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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
OCR for page 404
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.
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SPECIAL POPUIATIONS: CONCLUSIONS AND RECOMMENDATIONS
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Representative terms from entire chapter:
special populations
