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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
OCR for page 373
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.
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Representative terms from entire chapter:
american indian
