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15 Populations Defined by Structural Characteristics This chapter specifically examines current research and clinical practice emphases for several representative special populations. The discussion is not meant to be a comprehensive review of research and clinical practice but a selective evaluation of the current state of knowledge about these groups in order to suggest what needs to be taken into account in future program development efforts and the studies of treatment organization and outcome that are required for such development. The groups discussed in this chapter are those which are defined by a common structural (demographic) characteristic: women, adolescents, the elderly, American Indians, Asian Americans and Pacific Islanders, blacks and Hispanics. These special populations are defined in terms of a fixed characteristic (gender, race, or ethnicity) or a developmental characteristic (age). Women The studies conducted over the last seven years have shown nothing to warrant significant changes in the conclusions reached following a systematic review of the treatment outcome literature from 1972 to 1980 on women with alcohol problems (Vannicelli, 1984, 1988; Blume, 1986, 1987; Roman, 1988~. In keeping with earlier reviews, Vannicelli concluded that there are relatively few solidly established facts about the specific interventions that increase the probability of successful outcomes of treatment for women with alcohol problems. A number of treatments have been enthusiastically endorsed for women including family therapy, group therapy, separate rather than combined treatment for men and women, and female rather than male therapists. Yet, there are few scientific studies that examine or support: (a) the superiority of group versus individual therapy for women, (b) the value of family therapy over other modalities, (c) the need for women to be treated separately, and (d) the value of a female over a male therapist. Moreover, there appears to be little evidence supporting the superior efficacy of any particular treatment modality for women. Blume (1987) and Roman (1988) also note that there has been no systematic research on the differential effectiveness of treatment programs designed for women. In general, in treatment for alcohol problems, males and females with comparable sociodemographic characteristics (marital status, employment, social stability, etc.) and at the same levels of problem severity appear to do equally well in the same treatment settings. Outcome monitoring in a selected set of programs that participate in the Chemical Abuse/Addiction Treatment Outcome Registry (CATOR) showed little difference on the basis of sex, leading Blume to suggest that there is no reason to believe that females are harder to treat than males or are less likely to recover-a common perception. What is not known are the components of treatment that would improve treatment outcome for both males and females (Blume, 1987~. What is known is that there has been a notable increase in the number of women appearing for treatment over the past 10 years, particularly younger women, although they are still seen as seriously underrepresented in treatment when prevalence rates are considered (National Council on Alcoholism, 1987~. The male-to-female ratio in national prevalence rates for alcohol problems and dependence appears to be about 2 to 1, while the treated prevalence rate appears to be closer to 4 to 1 (Gomberg, 1981; Beckman and Amaro, 1984; Blume, 1987, Roman, 1988~. There is some evidence that these ratios vary 356

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POPULATIONS DEFINED BY STRUCTURAL CIJAR\CTERISTICS 357 for those in treatment in publicly funded programs and those in treatment in private sector programs. The increase in women in treatment is paralleled by an increase in women affiliated with AA: 34 percent of its members are now women. The reasons commonly given for the continued under-representation of women in formal treatment are the greater stigma still associated with a diagnosis of having alcohol problems for women, including the associated stigma of perceived sexual promiscuity (Blume, 1987), and the lack of specialized treatment facilities, particularly the lack of child care facilities (Lex, 1985; Blume, 1987; Vannicelli, 1988~. There is also evidence suggesting that age of onset of drinking problems is later for women than for men and is often tied to important life transitions that have implications for the types of treatment needed. Age and marital status are seen as important variables for establishing both risk status and treatment response (Braiker, 1982; Harrison and Belille, 1987; Blume, 1987; Roman, 1988~. Research relating prognostic factors to treatment efficacy in females is equally nondefinitive. Debate continues regarding both how much of what we know about treatment outcome for males with alcohol problems can be applied to women and the extent to which special programs and treatment modalities for females are needed (Blume, 1987; Roman, 1988; Vannicelli, 1988~. These issues become especially problematic because the data for males comparing specific treatment modalities within subgroups of males with differential prognoses are also quite sparse. There are those who argue (e.g., Braiker, 1984) that much of what we know about treating males can be meaningfully applied to females as well. However, until the advent of systematic studies examining individual and key subgroup differences in response to various types of treatment, knowledge will continue to be limited regarding the therapeutic modalities differentially suited to females rather than to males and to different types of females with alcohol problems. It is important to note that there are also many subgroups within the population of women that may have specific needs for differential treatment services in addition to those required by all women. Typologies have been suggested based on personality differences, sexual orientation, age of onset, race/ethnicity, psychopathology, other drug use, childbearing status, and socioeconomic factors (Schuckit and Morrisey, 1976; Braiker, 1982; Dawkins and Harper, 1983; Vannicelli, 1984; Lex, 1985; Amaro et al., 1987; Blume, 1987; Roman, 1988~: Although an inclination to draw a profile of The typical alcoholic woman" still exists, it is generally agreed that female alcoholics comprise a heterogeneous group . . . Like male alcoholics, female alcoholics differ from one another on a variety of important dimensions including age, race, ethnicity, religion, psychopathology, occupational status, education and socioeconomic status. Consequently numerous classifications have appeared in recent years. (Lex, 1985:101) Clinical data supported by several studies (Braiker, 1984; Beckman and Amaro, 1986) suggest a number of areas in which females may differ from males, thereby suggesting differential programming needs. These findings indicate that women are more likely than men to have (a) primary affective disorders (as well as depressed/sad mood states); (b) serious liver disease; (c) marital instability; (d) instability of family of origin; (e) spouses with alcohol problems; (f) lower self-esteem; (g) a pattern of drinking in response to major life crises; (h) a history of sexual abuse; (i) opposition to treatment from family and friends; and (I) more child care responsibilities, which is inferred from data indicating that women in treatment are more likely to be divorced and single heads of households than are men. These apparent differences between men and women with alcohol problems point to a number of practical considerations in the treatment of women. Until definitive studies

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358 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS are undertaken, it is best to infer that treatment programs that specifically attend to some of the particular issues that are of more frequent concern to women will be most effective with women. For example, it is best in light of current knowledge to assume that more effective outcomes with women will be obtained with treatment programs that offer the following: (a) child care; (b) assessments of psychiatric disorder and treatment for depression, when indicated; (c) methods of building self-esteem, perhaps through skills training; (d) support offered to and education of family and friends; (e) assessments of accompanying medical disorders; (f) availability of staff to work with families; and (g) provisions for teaching coping strategies for dealing with stress. In the absence of outcome monitoring, however, the value of these recommendations remains speculative; providing the services detailed above may be just as significant in improving outcome for men who do not do well in standard treatment. In general, distinct types of treatment differ in attractiveness for different types of persons, but knowledge is currently limited regarding which women do best in particular treatment modalities. The potential gains in effectiveness of treatment for women with alcohol problems offered by programs that attend specifically to their needs are supported by the work of Beckman and her colleagues (1984~. These researchers indicated that environmental, social, and situational circumstances, as well as characteristics of the treatment delivery system, influenced whether women entered treatment in those facilities. In addition to the research noted thus far, there are studies that suggest useful approaches but that require replication before alternative policy recommendations can be made. Recommendations for gender-specific treatment that are based primarily on clinical experience emphasize providing social support (e.g. Gomberg, 1981; Roman, 1988~. Yet a study of structural factors in treatment program utilization in California suggested that women were more likely to choose programs on the basis of their need for alcohol problems treatment, with social support being a lesser consideration (Beckman and Kocel, 1982~. What is required to answer the question of whether gender-specific treatment programs for women are more effective than the standard treatment is a battery of adequate clinical and services research studies. The committee suggests that consideration be given to establishing a research demonstration grant program for women, similar to the former NIAAA categorical services demonstration grants but with much more stringent research and evaluation components (perhaps modelled after the current NIAAA homeless research demonstration program [NIAAA, 19873~. Currently there are a sufficient number of specialized women's treatment programs that could be brought together in properly managed research consortia to examine the effect of individual characteristics and treatment program structures and activities, similar to those listed earlier, on the outcome of treatment (Vannicelli, 1988~. At this point controversy persists regarding differences in prognoses for males and females and whether the course or quality of recovery differs for men and women. Although not substantiated by research, the myth prevails that women have a poorer treatment prognosis than men. The perpetuation' of this myth ir' the face of available outcome monitoring data, combined with the minimal available data regarding the superiority of any particular treatment for women, demonstrates a critical need for more and better treatment outcome research Such research should clear' specie the treatment process and derne the differential ingredients applicable to men arid Comer'. The results of treatment outcome studies should be analyzed and reported for both males and females. Adolescents The committee encountered several major problems in attempting to review the current status of treatment programming for youthful problem drinkers that make it

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POPUIATIONS DEFINED BY SltRUCTURAL CHARACTERISTICS 359 difficult to develop a coherent description of the field. Current efforts in treating youthful problem drinkers are marked by the following: (a) a lack of clinical studies comparing the variety of treatment approaches recommended as a result of clinical experience; (b) concerns about the overutilization and cost-eff~ciency of hospital-based and residential inpatient rehabilitation; (c) the lack of precision in and agreement on the definition of problem drinking and alcohol dependence in adolescents; (d) disagreement over the need for a combined substance abuse approach or an alcohol-focused approach to treatment; and (e) controversy over the need for age-segregated facilities. There is perhaps no special population about which so much has been written; yet, despite the more than 2,000 published papers, the common feeling among investigators in this area is that very little is known about how best to treat youth with alcohol and other drug problems (Filstead and Anderson, 1983; Blum, 1987, 1988; Winters and Henley, 1988~. On the one hand (as is the case with women), there is very little systematic research involving well-designed clinical trials that compare the alternative strategies suggested by clinical experience (e.g., Maloney, 1976; Millman and Khuri, 1982) for providing culturally and developmentally appropriate alcohol problems treatment to adolescents. It is not known, for example, which of the youths who drink heavily during adolescence will continue to do so as adults or and which will "mature out" of a course of heavy drinking without formal intervention or treatment (Fillmore et al., 1988) (see Chapter 6~. It is not known whether there are any biologic markers of juvenile addiction. Moreover, to date there has never been a treatment matching study conducted among youthful drinkers. Given the dramatic increases in the number of programs that purport to offer specialized treatment to youth (see Chapter 14) and given the concerns that have been expresses expressed regarding the overutilization of inpatient and residential treatment (e.g., Rodriguez, 1988), there has been a lamentable paucity of funding for studies to evaluate treatment process, outcome, and matching for youth. There are virtually no experimental studies on the effectiveness of treatment for alcohol problems among adolescent and young adult problem drinkers. Most research efforts with youth have studied the extent of alcohol use and problem drinking; few have investigated treatment effectiveness (Smart, 1979; Filstead and Anderson, 1983; Blum, 1988~. The design of treatment services for youth is proceeding primarily on the basis of limited clinical experience and values rather than on solid, generalizable empirical findings. On the other hand, some advances have been made over the last decade, particularly in understanding the processes by which youth are introduced to alcohol and other drug use. The Johnston team's Monitoring the Future Project has made an important contribution with its finding that although slightly more than 90 percent of high school seniors reported having had an alcoholic beverage, only approximately 5 percent reported drinking on a daily basis, with a male-to-female ratio of almost 2 to 1 (Johnston et al., 1987~. In addition, the natural history of alcohol abuse through adolescence into young adulthood has been more clearly elucidated by Kandel and her colleagues (Kandel and Logan, 1984; Yamaguchi and Kandel, 1984~. They reported a peak prevalence between 16-18 years of age, with maximal consumption continuing for the subsequent four years, then diminishing significantly. Likewise, in a large longitudinal study in Colorado, Donovan and his colleagues found that 57 percent of male and 73 percent of female subjects originally categorized as "problem drinkers were either abstinent or moderate drinkers at the time of follow-up seven years later (Donovan, Jessor, and Jessor, 1977~. Fillmore and her colleagues (1988) report similar findings in their review of longitudinal studies. Beyond the demographic trends, there is a spate of social-psychological research that characterizes the heavy juvenile drinker as follows (Blum, 1988~: (a) males predominate over females; (b) male drinkers tend to have lower achievement orientation and tend to be more rebellious than nondrinking peers; (c) heavy drinking correlates

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360 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS strongly with other socially deviant juvenile behaviors (e.g., precocious sexual behavior); (d) early onset drinking is the best single predictor of substance abuse; (e) juvenile drinking behavior tends to parallel that of parents; and (f) for youths in treatment programs, significant numbers have other problems concurrent with their drinking (e.g., learning disabilities, major depression). Yet for neither adults nor adolescents is there any consensus on what constitutes problem drinking or substance abuse. For juveniles, definitions range from the legal perspective that any use of a substance by juveniles is tantamount to abuse (National Council of Juvenile and Family Court Judges (1987) to defining abuse based on the impact which drinking has on adolescent development (Jessor et al., 1980~. Without agreement in the field as to what constitutes the disease or condition, the clinician is left to his or her own resources; as a result, adult definitions of alcohol problems tend to be applied to juveniles without the empirical justification to support such applications. Because there is considerable disagreement about the definition of alcohol dependence and problem drinking among youth, great care must be exercised in making such a diagnosis with youth. Juvenile possession or use of alcohol in most situations outside the home is legally defined as a status offense (Marden and Kolodner, 1978; Morrisey and Schuckit, 1978~. Labeling an adolescent a problem drinker as a result of being picked up for drinking or being intoxicated can be an unnecessarily stigmatizing and traumatizing experience. Furthermore, it may be an incorrect diagnosis. For example, Schuckit and Morrisey (1978) interviewed 693 adolescents (aged 20 and under) who had been referred by the courts to alcohol counseling and education centers (for evaluation and referral for treatment, if needed) as part of a diversion project for those arrested for alcohol-related crimes. The study compared three groups: (1) those who were arrested for some crime but who had never been arrested as a minor in possession (MIP) of alcohol, (2) those who had only one MIP arrest, and those with two or more MIP arrests. The multiple-MIP-arrests group manifested the most serious problems with antisocial behavior, drug and alcohol use, school problems, and other life problems. The no-MIP-arrests group was quite heterogeneous and demonstrated moderate levels of problems. The single-MIP-arrest group did not manifest any severe personal, social, alcohol, or drug problems; referral to treatment was not indicated, and they could have been harmed by being labeled a problem drinker. The authors concluded that the multiple-MIP-arrests group would be the least likely to be harmed by referral to alcoholism treatment, but even they might pass out of the adolescent drinking problem status if left untreated. Morrisey and Schuckit recommended against such mandatory programs in which all youths who had been picked up were referred for treatment. Thus, definitional issues must be clarified before systematic treatment design and implementation can take place. In addition to questions about what constitutes a youthful problem drinker, there is no agreed-upon standard as to which age groups make up the youth special population. Some define the age group as individuals 25 years of age or younger; others limit it to those in childhood and adolescence, setting the upper age at 18. In its original categorical grant and state plan initiatives, the federal government focused on adolescents aged 18 and under, but in some instances considered those aged from 19 to 24 as "youthsn. Some practitioners and researchers consider the upper age limit to coincide with the age at which purchase and possession of beverage alcohol becomes legal; formerly, the age limit varied among the states, but it has now been increased to 21 in all states in response to concerns over drinking and driving. The increase in alcohol use and problem drinking by adolescents and young adults has generated increasing concern in recent years, and much popular attention has been paid to alcohol as the Number one drugs abused by youth. Yet, there is still much disagreement about what constitutes a clinical state requiring formal treatment (Marden and Kolodner, 1978; Filstead and Anderson, 1983; Blum, 1985~. The point on which there

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POPULATIONS DEFINED BY STRUCTURAL CEIARACTERISTICS 361 is agreement is that the use of treatment facilities by young persons is on the increase, and as noted earlier, there has been a dramatic increase in the number of treatment units that either offer a specialized program for youth in a mixed age setting or serve as a specialized program only for youth. Another area in which little is known either pathophysiologically or psychologically is the comparability between heavy juvenile and adult alcohol ingestion. The lack of consensus as to what constitutes juvenile alcohol dependence weighs against any comparability among treatment center approaches. As Skinner (1981) notes, assessment decisions tend to be guided by the philosophical orientation of the specific treatment center. These concerns raise the question of whether adolescents and/or young adults should be treated in separate programs, whether existing adult-oriented programs should be modified to serve them more appropriately, or whether both changes are needed. There is a general assumption that those under the age of 18 are still struggling with the developmental tasks of adolescence and need separate programs which include specialized attention to these concerns (Blum, 1988; Filstead and Anderson, 1988~. Yet many treatment programs set their upper or lower age limits with no regard for this boundary. The age at which a minor can legally consent to treatment varies from state to state; this and other legal considerations can affect treatment design. There have been no recent studies of the varieties of approaches that are being used and the differential outcome, if any. Existing youth treatment programs for alcohol problems can be classified as traditional or nontraditional (Maloney, 1976~. Traditional treatment programs utilize many of the same techniques and concepts as adult programs and label the young person as an alcoholic or problem drinker. Concerns have been voiced by some in the treatment field that most of the new residential programs being established are based on the adult model of brief inpatient rehabilitation with minimal aftercare (Woltzen et al., 1986; Blum, 1988; Durst, 1988~. Nontraditional treatment facilities tend to use a different approach. They avoid labelling the youth as an alcoholic and try to work within the framework of the youth's culture and developmental tasks. The focus in this kind of treatment is on alcohol use as one of many expressions of the growing up process. Labeling the young person as an alcoholic is seen as potentially harmful, a technique that may restrict the individual's opportunities to grow out of the period of excessive use. Such nontraditional programs are usually conceptualized as youth services agencies and try to offer a wide range of activities-educational, recreational, and vocational as well as those focused on the adolescent's drinking behavior. Nontraditional programs stress outreach and early intervention. Nontraditional agencies are most likely to use peer counseling, a treatment modality in which young people who have recently been through the program are trained to work with newcomers. The premise is that the adolescent peer counselor will be better able to reach the youth new to treatment because of their shared personal and cultural experiences. The use of peer counselors in adolescent programs embodies the same principles as the use of recovered alcoholic counselors in AA-oriented adult programs and of counsels who share a common cultural background in other special population programs. There have been no recent studies to evaluate the effectiveness of either approach or to determine whether particular youth do better in one type of program or the other. Until recently, for the adolescent, no empirical base existed for the clinical assessment of the juvenile in need of treatment for alcohol problems. Yet many clinicians and researchers deem it essential that treatment of youth begin with such an assessment (Blum, 1988; Winters and Henley, 1988~. For example, Filstead and Anderson (1983) stressed the importance of beginning the treatment of adolescents, whether on an inpatient or outpatient basis, with an extended ~evaluation-assessment" period. Hoffmann and

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362 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS colleagues (1987) described such a process for evaluation and assignment to the appropriate level of care: they called for either a 3 to 6 hour assessment on an outpatient basis for adolescents who are socially and behaviorally compliant, or an inpatient assessment of approximately one week for noncompliant, nonstable adolescents. The assessment they proposed covered seven dimensions of clinical status that are held to be important for making such a placement decision: (1) acute alcohol or drug intoxication, or both, and potential for withdrawal; (2) physical conditions or complications; (3) psychiatric conditions or complications; (4) life area impairment (behavioral, social, academic, legal); (5) treatment acceptance or rejection (motivation; potential for compliance); (6) loss of control over drinking precipitating a possible relapse crisis; and (7) the recovery environment (supportive and remedial versus pathogenic and destructive). The levels of care which they identify are mutual/self-help, low-intensity outpatient treatment, intensive after-school treatment, structured day treatment, medically supervised intensive inpatient treatment, and medically managed intensive evaluation. However promising this approach appears, neither its program classification scheme nor its assessment battery has been empirically validated. Indeed, the majority of work on assessment and on matching has been done with adults. Specific research to develop concepts and assessment tools that are appropriate for use with adolescents is required. There continues, however, to be a lack of well-developed, standardized, and validated assessment instruments for use by clinicians in the identification, referral, level of care placement, and treatment planning for youth (Owen and Nyberg, 1983; Filstead and Anderson, 1986; Winters and Henley, 1988~. Although there have been some brief screening tools (e.g., the Adolescent Alcohol Involvement Scale; Mayer and Filstead, 1979) or high school survey instruments (e.g., Johnston et al., 1987) that were developed for use with adolescents, most programs tend to use questionnaires that they develop in-house and informal assessment procedures (Owen and Neyberg, 1983~. More recently, a three-dimensional assessment schema exploring the impact of drinking on psychosocial, biomedical, and school functioning was developed (Halikas, et. al., 1984~. The model was based on a study of 1,185 adolescents and has been useful in distinguishing problem drinkers from nonproblem drinkers. This work has been used in the development of the placement criteria described above (Hoffmann et al., 1987~. Most importantly, a new adolescent assessment instrument has recently been developed by the Adolescent Assessment Project in St. Paul, Minnesota, and it promises to be the most comprehensive adolescent alcohol assessment tool to date (Winters and Henley, 1988~. The assessment employs both a written instrument the Personal Experience Inventory~and an interview the Adolescent Diagnostic Interview. It could be validated through cooperative study in the many new programs which have been recently implemented, given a sufficient desire to remedy the lack of investment in studies on youth treatment process and outcome. For the adolescent, as for the adult with a drinking problem, there is a wide array of treatment alternatives that include: behavioral, operant conditioning, social learning, psychosocial, and self-help approaches. Yet despite the diversity of approaches, there has been little attempt at treatment matching for adolescents' and no controlled studies of treatment outcomes have ever been undertaken for this special population. The CATOR data base currently provides the most extensive outcome monitoring longitudinal data on juveniles who have been in treatment, conducting 6- and 12-month follow-ups on 493 youths (Harrison and Hoffmann, 1987~. The data collected through the registry are self-reported, which always raises methodological problems in interpreting the findings. Keeping this caveat in mind, Harrison and Hoffmann determined the following, using total abstinence of at least 3 months every 6 month posttreatment period as their criterion: (a) females did better than males; (b) for females, a prior history of a suicide attempt correlated poorly with outcome; (c) for males, those who viewed themselves more

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POPULATIONS DEFINED BY STRUCTURAL CHARACTERISTICS 363 negatively at treatment initiation have a lower relapse rate; (d) certain factors appeared to be unrelated to outcome including: prior sexual abuse, learning disabilities, a lack of intimate relationships, relationship with parents, or parental substance abuse; (e) treatment completion was positively correlated with outcome; and (e) a strong positive relationship between the duration of posttreatment involvement in AA and abstinence, such that two-thirds of those who remained in AA for the entire follow-up year reported total abstinence, compared with 11 percent of those who never attended. Although these data provide some clues about the individual characteristics that are most highly correlated with posttreatment abstinence, little is known of the treatment center and treatment modality characteristics that best meet this outcome objective. Most importantly, nothing is known of the treatment match or matches that will optimize outcome for adolescents who are problem drinkers. Moreover, a single criterion of treatment success (e.g., abstinence) has limited utility, as does a single follow-up evaluation source (e.g., adolescent themselves). Rather, a multiple-factor assessment model, such as that proposed in Chapter 10, is desirable for adolescents as well as adults. It is critical to include measures of school and job performance, as well as measures of interpersonal and social adjustment that are tailored to the adolescent's living situation. Such a multidimensional assessment model has rarely, if ever, been applied to assessing adolescent alcohol treatment programs and those who complete treatment. Because of the paucity of substantive evaluation or longitudinal data on adolescents in alcohol treatment programs, one is left with only vague impressions: that in the short run (e.g., 6 to 12 months), some kind of treatment is better than no treatment if abstinence is the goal. On the other hand, in the long run, it is uncertain whether the steady improvement which has been reported over a seven-year period is more a function of "maturing outs than of treatment itself (Barr and Antes, 1981; Fillmore et al., 1988~. An important innovation has been the development of the student assistance programs, which are modeled after employee assistance programs, or EAPs (Anderson, 1979; USDHHS, 1987~. As in an EAP, a critical feature of student assistance programs is the development of a policy and procedure for how the school will handle the problem drinking student. The policy development procedure is seen as helping school officials and students to confront their own ambivalent attitudes toward alcohol use and yields a consistent rather than erratic response to youth who are identified as needing assistance for alcohol problems. Proponents recommend that students be involved in the policy development process. Proponents also suggest that students be involved in program operations as lecturers, discussion leaders, and peer counselors should the school choose to implement its own alcohol education and intervention program in addition to the providing the identification components. The four essential ingredients of the student assistance program are (1) a clear policy that establishes expectations and limits; (2) consistent application of the policy; (3) identification, motivation, and referral of problem drinking adolescents; and (4) follow-up monitoring. These activities are generally carried out by a resource coordinator or counselor who acts as a safe, confidential linking agent between the troubled student, the school administration, and treatment personnel. The identification of students with alcohol problems is often an unforeseen outcome of alcohol education programs whose focus is primary prevention. Teachers ordinarily are ill-prepared to make an appropriate referral if and when a student comes forward. The implication is that didactic prevention programs should be linked with student assistance programs whenever prevention programs are introduced into a school setting. And, whenever these programs are designed as "broad-brush" efforts-that is geared to assisting the student with any type of problem-labeling and stigmatization can be avoided. Appropriate screening and assessment by the counselor to identify the variety and

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364 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS severity of problem drinking manifested can lead to early intervention either through brief intervention delivered on the spot or through referral to the most appropriate treatment setting as well as the definition of realistic goals. Student assistance programs, like employee assistance programs for adults in the workplace, can serve as the independent assessment and referral centers needed to ensure the appropriate use of specialty and primary care treatments. This mode of functioning is the essence of the committee's vision (see Chapter 9~. Again, like many of the recent innovations in treatment for adolescents, the number of student assistance programs has grown significantly, but the drawback is that there have been no systematic evaluations of their effectiveness. The evaluation of treatment for youth with alcohol problems is complicated by the lack of a single system that can be described and by the heterogeneity of adolescents' drinking problems (e.g., Welte and Barnes, 1987~. Indeed, an effort is required to describe in detail the many programs and agencies that are trying to provide such treatment. Assessment, intervention, and treatment are offered in a wide variety of school, social services, primary health care and correctional settings as well as in the specialty mental health and alcohol problems treatment sectors. There are no good available data on who is being treated where, by what modalities, and with what outcome. Although there has been concern expressed regarding the number of youths being admitted to inpatient treatment settings, there is data that suggest that young people are still underrepresented in treatment when publicly funded treatment programs are surveyed (Butynski et al., 1987~. Clearly, specific recommendations on how and where to treat adolescents are impossible without a better data base on existing treatment programs and their effectiveness for different individuals. The Elderly The prevalence of alcohol problems in the elderly (persons aged 60 and older) is given by the U.S. Department of Health and Human Services (1987) as 2 percent, which is less than the rate for younger age groups. The prevalence rate has been found to be higher for men (5 percent) than for women (1 percent). There are still concerns about the exact rate because of questions about the appropriateness of the methods used to identify elderly persons with alcohol problems (Graham, 1986, 1988; Douglas et al., 1988~. Generally, two different subgroups have been identified early onset problem drinkers and late onset problem drinkers-with different histories and prognoses. A threefold classification has also been proposed that has a third group with a history of experiencing mild or moderate problems earlier in life and developing a severe problem only in later years (Williams, 1985~. The value of these topologies for differential treatment assignment has yet to be established (Atkinson, 1988; Hurt et al., 1988~. Early onset problem drinkers are thought to account for two-thirds of elderly persons with alcohol problems; they generally have a history of long-term problem drinking and are likely to have serious physical problems. Late onset drinkers have no history of alcohol problems prior to their identification and typically begin heavy drinking in response to a major life stress (e.g., retirement, death of a spouse or friend, poor health). Early onset problem drinkers are assumed to have a poorer prognosis. It has been assumed by some clinicians that all elderly persons with alcohol problems can benefit more from psychological and sociocultural approaches than to physiological approaches (e.g., Zimberg, 1978, 1983~; this assumption remains untested. As with the other special population groups being discussed in this section, reports of empirical studies that compare treatment tailored to the special needs of the elderly with standard, "generics treatment for alcohol problems are lacking. Indeed, there are very ..

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POPUIA1IONS DEFINED BY STRUCTURAL CElARACTERISIICS 365 few studies of treatment effectiveness which focus on the elderly; much of what is currently believed about the assessment and treatment of the elderly remains based on unsystematic clinical observations and indirect evidence (Graham, 1988~. There are, however, a number of descriptive studies beginning to appear which do attempt to explore whether mixed-age settings or programs were more or less effective for treating elderly persons with alcohol problems (e.g., Kofoed et al., 1987; Hurt et al., 1888~. The results of these studies are conflicting, possibly because of the differing socioeconomic status of the persons studied (Atkinson, 1988~. A number of other studies have reviewed retention and outcome rates for younger and older persons treated in the same mixed-age programs. However, these studies were inadequate to establish which approach can lead to more successful outcome, and it is not possible at this time for the committee to suggest specific guidelines. There have also been a number of attempts to identify those factors that were associated with successful outcome in the elderly regardless of the modality or approach used. Characteristics that have been associated with poorer prognosis are chronic physical problems, psychiatric comorbidity, family drinking practices, and isolation (Williams, 1985~. There have been no studies on the long-term impact of treatment in this special population (Mishara, 1985; Hurt et al., 1988~. Another question often raised is whether elderly persons with alcohol problems can and should be treated in special programs within the alcohol problems sector or in special programs within the specialized geriatric services system (Williams, 1985~. There does not seem to be a great deal of activity in the development of either type of program at this time, although several states (e.g., New Jersey, Michigan, Connecticut) have made special outreach efforts to bring more elderly persons into standard treatment programs. Elderly persons continue to underrepresented in standard treatment programs (Graham, 1988~. American Indians According to May (1982), the "drunken Indians stereotype has been prevalent throughout American society since early colonial days. The literature is replete with descriptions that reinforce negative myths about the Indian and alcohol, and it is only in the last decades that researchers have attempted to consider the complexity and variation among the American Indian peoples and their associations with alcohol. Indeed Westermeyer (1974) maintains that understanding the cultural diversity among American Indians is crucial in avoiding the "drunken Indian" stereotype. Notwithstanding, although "alcoholism" may not be a universal Indian problem, it is a problem for many tribal groups (Mail and McDonald, 1980), and it has been identified by the Indian Health Service as requiring significant federal attention (USDHEW, 1971; Mason et al., 1985; Rhoades et al., 1988~. With the 280 recognized tribes in the United States, alcohol consumption rates, prevalence of alcohol problems, drinking practices, and beliefs about alcohol use are found to vary among tribal groups or communities (Westermeyer, et al., 1981; USDHHS, 1987~. There appear to be no common patterns of drinking behavior among the tribes, but instead high rates of both heavy drinking and abstinence are reported (Lemert, 1982; May, 1982; Lex, 1985~. Despite the abstinence patterns for some tribal groups, alcohol-related problems remain a major source of difficulty for American Indians. There is a strong correlation between American Indian alcohol problems and economic factors; in addition, alcohol abuse has been cited consistently as a major disruptive factor in the family life of American Indians (Lex, 1985~. American Indians and Alaska Natives constitute less than 1 percent of the total population in the United States (USDHHS, 1987~. These 1.5 million people maintain relatively higher rates of alcohol problems than the general population (Lex, 1985; Rhoades

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366 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS et al., 1988~. American Indians also rank higher in the proportion of abstainers, many of whom are former heavy drinkers who have given up alcohol (Lemert, 1982~. Alcohol consumption is reported to be highest and most problematic for American Indian men between the ages of 25 and 44, with a decline after the age of 40 in total consumption and number of drinkers (Indian Health Service, 1980~. Few studies have specifically focused on alcohol use in American Indian females, although the number of females who drink alcohol reportedly is increasing (Lex, 1985~. Although American Indian women drink less than men, they account for nearly half of all deaths among Indians from cirrhosis, and they appear to be at particular risk for giving birth to children with fetal alcohol syndrome. The death rate from cirrhosis for American Indian women is three times higher than the rate for other nonwhite women and almost six times higher than that for the population at large (S. Johnson, 1979~. American Indian adolescents show a high rate of alcohol use in comparison with other adolescent groups. Weibel-Orlando (1984) reported that American Indian adolescents began involvement with alcohol at younger ages than other subcultural groups in the United States. Donovan and Jessor (1978) found that 42 percent of American Indian adolescent male drinkers and 31 percent of Indian adolescent female drinkers reported alcohol problems, compared with 34 percent of white male and 25 percent of white female adolescent groups. Alcohol-related mortality rates are significantly higher for American Indians than for the general population. Thirty-five percent of all American Indian deaths involve alcohol, and 5 of the 10 most frequent causes of death among Indians are alcohol-related. Such deaths include accidents (the rate of motor vehicle accident deaths is 2.5 to 5.5 times higher than that of the general population), liver cirrhosis (2.6 to 3.5 times higher), clinical alcoholism, including psychosis and alcohol related cirrhosis (5.4 to 5.5 times higher), suicide (1.2 to 2.3 times higher), and homicide (1.7 to 2.3 times higher). In their review of alcohol problems among American Indians, Westermeyer and Raker (19861 cited six studies relating alcohol use in the group with incidents of _ ~ , _ ~ ~ pneumonia, burns, acciclents, fatalities from freezing, malnutrition among cn~aren, and infant mortality. American Indians also have a high rate of arrests related to alcohol use (e.g., driving under the influence, drunkenness, disorderly conduct, and violations of liquor laws), which is 12 times that of the general population (Lemert, 1982~. Despite the knowledge that alcohol use has created widespread problems among American Indians, there are relatively few studies that investigate treatment use and treatment effectiveness in this population group. Basic issues concerning the prevalence of problem drinking and the patterns of treatment for alcohol problems among American Indians remain unresolved (Lewis, 1982; Weibel, 1982~. In 1971 NIAAA adopted the reduction of alcoholism among Indians as a priority goal (USDHEW, 1971~. A consistent problem in planning alcohol treatment for this special population has been the differing cultural orientations of American Indians and mainstream society, upon whose values prevention and treatment programs are generally based. In general, treatment for the American Indian has been concluded to fall into one of four areas: (1) "nativistic endeavorsn; (2) conversion of Indians to evangelistic religions; (3) individually invented types of aids provided by psychotherapy and AA (i.e., the medical model); and (4) programs oriented specifically toward Indians (Lewis, 1982~. While the literature is inconclusive about which type of treatment focus is most effective, it is widely believed that few Indians with alcohol problems have been helped by the traditional medical approach to rehabilitation or through non-Indian chapters of AA Indeed, Westermeyer and Baker (1986) state that "[tic be effective, programs for Indians must consider cultural, historical, psychological, and social forces. It is also crucial that the treatment staff include positive Indian role models with whom the recovering Indian alcoholic can identify."

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370 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS difference was found between white men and black men in terms of the relationship between drinking behavior and income. Among white men, increases in heavy drinking were found to be related to increasing income levels; among black men decreasing income was found to be related to heavier drinking. There are regional differences in admission rates to treatment that are interpreted as reflecting the increasing urbanization of blacks. Herd (1989) reports on regional variations in admissions to treatment for whites and blacks. The proportions of each in treatment vary by region, with the proportion of blacks in treatment being two to three times higher than their proportion in the state's population in the urban Northeast. In the interior southern states, the proportion in treatment was generally about the same as the state's population. Blacks tended to enter treatment at a younger age than whites even though the age of onset of heavy drinking was later. epidemiological findings for treatment design is not immediately evident. The implications of these In the past, National Alcohol Profile Information System (NAPIS) data submitted by the NIAAA grantees revealed that more blacks were being treated in predominantly white treatment programs than in those that identified themselves as being black programs (Ferguson and Kirk, 1979~. Blacks treated in each of the NIAAA funded special population grant programs were more like the nonblacks seen in that grant program than like blacks seen in other program categories: when compared with blacks being treated in NIAAA funded drinking driver, poverty, or comprehensive treatment programs, blacks being treated in public inebriate programs reported the lowest income and the highest number of years of heavy drinking and average drinking per day just as their nonblack counterparts did; blacks being treated in drinking driver programs had the highest average household income and the lowest average amount of alcohol consumed per day. With the advent of the alcohol, drug abuse, and mental health services block grant, NIAAA funded treatment programs for blacks and other special populations were shifted to state support, and the ability to make such comparisons of person characteristics was lost. Analyses of existing state data bases, similar to those previously performed for the NAPIS data base and similar to those recently completed for Hispanics (Gilbert and Cervantes, 1986, 1988), may be a helpful first step in understanding patterns of utilization and linking these patterns with the epidemiological data to provide suggestions for treatment design. Hispanics Diversity is again the main characteristic of this special population group, which is the nation's fastest growing ethnic minority because of new immigrants from Mexico and Central America (Rogler et al., 1987~. Of the estimated 18 million Hispanics in the United States in 1986 (U.S. Bureau of the Census, 1987), the majority (60 percent) are Mexican Americans. Puerto Ricans (13 percent) are the next largest group. Each nationality group has a distinct cultural background that results in variations in their attitudes toward drinking and toward treatment for alcohol problems. Indeed, some investigators see no value in even using the general Hispanic category, given these differences (M. J. Gilbert University of California, Los Angeles, personal communication, October 7, 1988~. There is also great variation within each nationality group in education, occupation, income, health status, and degree of acculturation. Degree of acculturation is often determined by language (i.e., whether the individual is bilingual or monolingual). Acculturation is seen as a significant factor in treatment response. Mexican Americans are concentrated in the Southwest, Cubans, in Florida, and Puerto Ricans, on the east coast but mainly in New York (Lex, 1985~. These national groups differ in their drinking patterns, with Mexican American men having the highest rates of heavy drinking when compared to the other groups (Caetano, 1988~. Differences

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POPULATIONS DEFINED BY STRUCTURAL CHARACTERISTICS 371 in drinking patterns are also found between those born in this country and those born in the country of origin. Age variations in self reported problems were more similar to those for black men than for whites: the rates did not drop at 30 years of age but remained high until they were over the age of 40. Again, research on treatment effectiveness is lacking; there have been no major studies to determine whether culturally sensitive treatment is more effective than treatment in mainstream programs (Gilbert and Cervantes, 1986, 1988~. Different approaches have been advocated for the different nationality groups. Given the variations, services researchers see a need for treatment agency data collection systems to distinguish among the nationality groups rather than labeling them all ~Hispanic" (Gilbert and Cervantes, 1986~. Gilbert and Cervantes (1986) studied utilization patterns of Mexican Americans, by analyzing national and state data bases, which contain information on publicly funded programs. They found that variations in utilization among states reflected an age differentiation between Mexican Americans (who were younger) and the white population. There were also other determinants involved, For example, more of the Mexican Americans in treatment than the whites in treatment had been referred by the courts; these clients were most likely to be male. It was hypothesized that discriminatory practices in policing rather than differences in prevalence might account for the utilization patterns. Mexican Americans were more likely than other groups to be in outpatient than inpatient or residential treatment when compared to other groups. Gilbert and Cervantes suggested that this difference might be due either to the lack of culturally sensitive programs, the continued involvement of the problem drinker in an extended family network, or the lack of financial resourc - . They stressed the need to examine closely the effectiveness of various outpatient modalities for Mexican Americans being treated for alcohol problems. As with the other special population groups, reports of clinical impressions or descriptive studies constitute the majority of the treatment literature for Hispanics. Many of these reports emphasize the importance of the family in all of the Hispanic groups and the need to include the family in treatment (e.g., Panitz, 1983~. The form that this involvement should take has been most often based on clinical experience with a subgroup, however; applicability across nationality groups requires empirical testing. Accessibility to culturally sensitive treatment for Hispanics is the major concern. Researchers and clinicians working in the area recommend that all programs that serve Hispanics of all nationality groups provide bilingual/bicultural staff. An important consideration in the assignment to culturally sensitive treatment is the degree of acculturation-the more acculturated an individual is,the less likely he or she is to need culturally sensitive treatment (Rogler et al. 1987~. The committee suggests that large-scale studies of specific treatment approaches and their applicability to the diverse Hispanic population are necessary to go beyond the "findingsn of the current impressionist literature. Summary and Conclusions There are several common themes that emerge from the literature on the treatment of special populations defined by structural characteristics. These themes are particularly applicable to the ethnic and racial minority groups. First, program designers and clinicians must be wary of defining a given person only in terms of his or her gender, age, or racial or ethnic group membership; members of these special populations vary on other important dimensions that have implications for treatment outcome: socioeconomic status, education level, employment status, income level, presence of physical and psychiatric comorbidities, and degree of acculturation and assimilation to the majority culture.

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372 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS There are many possible examples of the importance of recognizing the heterogeneity that exists within these special populations. In his critique of the literature on black alcoholism, Harper (1979) noted the focus on drinking practices and treatment of lower income black males in the majority of available studies and criticized the practice of generalizing about treatment needs for all blacks (including black women and upper income blacks) based on data from this subgroup. Many reviewers of the research on particular ethnic groups have noted that Hispanics as well as Asian Americans come from many different countries, each of which has developed different attitudes about drinking practices and about appropriate treatment; they caution about generalizing from one culture to the other in designing treatment programs to overcome barriers because the sources of resistance to treatment may vary. Generational considerations are also important: third generation descendants of refugees typically differ from current immigrants in their responses. Tribal affiliation is a similar variable for American Indians; there are more than 280 different recognized tribes that have developed unique cultures and individualized norms around drinking and help-seeking behavior. Second, a major factor involved in the perception of underutilization of alcohol problems treatment facilities by racial and ethnic minorities is the lack of means to pay for treatment. For example, Fisher (1978) reported that blacks and Hispanics in a sample of people calling a referral service in New York City were less likely than whites to have insurance coverage for alcohol problems treatment; this lack influenced the nature of the referral made. More recent studies of the extent of insurance coverage for all Americans indicate that members of these racial and ethnic minority groups are more likely to be uninsured and to depend on Medicaid or some other form of public funding (state or local public assistance, local and/or state categorical funding) for their health care (USDHHS, 1985; U.S. Comptroller General, 1987~. Third, persons with alcohol problems who come from minority cultures are perceived as "less likely" to enter majority-run treatment programs. Westermeyer (1982) reviewed a series of studies demonstrating that Hispanics, blacks, and American Indians were less likely to enter white run treatment programs. However, he also found that for those ethnic minority patients who did enter the white-run generic programs, treatment outcomes appeared to be good; in fact, they were equal to those for whites. These findings implied that there was an absence of bias in the treatment process itself and that there need to be further differentiation among the reasons for not entering treatment and for succeeding in treatment. These findings also suggested a rationale for continuing to invest in special population programs: ~7 While long term careful independent evaluations of these [minority-run] programs have not yet been widely done, early findings indicate that outcomes are comparable to those of majority-run programs. The advantages of ethnically oriented programs appear not so much that something particularly efficacious happens in treatment, but rather that the attraction to treatment is greater when one can join peers in a familiar setting. (Westermeyer, 1982:43) Fourth, biomedical treatment of alcohol problems is seen as consistent across sex, age, ethnic, and racial groups and does not appear to require specialized culturally sensitive and culturally managed programs (Lex, 1985~. Culturally specific psychotherapeutic and sociotherapeutic approaches also appear to be similar across ethnic and racial groups but are believed to help reduce the cultural isolation caused by alcohol problems when applied by therapists from the same cultural group. This belief serves as another reason for continuing to invest in such programs, although these concepts have yet to be empirically tested; it may be that both culturally specific, separately managed and culturally sensitive

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POPULATIONS DEFINED BY STRUCTURAL CHARACTERISTICS ~ / integrated programs, in which all staff are trained about the cultural backgrounds of the persons entering treatment, are appropriate and equally successful. Despite the importance attached to structural characteristics in discussions of the need for culturally relevant services and despite the development of treatment strategies based on clinical experience and theories about the etiology of alcohol problems within a special population, there have been few studies testing the validity of these approaches. There is an inexcusable lack of systematic research on the application of specific treatment approaches to each of the special populations defined by structural characteristics. There have been few studies of the advantages and disadvantages of providing separate programs and of the difficulties to be encountered in their administration (Maypole and Anderson, 1987~. Despite the recurrent interest in legislation, clinical practice, and program development, there have been no tests of the comparative effectiveness of the various approaches that are advocated. The majority of the literature is descriptive, based either on surveys of clinical or community populations, reports of utilization, or on clinical experience. There are very few data that can be seen as offering guidance to policymakers regarding which treatment approaches are effective with which special populations. Because the majority of persons needing treatment for alcohol problems will continue to be treated in mainstream programs, age, gender, race, and ethnicity are critical individual characteristics to be considered in developing assessment, matching, and outcome monitoring schemes for mainstream treatment programs. Matching algorithms developed through research and the consensus process described in Chapter 11 should take these characteristics into account as well the degree of acculturation of a minority individual to the majority culture. REFERENCES Ahern, F. M. 1985. Alcohol use and abuse among four ethnic groups in Hawaii: Native Hawaiians, Japanese, Filipinos, and Caucasians. Paper presented at the National Institute on Alcohol Abuse and Alcoholism Conference on Epidemiology of Alcohol Use and Abuse among U.S. Minorities, Bethesda, Md., September 11-14. Amaro, H., L. J. Beckman, and V. E. Mays. 1987. A comparison of black and white women entering alcoholism treatment. Journal of Studies on Alcohol 48:220-228. American Bar Association. 1986. American Bar Association Policy Recommendation on Youth Alcohol and Drug Problems with Accompanying Report of the Advisory Commission on Youth Alcohol and Drug Problems, ABA Section of Individual Rights and Responsibilities. Washington, D.C.: American Bar Association. Anderson, G. L. 1979. The Student Assistance Program: An Overview. Madison, Wisc.: Wisconsin Bureau of Alcohol and Other Drug Abuse. Armor, D. J., J. M. Polich, and H. B. Stambul. 1978. Alcoholism and Treatment. Santa Monica: John Wiley and Sons. Atkinson, R. M., J. A. Turner, L. L. Kofoed, and R. L. Tolson. 1985. Early versus late onset alcoholism in older persons: preliminary findings. Alcoholism: Clincial and Experimental Research 9:513-515. Barnes, G., and J. Welte. 1986. Adolescent alcohol abuse: Subgroup differences and relationships to other problem behaviors. Journal of Adolescent Research 1:79-94. Barr, H. L., and D. Antes. 1981. Seven years after treatment: A follow-up study of drug addicts and alcoholics treated in Eagleville Hospital's inpatient program. Eagleville Hospital, Eagleville, Penn. Beckman, L. J. 1984. Treatment needs of women alcoholics. Alcoholism Treatment 1:101-114. Beckman, L. J., and H. Amaro. 1984. Patterns of women's use of alcohol treatment agencies. Alcohol Health and Research World 9:14-25.

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374 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Beckman, L. J., and H. Amaro. 1986. Personal and social difficulties faced by women and men entering treatment. Journal of Studies on Alcohol 47:135-145. Beckman, L. J., and K M. Kocel. 1982. The treatment delivery system and alcohol abuse in women: Social policy implications. Journal of Social Issues 38:139-151. Blum, R. W. 1985. The adolescent dialectic: A developmental perspective on social decision-making. Psychiatric Annals 15:614~18. Blum, R. W. 1987. Adolescent substance abuse: Diagnostic and treatment issues. Pediatric Clinics of North America 34:523-537. Blum, R. W. 1988. Executive summary: Adolescent alcohol treatment. Prepared for the Committee for the Study of Treatment and Rehabilitation Soviets for Alcoholism and Alcohol Abuse, June. Blume, S. B. 1986. Women and alcohol: A review. Journal of the American Medical Association 256:1467-1469. Blume, S. B. 1987. Executive summary: Treatment and rehabilitation for alcoholism and alcohol abuse. II. Treatment for women. Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, December. 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. Braiker, H. B. 1984. Therapeutic issues in the treatment of alcoholic women. Pp. 394-368 in Alcohol Problems of Women: Antecedents, Consequences, and Interventions, S. Wilsnack and L. J. Beckman, eds. New York: Guilford. Butynski, W., N. Record, P. Bruhn, and D. Canova. 1987. State Resources and Services for Alcohol and Drug Abuse Problems: Fiscal Year 1986 An Analysis of State Alcohol and Drug Abuse Profile Data. Prepared for the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse. Washington, D.C.: National Association of State Alcohol and Drug Abuse Directors. Caetano, R. 1988. Alcohol use among Hispanic groups in the United States. American Journal of Drug and Alcohol Abuse 14:293-308. Caetano, R., and M. E. Medina Moral 1988. Acculturation and drinking among people of Mexican descent in Mexico and the United States. Journal of Studies on Alcohol 49:462471. Clark, W. B. 1985. Drinking patterns among Americans of Japanese ancestry in two study sites. Alcohol Research Group, University of California, Berkeley Calif., September. Costello, R. M. 1987. Hispanic alcoholic treatment considerations. Hispanic Journal of Behavioral Sciences 9:83-89. Dawkins, M. P., and F. D. Harper. 1983. Alcoholism among women: A comparison of black and white problem drinkers. International Journal of the Addictions 18:333-349. Donovan, J. E., and R. Jessor 1978. Adolescent problem drinking: Psychosocial correlates in a national sample study. Journal of Studies on Alcohol 39:1506-1524. Donovan, J. E., R. Jessor, and L. Jessor. 1983. Problem drinking in adolescence and young adulthood: A follow-up study. Journal of Studies on Alcohol 44:109-137. Douglas, R. L., E. O. Chuster, and S.C. McLelland. 1988. Drinking patterns and abstinence among the elderly. International Journal of the Addictions 23:399415. Durst, M. E. 1988. Statement presented on behalf of the National Council of Juvenile and Family Court Judges at the open meeting of the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, Washington, D.C., January 25. Emrick, C. D. 1975. A review of psychologically oriented treatment of alcoholism: II. The relative effectiveness of treatment versus no treatment. Journal of Studies on Alcohol 36:88-108. Ewing, J. A., B. A. Rouse, and E. D. Pellizari. 1974. Alcohol sensitivity in ethnic background. American Journal of Psychiatry 131:206-210.

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