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17 The Treatment of Special Populations: Conclusions and Recommendations What is most apparent from the committee's examination of the research and clinical literature on special populations is that, in some ways, every individual is ~special" in this sense; that is, if the demarcations of special population groups are based on demographic, social, legal, economic, and biological factors, there is really no person who would be excluded from one or more groupings. These groupings appear logical, yet it is not known whether the concept of special populations always has heuristic value for providing treatment for alcohol problems that speaks to a group's particular needs. The concept has undoubtedly helped some individuals by providing more attractive, culturally specific, and relevant treatment organizations. Given the absence of adequate studies, however, it is not possible to determine whether programs targeted toward a special population are any more effective than an integrated mainstream program in reducing alcohol problems. The committee has tried to determine whether there are data available to resolve such questions about the need for special programs and for special emphases. Like Saxe and colleagues (1983), however, it found that there has been little evaluation of efforts to develop treatment programs tailored to the diverse needs of special populations. There have been no additional studies since the Saxe review to change the conclusion that the evidence is not available to resolve the ongoing disagreement between those who believe that it is important to provide culturalb specialized treatment programs using sta~who share the cultural background (and language, where appropriate) of the individuals being treated and those who believe treatment should focus on the alcohol problem itself. The situation today is perhaps even more complex with the emergence of additional special population groups, defined in terms of functional as well as structural characteristics. A useful notion that has recently evolved is that problem drinking in special population groups is multidimensional. As is emphasized in other sections of this report, professionals are beginning to understand that alcohol problems do not constitute a unitary disease process but are more analogous to cancer or diabetes, with the occurrence and manifestation of symptoms that are unique to each individual. The emergence of this perspective has led to the identification of key subgroups within special populations using variables to categorize the subgroups that are the same as those used to define other special populations (e.g., Gilbert and Cervantes' [1988] discussions of the differential treatment needs of Mexican American males and females and of Mexican American male drinking drivers and Caucasian male drinking drivers; Argeriou's [1979] discussion of the differential treatment needs of black drinking drivers and black public inebriates; Bander and colleagues' [19B3] study of the difference in response to treatment for women varying in socioeconomic status). Despite the current emphasis on subtype variability, the treatment blend of individual characteristics, attitudes, traits, and special population membership nuances has yet to be empirically determined. There is general agreement that members of the identified special populations vary considerably on characteristics that are relevant to treatment outcome; the assumption is made that group members would benefit from some homogeneous treatment based on practices, values, or beliefs that reflect their special population membership. Yet, interdependent factors germane to the individual are also known to influence the way persons use or abuse alcohol. Many, perhaps even most persons in treatment have certain general or common identities as well as one or more special identities. Some examples that were encountered at one treatment facility over a brief period included the following: 399

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400 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS a 32-year-old college-educated, employed male with special identities: he is single, Native American, and homosexual; a 28-year-old married female with special identities: she is pregnant and has a bipolar disorder; an 18-year-old single female college student with special identities: she has a social phobia and is depressed; a 25-year-old married employed male with special identities: he had an alcoholic mother, is legally blind, and is of borderline intelligence (i.e., as a result of fetal alcohol effect). The personal and situational heterogeneity encountered among persons with alcohol problems suggests that identifying the key structural or functional characteristic to use in determining referral to a special population program is difficult in many cases. It is clear that an individual can be a member of numerous special population groups, depending on the definitions and focuses used. Following this logic, if alcohol problems are heterogeneous and it is recommended that treatment for the general population should be heterogeneous, then treatment for special population groups should also be heterogeneous. The committee recognizes, however, that there is a limit on the number of separate programs that can be funded. Therefore, it has considered whether efforts should be focused on improving the match be- tween individuals and well-speciffed treatment regimens, regardless of a person's special population membership, rather than on developing additional separate special population programs. Cautiously, the committee has concluded that the concept of special populations is a dynamic one and that it is necessary to consider all of the factors in an individual's life that may or may not contribute to a positive treatment outcome. In other words' numerous considerations must be addressed in the planning of effective treatment for alcohol problems for any member of a special population, or, in fact, for any person with alcohol problems. One cannot say: "Here is a woman, and because she is a woman, she will benefit from Treatment X." A clinician may be confronted with a woman who is a white, unmarried, deaf mother of two children, or one who is a married, Asian American housewife with no children. Where should the treatment emphasis lie? Which characteristic of special populations requires the most emphasis? How does the clinician adequately assess an individual's characteristics and life circumstances to provide the best treatment? Providing culturally specific programming is not simply the identification of an individual's special population status or cultural orientation and other personal characteristics and the subsequent provision of a clearly indicated treatment. Treatment in this case involves a complex interplay of forces including administrative and funding issues (Maypole and Anderson, 1986/1987~. Such factors as racial and ethnic group identification of the target population and of the program staff, service locations, the structure and programs of the service delivery system, the source and means of financing, and the racial and academic backgrounds of administrators of minority service programs are important variables to be considered in providing culturally specific programming. The committee recognizes that total reliance on isolated treatment programs, each serving a particular subpopulation that has been defined as Special, is neither cost-effective nor realistic at best, and, may be anti-therapeutic at worst. The committee, therefore, has sought to take account of individual uniqueness and special population membership but not to advocate only for increasing the number of separately run programs. It sees a need to

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SPECIAL POPULATIONS: CONCLUSIONS AND RECOMMENDATIONS 401 continue the emphasis on special populations to improve access to treatment but at the same time decries the lack of adequate research on the extent to which these programs have actually improved either access or effectiveness. Matching persons seeking treatment to particular types of therapists and particular treatment modalities can have a far reaching effect in improving retention in treatment and outcome of treatment for special populations. Thus far, matching efforts have had little clinical impact in working with special populations because matching schemes are complex and not readily implemented in the current funding environment. However, adoption of the committee's recommendations regarding outcome monitoring, independent assessment, and funding for all clinically effective interventions will make such matching more appropriate in treatment for special populations. The committee originally began its review of the current status of programming, research findings, clinical observations, and legislative actions involving special populations in order to provide recommendations for future services development. Yet the lack of adequate data has led instead to our emphasis on the need for more adequate study of existing practice. He committee recomrrzer~ds that funding should be provided for discrete evaluafiorls of special populafior~ ir~errenfio~I arid treatment programs. The federal government, through NIAAA, should fund national, multicenter studies of treatment process and outcome that are designed to investigate the factors that determine positive treatment n''lrnm~. for Ok of the major special populations. These studies could be patterned after the current research demonstrations being carried out to evaluate treatment for the homeless with alcohol problems (Lubran, 1987; NIAAA, 1987) and to study matching (NIAAA, 1989~. Because there continue to be unanswered questions regarding the effectiveness of customized, culturally relevant treatment, it is recommended that study groups be specifically created to pursue these issues for each of the major special populations and to design a specific services research agenda for each. These groups should begin by undertaking reviews and analyses of the existing literature and data. The current research on special populations leaves much to be desired. Little is known regarding the impact on outcome of culturally specific treatments whether implemented in culturally specific programs or generic mainstream programs. There is also limited information on the comparative effectiveness of mainstream treatment for different special population groups and on whether the increased availability of special treatment programs encourages those within the targeted population who are in need of treatment to seek it. Considering the literature on special populations and the many outstanding questions that have emerged, it seems more than likely that there is a need for novel research strategies to examine the complexities treatment issues for these groups. Much of the current research being funded by the federal government has no direct relevance to treatment decisions, planning, or intervention with these groups. Instead the emphasis in these efforts has been either on "theory rich" research that might uncover new theories of etiology or on specific treatments. After two decades, this strategy has added much to our understanding of the mechanisms of alcohol abuse and dependence but relatively little to _ , treatment efforts. What is needed now is a new research direction that is characterized by being "theory poor," in the sense that it is aimed not at new theories or interventions but at demonstrating the applied utility of current theory and practice. On the other hand, this new research direction should be "method richn-or at least "method complexn- in requiring careful sampling, precise descriptions of treatment, random assignment to controlled interventions, long-term interventions persisting over several months to a few years, and the longitudinal study of outcome beyond the treatment period. The research program that is shaped by these new emphases must provide representative coverage of each of the major special population groups and not limit work only to one group.

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402 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS The extent to which culturally specific treatment programs enhance the probability of successful outcome for their target populations is the critical question to be answered regarding treatment for special populations. A major effort should be undertaken to encourage existing special population programs and mainstream programs that serve large numbers of special population members to participate in multisite comparative trials. It will then be possible to compare treatment process and treatment outcome for the special population in culturally specific and mainstream programs. The design of such studies should also include identification of the unique and specific elements of treatment in culturally relevant treatment programs. The use of multisite naturalistic and quasi-experimental studies and clinical observation to identify characteristics of special population members who respond differently to mainstream or culturally sensitive treatment approaches will allow the formulation of more practical recommendations for treatment design and funding. These initial quasi-experimental trials can then be followed by more precise multisite clinical trials. These trials can test the program models that are potential candidates for replication and identify the characteristics of those special population members for whom a specific treatment approach is appropriate. Consideration should be given to developing clinical trials to test the effectiveness and appropriateness of culturally relevant treatment. Such trials should evaluate the following: (a) comparative outcomes of members of the special population and other Americans involved in the same treatment programs; (b) comparative outcomes of members of the special population and other Americans receiving the same treatments but in culturally segregated groups; (c) comparative outcomes of members of the special population assigned to culturally oriented treatment programs and those assigned to non-culturally specific treatment programs; and (d) treatment outcomes for special populations stratified by structural and functional characteristics (e.g., gender, age, class, and acculturation). Any attempt at effective matching of members of a special population group to a specific treatment, whether culturally specific or not, is premature at this time. Each of the special populations itself is heterogeneous. There may well be various culturally specific treatments that are appropriate for different population subgroups, but the assessment of what constitutes an alcohol problem and the grading of problem severity need further refinement to determine the appropriate measurement techniques and cut-off points for each special population. It is obvious that different concepts apply to different population extremes (e.g., adolescents and the elderly). The assessment tools that are currently available have been developed for and with adults, primarily white males, and their applicability to other special population groups requires empirical verification. It is extremely important that any effort to match adolescents and young adults to appropriate types and levels of treatment be preceded by an effort to develop distinct assessment and referral tools. It is also important that assessment and referral tools be validated for each of the special population groups in which they will be employed; the need for such validation is particularly acute for the referral and matching of persons from each of the racial and ethnic minorities. Exclusive special population programs may be feasible and desirable in some facets of treatment but impractical or suboptimal in others. In the early stages of treatment (detoxification, crisis intervention, and the process of self-assessment), persons with alcohol problems, regardless of their special demographic, legal, social, or clinical characteristics, have similar needs. Thus, sensitivity to cultural issues is not pivotal in the first stages of recovery (Moos et al., 1985; Westermeyer, 1988~. During this period, the individual is coming to terms with his or her problems, and drinking-related factors assume a greater importance than personal or social factors. It is during this period in the treatment sequence that matching a person either to a generic or to a special population rehabilitation and maintenance program appears critical.

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SPECIAL POPUIAIIONS: CONCLUSIONS AND RECOMMENDATIONS 403 Clinical observations indicate that members of special populations tend to use generic treatment programs when their need is great and special population resources are not available. Yet once the crisis is past, many special population members are apt to reject further recovery in mainstream programs in which they are uncomfortable because of their special identity or that do not meet their special needs. The predictable result is a high rate of dropout from treatment and a high rate of readmission to crisis-oriented treatment the so-called "revolving door" problem (Westermeyer and Peake, 1983; Kivlahan et al., 1985; Babor and Mendelson, 1986~. It is in the assessment and referral, rehabilitation, and maintenance phases of treatment for alcohol problems that the individual's status as a member of one or more special populations appears to gain in importance. For example, members of the person's social network, who often belong to special demographic populations themselves, are key to adequate social assessment and may prove valuable in aiding the person's rehabilitation. The person in treatment who is undergoing rehabilitation (and later, maintenance) is acquiring and solidifying a new identity as a person who no longer drinks hazardously. He or she is faced with two difficult social tasks: (1) dropping social network members (mostly heavy drinkers) whose company is an occasion for excessive alcohol use and (2) replacing them with new members. If recovery requires that the person develop alternative coping mechanisms and an identity that is not based on alcohol use, it is important that, while in rehabilitation, the person have access to other recovering individuals with whom they can identify. This identification is made easier when those persons are members of the same special population (Favazza and Thompson, 1984; Westermeyer and Neider, 1988~. It is also important for treatment staff to be able to establish a rapport with the person's network members and involve them in recovery (including the amelioration of codependence problems, if appropriate). In addition, as treatment and rehabilitation progress, staff must know the resources available in the community to meet individuals' special needs. In the case of special populations, the establishment of rapport with social network members and intimate knowledge of community resources may depend on staff themselves being part of the special population with which the person in treatment is identified. This objective can be achieved either by increasing special population representation among treatment staffs or by increasing the heterogeneity of staff and broadening their training accordingly. The committee prefers to see both avenues pursued. Yet it is doubtful that full representativeness can ever be achieved. Staff who are conducting assessments, making referrals, and carrying out specific treatments must understand the problems presented by special population members in order to deal with them constructively. A married, middle-class suburban male staff member may have difficulty in empathizing wither confronting, when appropriate-a single parent, inner-city mother of five children. This level of understanding can be facilitated by staff who share some of the same characteristics as the persons in treatment, but obviously, treatment staff cannot totally share the identities of all persons whom they treat. There appears to be some critical level of identity that enables an individual seeking treatment to view a particular program's staff as acceptable; however, its parameters are not known. To what extent should the staff demographically resemble those whom they treat? Does each program require a solo parent, a paraplegic, a fundamentalist Christian, and an HIV-seropositive homosexual on staff? Even if this were desirable-and it is not clear that this arrangement is therapeutically advantageous (e.g., Padilla et al., 1975; Sue, 1988) the diversity of special populations makes it impossible to achieve staff representativeness in large, mainstream programs that serve multiethnic, diverse special populations. Given the current resources available, the committee recognizes that many members of special population groups will continue to be treated in majority-run, mainstream programs. Thus, expanded training, incorporating the most recent developments in clinical

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404 BROADENING TEIE BASE OF TREATMENT FOR ALCOHOL PROBLEMS practice and research findings, is required. The committee mcommends that there be a major effort to train staf~workir~gin these mainstream programs in the skills and sensitivity needed to identity and work with the special populations that can be expected to seek Moment in their programs. This recommendation is based or a twofold need: to improve existing services arid to provide opportunities to study whether such training can unprove treatment outcome for specu~l population members who receive Comment u' these programs. Questions of staff and program representativeness can and should be addressed by future research efforts about the contribution of therapist characteristics to treatment effectiveness (see Chapters 4 and 11~. To avoid misinterpretation, the committee believes it prudent to emphasize that the conclusion it noted at the beginning of this chapter regarding the lack of more refined knowledge on the effectiveness of culturally specific treatments should not be taken as a rationale for discontinuing the funding of such programs. Even though there is no definitive evidence at this time that these programs provide more effective treatment, the committee has concluded that there is evidence that access to treatment has been improved for members of special populations, in many cases simply because of the development of these additional culturally sensitive programs. Thus, the committee recommends that there be continuation' of funding for special population' treatment programs ir' order to to facilitate access to treatment arid to provide the basis for examining effectiveness. These examinations can be carried out both through special studies and through the routine outcome monitoring the committee wishes to see conducted by every treatment program as a condition of funding. The committee also urges that there be predictable funding on a long-term basis for these studies, so that clinicians and researchers alike are given appropriate opportunity to investigate the relevant questions, provide comparisons, and address issues related to special population groups. REFERENCES Argeriou, M. 1979e Reaching problem drinking blacks: The unheralded potential of drinking driving programs. International Journal of Addictions 13 443-459e Babor, T. F., and J. H. Mendelson. 1986. Ethnic/religious differences in the manifestations and treatment of alcoholism. Annals of the New York Academy of Sciences 472 46-590 Bander, K W., N. A. Stilwell, E. Fein, and G. Bishop. 1983. Relationship of patient characteristics to program attendance by women. Journal of Studies on Alcohol 44:318-327. Favazza, A. R., and J. J. Thompson. 1984. Social networks of alcoholics: Some early findings. Alcoholism: Clinical and Experimental Research 8:9-15. 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, Univerity of California, Los Angeles. Kivlahan, D. R., R. D. Walker, D. M. Donovan, and H. D. Mischke. 1985. Detoxification recidivism among urban American Indian alcoholics. American Journal of Psychiatry 142:1467-1470. Lubran, B. G. 1987. Alcohol-related problems among the homeless: NIAAA's response. Alcohol Health and Research World 11(3):4^,73. Maypole, D. E., and R. B. Anderson. 1986/1987. Alcoholism programs serving minorities: Alcohol Health and Research World 11(2):62~5. Administrative issues. Moos, F., D. E. Edwards, M. E. Edwards, F. V. Janzen, and G. Howell. 1985. Sobriety and American Indian problem drinkers. Alcoholism Treatment Quarterly 2:81-96.

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SPECIAL POPUIATIONS: CONCLUSIONS AND RECOMMENDATIONS 405 National Institute on Alcohol Abuse and Alcoholism (NLAAA). 1987. Request for Applications: Community Demonstration Grant Projects for Alcohol and Drug Abuse Treatment of Homeless Individuals, RFA AA-87~4. Rockville, Md.: NIAAA National Institute on Alcohol Abuse and Alcoholism (NLAAA). 1989. Request for Cooperative Agreement Applications: Matching Patients to Alcoholism Treatments, RFA AA-892a, Coordinating Center. Rock~ille, Md.: NIAAA. Padilla, A., R. Ruiz, and R. Alverez. 1975. Community mental health services for the Spanish-speaking/surnamed populations. American Psychologist 30:892-9050. 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. Sue, S. 1988. Psychotherapeutic services for ethnic minorities: Two decades of research findings. American Psychologist 43:301-308. Westermeyer, J. 1988. Executive summary: Culture, special populations and alcoholism treatment. Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, April. Westermeyer, J., and E. Peake. 1983. A ten year follow-up of alcoholic Native Americans in Minnesota. American Journal of Psychiatry 140:189-194. Westermeyer J., and J. Neider. 1988. Social networks and psychopathology among substance abusers. American Journal of Psychiatry 145: 1265-1269.