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7
THE SOCIAL AND HISTORICAL CONTEXT OF
ALCOHOL TREATMENT RESEARCH
A variety of factors, many of them outside the academic scientific community, have
influenced the course of alcohol treatment research during the past few years. These
historical factors and trends need to be understood before considering new research
directions because they will continue to influence future research efforts. Some of the
factors that affect treatment research priorities include (a) changing federal involvement in
alcohol treatment; (b) emerging trends in the size, financing, and public/private ownership
of alcohol treatment services; (c) demographic trends in the general population; and (d)
popular movements in treatment and referral.
FEDERAL INVOLVEMENT IN ALCOHOL TREATMENT
The foundation of a federal alcoholism effort was laid during the late 1960s through a
series of policy studies, court decisions, and congressional initiatives (Lewis, 1982~. The
1967 and 1969 amendments to the Economic Opportunity Act created the first federally
funded alcoholism treatment programs. In 1970, amendments to the Community Mental
Health Centers Act authorized direct grants for special alcohol treatment projects. Around
this time, separate treatment systems were also established at the federal level within the
Veterans Administration (VA) and the military. Despite these initiatives, however, alcohol
treatment services in the United States were administered primarily through state, local, and
voluntary efforts.
This situation changed dramatically with the enactment of the Hughes Act in late 1971.
Officially known as the Comprehensive Alcohol Abuse and Alcoholism Prevention,
Treatment, and Rehabilitation Act, this legislation created the National Institute on Alcohol
Abuse and Alcoholism from a section of the National Institute of Mental Health and
charged the new agency with responsibility for education, training, research, and planning
in the areas of alcohol treatment and prevention. One year after its inception, NIAAA
inherited nearly 200 alcohol treatment programs from the Office of Economic Opportunity.
Under the leadership of Morris Chafetz, its first director, NIAAA launched a major effort
to alter the public's perception of alcoholism and encourage people to see it as a treatable
disorder (Chafetz, 1975~. During this time, high priority was given to the development of
a comprehensive system of treatment services at the state and community levels, primarily
through the mechanism of formula grants (NIAAA, 1977~.
By 1981, NIAAA had distributed $654.4 million in project grants and contracts and $468.3
million in formula grants to the states (Lewis, 1982~. In choosing grant recipients the
agency placed special emphasis on the development of innovative treatment services,
especially those that were accessible to undersexed populations such as women, racial and
ethnic minorities, the disabled, the elderly, young persons, and the families of alcoholics
(NIAAA, 1980~. In contrast to its role in the development of treatment services, however,
only a small portion of NIAAA's total budget was spent to support research and training.
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During this period, the agency initiated several innovative programs in the areas of
treatment evaluation and reimbursement policy. In 1977, NIAAA contracted for a study
of the barriers to third-part~r reimbursement for alcohol treatment and initiated a National
Alcoholism Program Information System (NAPIS). By monitoring categorical community
treatment programs in terms of client characteristics, services provided, and treatment
outcomes, NIAAA created a valuable data base for the influential Rand Corporation study,
the first comprehensive evaluation of treatment effectiveness (Armor, Polich, and Stambul,
1978~. During this period, NIAAA also initiated special cost and utilization studies of
various federally and state-mandated programs to provide health insurance coverage for
alcohol treatment (NIAAA, 1980, 1985; Plotnick et al., 1982~.
In addition to its direct support of treatment services and program evaluation research,
the agency promoted early intervention activities directed at high-risk groups. NIAAA gave
impetus to the development of occupational alcohol programs, drinking driver education
programs, the federal employees alcohol program, and criminal justice programs, as well
as efforts to educate pregnant women about the risks of excessive alcohol consumption
(NIAAA, 1977, 1980~.
In the early l9&0s, NIAAA's pivotal role in the dramatic expansion of treatment services
came to an end. Direct service grants were curtailed as third-party insurance expanded to
cover the costs of alcohol treatment services. Congress then eliminated project formula
grants, and funds were henceforth distributed directly to the states as Dart of the block
grant mechanism. This action coincided with a shift in NIAAA's priorities away from
treatment services to the support of biomedical and psychosocial research and the
development of a basic science infrastructure through the agency's intramural research
program, investigator-initiated grants, and the National Research Centers Program. Despite
its recognized expertise in the area of alcohol treatment and the continued support of
NIAAA by influential constituency groups, NIAAA's treatment efforts were rapidly eclipsed
by other initiatives, creating a leadership vacuum that has been filled only recently through
the agency's renewed commitment to treatment research. This renewed interest has been
signaled by the creation of the new Division of Clinical and Prevention Research within the
institute and by the congressional appropriation of funds specifically to support treatment
research.
EMERGING TRENDS IN TREATMENT SERVICES
Coincident with the shift in NIAAA's role from treatment provider to research institute,
chances have occurred in the organization and ownership of alcohol treatment services in
the United States (Lowman, 1983; U. S. Department of Health and Human Sen~ic~es, 1983;
Korcor, 1985~. Alterations in reimbursement policy for treatment of alcohol problems, the
expansion of inpatient treatment, an increase in the number of for-profit treatment
providers, the growth of Alcoholics Anonymous (AA) (Robertson, 1988), and the emergence
of nontraditional sources of recruitment into treatment (e.g., media advertising, employee
assistance programs, drinking driver programs) have all been part of these changes.
According to a survey by the federal government, in 1984 there were 6,963 alcoholism units
providing treatment services to more than a half-million patients (Reed and Sanchez, 1986~.
(Compared with 1982, 6,963 units is an increase of 64 percent in the number of service
units.) Of the 540,231 patients in treatment on the date of the survey, 82.9 percent were
being treated as active outpatients, whereas smaller proportions were receiving treatment
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in inpatient (7.6 percent) or residential (9.6 percent) settings. Almost half of the
alcoholism treatment units were freestanding facilities; 21 percent were based in community
mental health centers; and 19 percent were allocated to general, specialized, or VA
hospitals. Compared with previous surreys, this study showed a large increase in the
number of proprietary programs, especially in the proportion being run on a profit-making
basis. For-profit units had increased almost 200 percent from 1982 and constituted 12
percent of all alcoholism treatment units. Another more recent study has documented the
emergence of two separate treatment systems within the United States: one is privately
owned and serving middle- and upper-income clients, while the other is publically owned
and senring uninsured lower-income patients (Yahr, 1988~.
Within both of these treatment systems, there has been a marked trend toward
diversification and specialization. Early counseling or referral to specialized treatment is
becoming increasingly prevalent in employment settings and health maintenance
organizations (HMOs). Both inpatient and outpatient programs are directing their services
toward special population groups (e.g., the military, adolescents, children of alcoholics,
employee groups, professionals, women, homosexuals, and drunk drivers). Media advertising
Is being used to promote program utilization in many parts of the country (Korcor, 1985~.
Alongside the tremendous increases in the availability and scope of alcohol treatment
services, there has also been a trend to organize therapeutic approaches around a single
inpatient rehabilitation model consisting of detoxification, alcohol education, group
confrontational therapy, AA meetings, and disulfiram therapy (Miller and Hester, 1986~.
This treatment package is typically delivered to all types of patients in the course of a
standard three- to four-week residential program. What is surprising about this trend is
the relative lack of empirical data that could serge as a rational basis for the selection of
these or other treatment components or to justify the duration of intensive care (Saxe,
1983; Miller and Hester, 1986~.
Lee trend toward rapid expansion, standardization, and integration of alcohol treatment
services creates special challenges and opportunities for research. The emergence of a
complete continuum of services from detoxification to aftercare makes it imperative to
investigate how best to assign a patient to the least expensive, yet therapeutically
appropriate, alternative. The broad range of available services makes it possible to study
the relative efficacy of different therapeutic modalities and treatment programs. For
example, Social model" detoxification and rehabilitation programs were developed in
California during the 1970s (Borkman, 1986~. They feature community-based facilities,
variable lengths of stay, and treatment of clients by nonprofessional staff. These programs
apparently treat clients at a fraction of the cost of standard, medical-model private
programs. A fundamental and as yet unanswered research question concerns the relative
effectiveness of these programs for similar types of clients.
DEMOGRAPHY, EPIDEMIOLOGY, AND THE DELIVERY OF TREATMENT SERVICES
Recent demographic trends in the American population, coupled with changing patterns of
alcohol and drug abuse, may have important implications for the demand for alcohol-related
health services in the future. These trends may also affect the need for more carefully
evaluated treatment interventions that go beyond the specialized treatment systems that
have developed in recent years. National and regional surveys of the adult U.S. population
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(Regier et al., 1984) have indicated that alcohol abuse and dependence are among the most
prevalent psychiatric conditions. Survey data and hospital records have consistently shown
that alcohol dependence reaches its peak prevalence among persons 35 to 45 years old
(Hilton, 1987~. The maturing of the postwar baby boom population, which encompasses
the 1945-1960 birth cohorts, means that an increasingly larger proportion of the population
is passing through this period of greatest risk for alcohol-related consequences (Williams
et al., 1987~. Other demographic trends that have the potential to influence the nature and
availability of treatment services are increases in the Hispanic population, changes in the
configuration of the nuclear family, increases in the number of homeless persons, the aging
of the population, and the deinstitutionalization of psychiatric patients.
Epidemiological data point to a broad diversity of alcohol-related problems, only some of
which overlap with the continuum of alcohol dependence symptoms. For example, a 1979
survey estimated that there were 10 million adult men and women who consumed four or
more drinks per day, a common criterion for heavy drinking (U. S. Department of Health
and Human Services, 1981~. Although heavy or frequent drinking is not necessarily
indicative of alcoholism, it is an important risk factor and can lead to health problems even
in the absence of alcohol dependence (Babor, Kranzler, and I~uerman, 1987~. The findings
of a 1982 study showed that the prevalence of alcohol-related problems and heavy drinking
in patients seeking treatment for other health problems in general hospital settings ranged
from 15 to 20 percent of male patients and from 4 to 10 percent of female patients
(MacIntosh, 1982~.
Epidemiological surveys indicate that the baby boom cohorts of younger heavy drinkers
are also frequent users of other psychoactive substances (e.g., marihuana, cocaine) and are
more likely than primary alcoholics to have other psychiatric comorbidities (especially
depression or antisocial personality disorder). These trends toward multiple substance-use
patterns, greater numbers of individuals at risk, and the pervasiveness of alcohol-related
problems in general medical patients not only should be taken into consideration in the
planning of health services but also should guide the design of health services research
For example, the high prevalence of heavy drinking and alcohol abuse among general
medical patients suggests that attempts should be made to integrate the identification and
management of alcohol abuse into general medical practice and to evaluate the impact of
this practice change on the health of the primary care population. Similarly, the high
concordance of tobacco dependence, alcohol dependence, and dependence on other
psychoactive substances means that alcohol-specific treatments may have to be broadened
to include the remediation of multiple substance-use disorders.
Finally, the projected increase in the absolute numbers of persons at risk, as well as the
anticipated changes in patterns of substance abuse, argues for the development of a more
empirically based approach to estimations of the need for treatment services. These
estimation techniques should rely on current social indicators, census data, or other readily
available information sources. They may also rely on extrapolation or "synthetic. estimates
drawn from well-executed population surveys such as the Epidemiologic Catchment Area
Study (Regier et al., 1984) or the National Health Interview SuIvey. These techniques must
be sensitive to variations in those demographic variables (e.g.,age, sex, ethnicity, education,
socioeconomic status) that are related to the prevalence of alcohol problems and to the
conditions that promote efficacious treatment. The development of these techniques may
involve research on uniformly coded data bases to help reduce the variability of current
social indicator data. It may also involve the comparative evaluation of these techniques
in a variety of field settings.
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The assessment of a community's need for alcohol treatment services consists of an accurate
estimate of three factors: (1) the actual need for treatment in the community; (2) the total
treatment resources available to the community at all levels of care; and (3) the demand
for those resources from the community. Once these components are known, they can be
analyzed to see how need, resources, and utilization compare; where the gaps of unmet
need are located; what types of resources are required; and where the new resources ought
to be placed.
Although considerable progress has been made since the 1950s in assessing the need for
treatment services, more work should be done to refine the needs assessment methods that
are currently used. These methods are vital to local, state, and national planners who are
attempting to allocate limited resources in the most efficient way.
POPULAR TRENDS IN TREATMENT AND REFERRAL
Popular trends in treatment and referral may have a profound effect on the
treatment-seeking population as well as on the treatments being delivered. Researchers
must be prepared to describe, investigate, and interpret these trends. For example, the
emergence during the 1980s of public interest groups devoted to the prosecution and
prevention of drunk driving has placed special demands on treatment services (see Chapters
3 and 4~. Legally mandated treatment has raised questions about the appropriateness of
using the same conventional approaches that in other contexts rely heavily on individual
motivation. Another trend that is affecting the design of treatment services is the
increasing health consciousness of the American public, combined with changing norms
about the advisability and appropriateness of heavy drinking. As noted in Chapter 4,
during the past decade there has been a sharp decline in the public's preference for distilled
beverages and a concomitant switch to beers and liquors with lower alcohol contents (Kling,
in press). Public awareness of the possible hazards of heavy drinking may increase the
acceptability of minimal or brief interventions targeted at the large population of heavy
drinkers who are at high risk for alcohol dependence (Babor, Kranzler, and Lauerman,
1987~.
Within the alcohol field itself, there have been significant changes in the acceptance of
different ideas and concepts. Adult children of alcoholics have received a great deal of
attention in the media, which has been fueled in part by advocates of the need for special
therapeutic approaches to this population. Similarly, the concept of "codependence~ of
family members has gained popularity as a clinical entity that is assumed to be partly
responsible for maintaining the alcoholic's self-defeating behavior (Cermak, 1986~. Little
research attention has been devoted to the implications of these new ideas for the
improvement of treatment services.
The treatment field has also seen a growing professionalism among alcoholism counselors,
as well as an increasing tendency to monitor and coordinate services through managed care
systems. These trends will place special demands on the research community, which
increasingly is being asked to provide the answers to such complex questions as the relative
effectiveness of credentialed versus noncredentialed counselors or the cost savings that can
be realized from managed care approaches.
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POLICY-ORIENTED SERVICES RESEARCH
Although other sections of this report address the more traditional types of research
opportunities, it is appropriate to begin this discussion of the treatment research agenda
with the following recommendations for policy-oriented services research to set the stage
for the future:
· Research is needed on the multiple economic forces that shape the demand for,
and provision of, treatment services for alcohol-dependent persons and problem drinkers.
· More research is needed, especially at the local level, on the geographic distribution
of alcohol treatment. Some of the questions to be answered in this area concern the
appropriate and efficient distribution of resources and the social, economic, and geographic
factors that affect the development of treatment services.
· Reliable and valid techniques of prevalence assessment that are sensitive to local
conditions are needed for health services planning. Researchers should be encouraged to
use national sample surreys (e.g., Clark and Midanik, 1982), as well as psychiatric
epidemiological methods (e.g., Regier et al., 1984), to develop forecasting models to
estimate the need for treatment services.
· The importance of emerging trends in patient characteristics, population
demographics, alcohol-use patterns, and service utilization has revealed a need for
systematic health services data to describe these trends. Vigorous support should be
-provided to the national survey of alcoholism, drug abuse, and combined treatment units,
which has been conducted for NIAAA and the National Institute on Drug Abuse (NII)A)
since 1979. These surveys could be fruitfully expanded with the use of a more intensive
data collection procedure and the identification of a representative sample of facilities.
· In addition, other data bases are needed to assess alcohol-related general service
and specialty service utilization in ambulatory settings. This research should span a wide
range of services such as community mental health centers, family service agencies, prisons,
HMOs, primary care clinics, and general hospitals. The development of data bases on
ambulatory services will allow more precise estimates of the scope, severity, and cost effects
of alcohol use on mental health and general medical problems.
· Both the alcohol and the drug abuse fields have benefited from longitudinal cohort
studies of clients sampled from multiple facilities (Armor, Polich, and Stambul, 1978;
Hubbard, Marsden, and Allison, 1984~. The NIAAA should support major outcome
monitoring studies, preferably covering a representative sample of units drawn from the
national survey census.
· Researchers should be encouraged to investigate popular trends and concepts in
the treatment field--for example, the need for special treatment services for adult children
of alcoholics and codependents, and the efficacy of such services once they have been
established and marketed.
· Greater attention should be devoted to comparing alternative treatment systems,
both in the United States and in other countries. (For example, California's social model
program could be compared with other public and private systems in terms of costs and
efficacy of both detoxification and rehabilitation treatment.) Detailed historical analyses,
contrasting case studies, and large-scale statistical studies are now needed to provide a
knowledge base to guide health planning and treatment policy. In a world of great diversity
among health systems, all of which seem to be affected by similar economic problems, the
promise of comparative treatment systems research both within the United States and
internationally is substantial.
· Policy studies should be undertaken tO evaluate the impact of recent changes in
training, credentialing, and licensing of personnel who treat alcohol problems.
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~O
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Representative terms from entire chapter:
alcohol treatment
