findings and clinical observations in the chapter on treatment. The report included a description of the current status of research on cultural or subgroup drinking practices and on the prevalence and form of problem drinking among subgroup members. The emphasis of the discussion on treatment was the barriers to gaining access to treatment experienced by members of each special population and the

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THE TREATMENT OF SPECIAL POPUIATIONS: OVERVIEW AND DEFINITIONS 347 design of Culturally specific" or Culturally relevant treatment interventions to ensure the retention of group members in treatment and a successful outcome of treatment efforts. The Research Perspective on Special Populations Diesenhaus (1982) attempted to offer a comprehensive definition of special populations as groups that have common social, psychological, or legal characteristics and that have encountered barriers in obtaining appropriate treatment. He reviewed the status of specialized treatment programming for a number of groups: drinking drivers, incarcerated alcoholics, migrant farm workers, military personnel and other occupational groups, public inebriates and skid row alcoholics, the physically impaired, and those experiencing problems with both alcohol and other drugs. Diesenhaus also described what he considered to be the current research trend to develop a unifying conceptual framework of special population classification schemes to be used in evaluation of treatment for alcohol problems. According to Diesenhaus, this trend had evolved from the need to design specialized and culturally sensitive treatment programs that might better meet the needs of those special population groups whose members shared common nsvchosocia attributes or social status. ~ r-~- Prior to 1970 scientific research and clinical experience in the treatment of alcohol problems was based predominantly on studies of Caucasian males aged 40 or older in inpatient treatment settings (cf., Gomberg, 1982; Vannicelli, 1984; Lex, 1985; Westermeyer, 1988~. The preeminence of the Minnesota model as the most widely used model for treatment has arisen from its success in treating alcohol problems among this same core group of identified men (see Chapter 3~. Treatment for special populations was also structured on the increasingly popular model of short-term inpatient primary rehabilitation followed by a variable period of aftercare using a multidisciplinary approach and incorporating the principles of Alcoholics Anonymous; efforts were made, however, to use counselors who were recovering alcoholics from the same socioeconomic and ethnic group as the persons being treated (e.g., Staub and Kent, 1973; Mitnick, 1978; Rosenberg, 1982) (see Chapter 4~. In the early 1970s, a consensus developed that using findings of studies of middle-aged white males to understand attitudes, treatment concepts, and prognostic expectations for members of special population groups was not useful. Rather, there was a need to develop treatment approaches tailored to what was known about the relevant culture of each group. This consensus was not limited to the treatment of alcohol problems; it was a major theme in the development of community-based\general health and mental health services (Rogler et al., 1987~. Lex (1985) summed up this change in perspective: \ It is now recognized that a society as heterogeneous as the United States is best viewed as an aggregation of numerous subgroups. There is considerable variation in patterns of alcohol use and alcohol problems in distinctive subgroups who share common racial or ethnic backgrounds-such as blacks, Hispanics, and American Indians. Persons who share demographic characteristics of sex or ag~such as women, youth, and the elderly-similarly constitute discernible subgroups whose alcohol use patterns and problems also have implications for diagnosis and treatment. (p. 90) By the early 1980s, it became apparent that there had been little evaluation of these efforts to develop treatment programs tailored to the diverse needs of special populations. Saxe and colleagues (1983) reviewed the status of treatment programming for

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348 BROADENING ME BASE OF TREATMENT FOR ALCOHOL PROBLEMS nine special populations: the elderly, youth and adolescents, women, blacks, Hispanics, American Indians, problem drunk drivers, and public inebriates and skid row alcoholics. The Saxe team reviewed a variety of studies for each of these subgroups to try to establish whether their overrepresentation (e.g., blacks, American Indians) or underrepresentation (e.g., women, the elderly) in the treatment population reflected real differences in the incidence and prevalence of alcohol problems among groups or the lack of appropriately designed, culture-specific treatment programs. They concluded that there was insufficient evidence to resolve what had come to be ongoing disagreement between those who advocated culturally specialized treatment programs using staff who share the patients' cultural and experiential background (and language, when appropriate) and those who believed that treatment should focus on the alcohol problem itself rather than on the cultural considerations. Saxe and coworkers also stressed the heterogeneity of the groups discussed in their review. They particularly noted this quality among the Hispanic American subgroup. Although most research up to that point had focused on Mexican Americans, the Saxe team urged attention also to the alcohol problems of Hispanic Americans whose cultural origin was Puerto Rico, Cuba, or one of the other Central or South American countries. Similarly, Saxe and his group pointed to the socioeconomic heterogeneity that exists among public inebriates who do not all fit the stereotype of the homeless, skid row alcoholic. The Fifth Special Report to Congress (USDHHS, 1983) introduced the concept of special need populations, focusing on informal selection of treatments by members of these groups and the matching of needs to specific treatments: Despite the increasing variety of programs, settings and treatment modalities, many alcoholics do not have the opportunity to find an informal match between their own specific needs and the type of treatment available. This is especially true of special needs populations, such as women, ethnic minorities, the multidisabled, the elderly, and skid row alcoholics. For these groups access to treatment and successful rehabilitation are often impeded by cultural barriers, financial constraints, and program design characteristics. (p. 108) The report's listing represents another expansion of the groups identified as special populations. The most important common characteristic of the groups is that they all face barriers to treatment access that the report states are being dealt with in program design: "With the growing recognition that utilization rates may be improved by removing barriers to access, greater attention is now being given to special population groups in the design of treatment programs" (USDHHS, 1983:108~. A new emphasis found in this report is the need to evaluate these programs once they have been implemented: As these programs become available, research will need to move from program descriptions to actual evaluation studies in which programs designed for special population groups are compared with more traditional approaches" (p. 109~. The Fifth Special Report identifies specific services that are thought to be needed by some of the special populations if treatment is to be more attractive and retention and outcome is to be improved: (1) for women, child care services and same-sex counselors are needed; (2) minority groups for whom language differences impose a barrier require minority staff who speak the same language and come from the same cultural background; (3) for American Indians and Hispanic Americans, native healing and folk medicine should be included; and (4) those who have problems with alcohol as well as other drugs need combined alcohol/drug treatment programs. Financial restrictions on the availability of treatment are identified as a concern for all these special need populations. The report raises the issue of the unknown impact that the shift from federal categorical grants

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THE TREATMENT OF SPECIAL POPULATIONS: OVERVIEW AND DEFINITIONS 349 targeted toward special need populations to the block grant has on the continuing efforts to improve access for these groups. The review of treatment in the SiUh Specu~l Report to the U.S. Congress or' Alcohol and Health (USDHHS, 1987) does not contain a discussion of the treatment needs of special populations. The questions about the impact on efforts to improve access identified in the prior report remain largely unstudied. Yet NIAAA's most recent publication on the planning of treatment services does include a section on the consideration of the special needs for members of several special populations which I. . . research suggests may be particularly underserved by alcoholism treatment programs" (McGough and Hindman, 1986:41~. The report identifies eight major groups on the basis of sex, age, race, and ethnicity: (1) elderly; (2) youth; (3) multidisabled; (4) American Indians; (5) Black Americans; (6) Hispanic Americans; (7) Asian/Paciffc Americans; and (8) women. The report contains a brief chapter for each of these special populations summarizing research findings and actual program experiences. For several, there is further discussion of the differences among subgroups with need be taken into account in planning. For example, the multidisabled individual can be physically or mentally disabled. Specific subgroups identified within this special population are the mobility impaired, hearing impaired, vision impaired, mentally retarded, and developmentally disabled. Similarly, the American Indian special population is further broken down to identify Aleuts and Alaskan Natives as distinct subgroups; the existence of tribal variation on key variables relevant to the treatment process is also stressed. The Hispanic American special population is similarly divided into subgroups that differ in terms of national origin, educational attainment, socioeconomic status, and degree of acculturation. Subgroups that are specifically mentioned include Mexican Americans, Puerto Ricans, Cubans, Caribbean Islanders, and Central and South Americans. Additionally, Hispanic American migrant and seasonal workers are identified as a high-risk occupational group whose mobile lifestyle calls for special efforts to coordinate treatment services. The planning manual has two key criteria for defining a special population: (1) the group must be identified by research as underserved in current treatment programs and (2) clinical experience and research must demonstrate the necessity for subgroup-specific interventions (e.g., linking the elderly with recreational, medical and social services; dealing with educational and vocational issues for youth; providing employment counseling and job placement within a program targeted at black Americans; and being sensitive to language barriers with Hispanic Americans). Over the years, Congress has also reviewed the status of alcohol problems treatment for individual special population groups and included specific references to them in legislation and reports. Groups so identified have been drinking drivers, "federal offenders," military personnel, federal employees, the elderly, families of alcoholics, the handicapped, the homeless, victims of domestic violence, public inebriates, Native Americans, poverty groups, veterans, Native Hawaiians, ethnic minority groups, women, underserved populations, and youth (DeVita, 1988~. Legislative actions have covered a wide range of assistance efforts. Legislation has been enacted mandating that treatment for alcohol problems be provided or made available to particular groups (the military, federal employees); it has also been used to require representation of identified underserved or high-risk groups (e.g., the elderly, racial and ethnic minority groups, poverty groups, and women) in the state advisory councils that had to be established for a state to obtain formula grant funds. Legislation has also required that the states conduct surveys to determine needs and ensure services for particular special populations (the elderly, youth, and women); it also required the Department of Health and Human Services (DHHS) and NIAAA to give special consideration to certain applications for treatment funds that were directed to these groups (the elderly, the physically and mentally handicapped, families of alcoholics, underserved populations such

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350 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS as ethnic and racial minorities, Native Americans, public inebriates, victims of domestic violence, women, and youth under age 18~. Legislative activity in regard to federal employees has focused on providing emolovee assistance Programs and on the ouestion of whether treatment for alcohol problems Should De mandated m the Pederal Employees Health ~enents Plan. Legislative activity in regard to other groups (most notably, the elderly, youth, and women) has been directed toward ensuring that the identified special populations receive the services that they need. At times Congress has been quite directive in its designation of a special population that requires additional consideration in planning and funding treatment services; for example, in 1980, the Congress required DHHS to give special consideration to grants and contracts designed to provide specialist treatment programs for the elderly. Its action was prompted by the belief that older persons are less likely to seek services in centers populated by young alcohol abusers. Also in 1981, Congress instructed DHHS to provide funding for a designated center for research on the effects of alcohol on the elderly. In the years since the passage of the block grant in 1981, congressional emphasis has been on meeting research needs rather than on directing federal funding to meet service access needs of selected populations. The authorization for services funding efforts was subsumed under the new block grant in 1981, with the expectation that the states would carry on the efforts to meet the service needs of special populations according to their own priorities. The three special population groups which have received some degree of congressional attention in recent years have been women, youth, and the homeless. In 1984, Congress mandated that at least 5 percent of the block grant funds for alcohol and drug abuse services be used to support new or expanded services for women. Congress also singled out for research attention the problems that are created when pregnant women drink. High risk youth, including those at risk of becoming an alcohol abuser, are the target population for the new services demonstration programs to be carried out by the Office of Substance Abuse Prevention, established in 1986. In 1987, research demonstration projects for the treatment of homeless persons with alcohol problems were authorized along with more broadly defined efforts to provide health care, emergency shelter, and social services to the homeless. In 1988, the new alcohol and drug abuse treatment resources block grant identified desirable services to nationally targeted populations; these groups were most often identified as the homeless, youth and adolescents, and intravenous drug abusers (ADAMHA, 1988~. Given the diversity of special population groups identified as needing culturally sensitive treatment in legislative and program development activity, it becomes necessary to ask: where then has the research and clinical emphases lain? What groups are being defined in clinical and services research efforts as special populations? What special treatments or treatment programs have been developed for them? Does the availability of culturally appropriate treatment increase accessibility, retention, and outcome for special populations? First, as a means of understanding the historical evolution of the interest in special populations in the alcohol literature, the committee examined the field's research and clinical practice priorities as captured by the National Clearinghouse for Alcohol and Drug Abuse Information (NCADI) since the inception of its data base in 1973. The NCADI database, one of the most complete resources in the field, classifies the materials in its file of abstracts into the 14 special population groups shown in Table 14-1. Catalogued materials include research studies, books, newsletter articles, case studies, program descriptions, journal articles, monographs, communications, and so forth. Table 14-1 shows the frequency distribution of materials in each of the specified areas for three distinct time periods: 1973-1982, 1983-1985, and 1986-1987. The table also contains a summary for the total 15-year period, 1973-1987.

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THE TREATMENT OF SPECIAL POPUIAllONS: OVERVIEW AND DEFINITIONS 351 TABLE 14-1 Total Number of Resource Materials on Special Population Groups Included in the National Clearinghouse for Alcohol and Drug Abuse Information (NCADI) Data Base Total Special Population Group 1973-19821983-1985 1986-19871973-1987 Youth 7221,120 5112,353 College/un~versity students 8119 134261 Elderly 205186 49440 Alcoholic females 425347 208980 Homosexuals 1614 2252 Economically disadvantaged 3966 47152 Racial and ethnic groups (general) 301338 165804 Blacks 103131 69303 Hispanics 4854 42144 Asians and Pacific Islanders 5460 30144 American Indians 11785 35237 Religious groups 79113 51243 Public inebriates 233 4681 Handicapped/disabled 022 2345 SOURCE: Committee analysis of data from the National Clearinghouse for Alcohol and Drug Abuse Information data base. Over the 15 year period the emphasis in catalogued material has been predominantly on youth, women, and racial and ethnic groups. The increase in abstracted materials for all the special populations in the last five years deserves notice; youth and women are the categories for which the most materials are recorded. There is also a marked increase in attention paid to college students, whereas there seems to be a slight tapering off in attention paid to elderly, youth, and American Indians. It is possible to characterize the literature abstracted in the NCADI data base as containing only a very few controlled trials in which the effectiveness of generic treatment is compared with treatment specifically tailored to the characteristics of the special population under consideration. There is a paucity of adequate studies on treatment outcome for any of the groups identified (Gilbert and Cervantes, 1988; Vannicelli, 1988; Westermeyer, 1988~. The comment on treatment outcome made by Braiker (1982) continues to have current general applicability to all special population groups: A review of the general literature on alcoholism treatment effectiveness reveals that most studies either fail to distinguish between outcome rates for men and women alcoholics or exclude the latter group from the study samples altogether. Among those studies that distinguish outcome rate by sex, varying and often conflicting results are reported. (p. 127) Whereas the NCADI data base offers with insight into the research and and clinical practice emphasis on special populations, data from the National Drug and Alcohol Treatment Survey (NDATUS) can help to identity both the trends and the current distribution of treatment programs available for special population groups. These were surveys of alcoholism treatment services provided by all known public and private alcoholism and drug abuse facilities and units in the United States (NIAAA, 1983; Reed and Sanchez, 1986; NIDAINIAAA 1989) (see Chapters 4 and 7~. Table 14-2 presents data on the number of specialized programs offered by alcoholism treatment units by the year

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352 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS TABLE 14-2 Specialized Programs Offered by Alcoholism Treatment Units by Survey Year. Percentage of Total Units Reporting Specialized Program 1982b1g~cl987d Youth 212731 Elderly 998 Women 232228 Hispanics 9911 Blacks 876 American Indians/Alaskan natives _e55 Public inebriates 1397 Other 13915 None 514641 Total units reporting 4,2336,9635,791 aIncludes both alcoholism~nly units and combined alcoholism and drug abuse units. bData from the 1982 National Drug and Alcoholism Treatment Utilization Survey (NAAAA, 1983). CData from the 1984 National Alcoholism and Drug Abuse Program Inventory (Reed and Sanchez, 1986~. dData from the 1987 National Drug and Alcoholism Treatment Unit Survey (NIDA/NIAAA, 1989). eNot included in the 1982 survey. Of the survey. Youth, women, the elderly, Hispanics, public inebriates, and blacks were the only special population groups included in all three of these surveys; American Indians/Alaskan natives were included in the last two surveys. The inventory asked respondents to identify whether they offered one or more specialized programs to certain population groups. Judging on the basis of the treatment units reporting, it appears that an increasing percentage of units are offering one or more specialized programs. In 1987 the largest number of specialized programs offered in treatment units were for youth (31 percent), followed closely by those for women (28 percent), with a sharp drop to programs for Hispanics (11 percent) and the elderly (8 percent). Changes in the total number of units reporting and in the number of specialized programs must be interpreted cautiously because there was a more thorough outreach effort in 1984 to locate all units that were either not identified in 1982 or that did not respond; this effort may simply have uncovered existing units that had not responded earlier rather than identifying new units that had only recently been established (cf. Reed and Sanchez, 1986:2~. An examination of these two sources-the NCADI database and the NIAAA surveys of treatment units-shows that women and youth are the special population groups that have received the most attention since the early 1970s. What they do not reveal are the most effective ways to meet the needs of individual problem drinkers or how to identify factors germane to a special population that might affect treatment. The overviews are also unable to provide guidance on when treatment should emphasize an individual's special population membership to facilitate a successful outcome. Indeed, if these overviews tell us anything, it is that women and youth appear to be the special population groups that people are most concerned about. Given the historical dilemmas, variations, and inconsistencies in defining which groups should be considered as special populations in the planning, funding and evaluation ~. . . A ~A A A

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THE TREATMENT OF SPECIAL POPUIAIIONS: OVERVIEW AND DEFINITIONS 353 of alcohol problems treatment, Lex (1985:90) has suggested that a special population be defined as any subgroup that is Special in terms of their uniformity on some dimension and their differences from more typical societal patterns and problems." The committee agrees with this definition. However, the definition does not fully capture the problems encountered in attempting to review existing knowledge on the value of special population programming. This review of the history of attention to special population groups suggests that their definition is often not only in terms of the unique biological and sociocultural characteristics that define a group with similar risk factors and drinking practices but also in terms of the momentary concern regarding access to appropriate services. Interest in each group has waxed and waned. There has been no systematic follow up to determine whether access has been improved or treatment outcome positively affected by these periods of attention. What is challenging, for both researchers and clinicians, is to determine where and how the emphasis on special population membership can best facilitate effective treatment for alcohol problems. Given this background, for the purposes of this report, a special population will be viewed as any subgroup that has been identified by the field as needing a specifically tailored Culturally sensitive" treatment program. The committee has chosen to look at developments and issues for only a few of the commonly identified special population groups and the evolution and effectiveness of treatment programs designed for them as portrayed in the research and clinical literature. It is important to note that these groups are by no means inclusive of all special population groups; rather, they have been selected as representatives of special populations as a whole. Chapter 15 considers these groups on the basis of structural characteristics (i.e., demographic characteristics); Chapter 16, adapts the perspectives of functional characteristics (i.e., circumstantial concerns) as a definitional framework. Chapter 17 presents the committee's conclusions and recommendations on the issue of treatment for alcohol problems among special populations. REFERENCES Aleohol, Drug Abuse, and Mental Health Administration (ADAMHA). 1984. Alrmbr`' anA nor, Ah ~n`1 Mental Health Services Data: Report to Congress. Roekville, Md.: ADAMHA Aleohol, Drug Abuse, and Mental Health Administration (ADAMHA). 1986. Aleohol and Drug Abuse and Mental Health Services Block Grant: Report to Congress. Rockville, Md.: ADAMHA. Aleohol, Drug Abuse, and Mental Health Administration (ADAMHA). 1988. Alcohol and Drug Abuse Treatment and Rehabilitation Block Grant: Report to Congress. Roekville, Md.: ADAMHA. Braiker, H. B. 1982. The diagnosis and treatment of alcoholism in women. Pp. 111-139 in Special Population Issues, J. de Luca, ed. Washington, D.C.: U.S. Government Printing Office. DeVita, A. 1988. Congressional activity to define and address alcohol-related problems of special populations: Selected provisions, 1970-1987. Compiled for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse. Office of Policy Analysis, National Institute on Alcohol Abuse and Alcoholism, Rockville, Md., July. Diesenhaus, H. I. 1982. Current trends in treatment programming for problem drinkers and alcoholics. Pp. 219-290 in Prevention, Intervention, and Treatment: Concerns and Models, J. de Luca, ed. Washington, D.C.: U.S. Government Printing Office. Gilbert, M. J., and R. C. Cervantes. 1988. Alcohol treatment for Mexican Americans: A review of utilization patterns and therapeutic approaches. Pp. 199-231 in Alcohol Consumption among Mexicans and Mexican Americans: A Binational Perspective, M. J. Gilbert, ed. Los Angeles: Spanish Speaking Mental Health Research Center, University of California, Los Angeles .

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354 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Gomberg, E. L. 1982. Special populations. Pp. 337-354 in Alcohol, Science, and Society Revisited, E. L. Gomberg, H. R. White, and J. A. Carpenter, eds. Ann Arbor, Mich.: University of Michigan Press. Gunnerson, U., and M. L. Feldman. 1978. Alcohol and Alcoholism Programs: A Technical Assistance Manual for Health Systems Agencies. San Leandro, Calif.: Human Services, Inc.. Heckler, M. M. 1985. Report of the Secretary's Task Force on Black and Minority Health. Washington, D.C.: U.S. Department of Health and Human Services. Led, B. W. 1985. Alcohol problems in special populations. Pp. 89-187 in The Diagnosis and Treatment of Alcoholism, J. H. Mendelson and N. K Mello, eds. New York: McGraw-Hill. McGough, D. P., and M. Hindman. 1986. A Guide to Planning Alcoholism Treatment Programs. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. Mitnick, L. 1978. Manpower issues in community alcoholism programs. Pp. 159-169 in Report of the ADAMHA Manpower Policy Analysis Task Force. vol. 2, Working Papers and Other Supporting Documents, D. M. Kale, ed. Rockville, Md.: Alcohol, Drug Abuse, and Mental Health Administration. National Institute on Alcohol Abuse and Alcoholism (NLAAA). 1983. Executive Report: Data from the September 1982 National Drug and Alcoholism Treatment Utilization Survey. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. National Institute on Drug Abuse/National Institute on Alcohol Abuse and Alcoholism (NIDA/NIAAA). 1989. Highlights from the 1987 National Drug and Alcoholism Treatment Unit Survey (NDATUS). Rockville, Md.: NIDA/NIAAA. Plaut, T. F. A., ed. 1967. Alcohol Problems: A Report to the Nation. New York: Oxford University Press. Reed, P. G., and D. S. Sanchez. 1986. Characteristics of Alcoholism Services in the United States-1984: Data from the September 1984 National Alcoholism and Drug Abuse Program Inventory. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. Rogler, L. H., R. G. Malgady, G. Costantino, and R. Blumenthal. What do culturally sensitive mental health services mean: The case of Hispanics. American Psychologist 42:565- 570. Rosenberg, C. M. 1982. The paraprofessionals in alcoholism treatment. Pp. 802-809 in Encyclopedic Handbook of Alcoholism, E. M. Pattison and E. Kaufman, eds. New York: Gardner Press. Saxe, L., D. Dougherty, K Esty, and M. Fine. 1983. The Effectiveness and Costs of Alcoholism Treatment. Washington, D.C.: U.S. Congress, Office of Technology Assessment. Staub, G. E., and L. M. Kent, eds. 1973. The Paraprofessional in the Treatment of Alcoholism. Springfield, Ill.: Charles C. Thomas. U.S. Department of Health and Human Services (USDHHS). 1981. Founh Special Report to the U.S. Congress on Alcohol and Health. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. U.S. Department of Health and Human Services (USDHHS). 1983. Fifth Special Report to the U.S. Congress on Alcohol and Health. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. U.S. Department of Health and Human Services (USDHHS). 1986. Toward a National Plan to Combat Alcohol Abuse and Alcoholism. Report submitted to the United States Congress. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. U.S. Department of Health and Human Services (USDHHS). 1987. Sixth Special Report to the U.S. Congress on Alcohol and Health. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. U.S. Department of Health, Education, and Welfare (USDHEW). 1971. First Special Report to the U.S. Congress on Alcohol and Health. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. U.S. Department of Health, Education, and Welfare (USDHEW). 1974. Second Special Report to the U.S. Congress on Alcohol and Health. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism.

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