Broadening the Base of Treatment for Alcohol Problems

s into the 14 special population groups shown in Table 14-1. Catalogued materials include research studies, books, newsletter articles, case studies, program descriptions, journal articles, monographs, communications, and so forth. Table 14-1 shows the frequency distribution of materials in each of the specified areas for three distinct time periods: 1973-1982, 1983-1985, and 1986-1987. The table also contains a summary for the total 15-year period, 1973-1987. THE TREATMENT OF SPECIAL POPULATIONS: OVERVIEW AND DEFINITIONS 350 Broadening the Base of Treatment for Alcohol Problems Copyright National Academy of Sciences. All rights reserved. TABLE 14-1 Total Number of Resource Materials on Special Population Groups Included in the National Clearinghouse for Alcohol and Drug Abuse Information (NCADI) Data Base Special Population Group 1973-1982 1983-1985 1986-1987 Total 1973-1987 Youth 722 1,120 511 2,353 College/university students 8 119 134 261 Elderly 205 186 49 440 Alcoholic females 425 347 208 980 Homosexuals 16 14 22 52 Economically disadvantaged 39 66 47 152 Racial and ethnic groups (general) 301 338 165 804 Blacks 103 131 69 303 Hispanics 48 54 42 144 Asians and Pacific Islanders 54 60 30 144 American Indians 117 85 35 237 Religious groups 79 113 51 243 Public inebriates 2 33 46 81 Handicapped/disabled 0 22 23 45 SOURCE: Committee analysis of data from the National Clearinghouse for Alcohol and Drug Abuse Information data base. Over the 15 year period the emphasis in catalogued material has been predominantly on youth, women, and racial and ethnic groups. The increase in abstracted materials for all the special populations in the last five years deserves notice; youth and women are the categories for which the most materials are recorded. There is also a marked increase in attention paid to college students, whereas there seems to be a slight tapering off in attention paid to elderly, youth, and American Indians. It is possible to characterize the literature abstracted in the NCADI data base as containing only a very few controlled trials in which the effectiveness of generic treatment is compared with treatment specifically tailored to the characteristics of the special population under consideration. There is a paucity of adequate studies on treatment outcome for any of the groups identified (Gilbert and Cervantes, 1988; Vannicelli, 1988; Westermeyer, 1988). The comment on treatment outcome made by Braiker (1982) continues to have current general applicability to all special population groups: A review of the general literature on alcoholism treatment effectiveness reveals that most studies either fail to distinguish between outcome rates for men and women alcoholics or exclude the latter group from the study samples altogether. Among those studies that distinguish outcome rate by sex, varying and often conflicting results are reported. (p. 127) Whereas the NCADI data base offers with insight into the research and and clinical practice emphasis on special populations, data from the National Drug and Alcohol Treatment Survey (NDATUS) can help to identify both the trends and the current distribution of treatment programs available for special population groups. These were surveys of alcoholism treatment services provided by all known public and private alcoholism and drug abuse facilities and units in the United States (NIAAA, 1983; Reed and Sanchez, 1986; NIDA/NIAAA 1989) (see Chapter 4 and Chapter 7). Table 14-2 presents data on the number of specialized programs offered by alcoholism treatment units by the year THE TREATMENT OF SPECIAL POPULATIONS: OVERVIEW AND DEFINITIONS 351 Broadening the Base of Treatment for Alcohol Problems Copyright National Academy of Sciences. All rights reserved. of the survey. Youth, women, the elderly, Hispanics, public inebriates, and blacks were the only special population groups included in all three of these surveys; American Indians/Alaskan natives were included in the last two surveys. TABLE 14-2 Specialized Programs Offered by Alcoholism Treatment Units by Survey Yeara Percentage of Total Units Reporting Specialized Program 1982b 1984c 1987d Youth 21 27 31 Elderly 9 9 8 Women 23 22 28 Hispanics 9 9 11 Blacks 8 7 6 American Indians/Alaskan natives —e 5 5 Public inebriates 13 9 7 Other 13 9 15 None 51 46 41 Total units reporting 4,233 6,963 5,791 a Includes both alcoholism-only units and combined alcoholism and drug abuse units. b Data from the 1982 National Drug and Alcoholism Treatment Utilization Survey (NIAAA, 1983). c Data from the 1984 National Alcoholism and Drug Abuse Program Inventory (Reed and Sanchez, 1986). d Data from the 1987 National Drug and Alcoholism Treatment Unit Survey (NIDA/NIAAA, 1989). e Not included in the 1982 survey. The inventory asked respondents to identify whether they offered one or more specialized programs to certain population groups. Judging on the basis of the treatment units reporting, it appears that an increasing percentage of units are offering one or more specialized programs. In 1987 the largest number of specialized programs offered in treatment units were for youth (31 percent), followed closely by those for women (28 percent), with a sharp drop to programs for Hispanics (11 percent) and the elderly (8 percent). Changes in the total number of units reporting and in the number of specialized programs must be interpreted cautiously because there was a more thorough outreach effort in 1984 to locate all units that were either not identified in 1982 or that did not respond; this effort may simply have uncovered existing units that had not responded earlier rather than identifying new units that had only recently been established (cf. Reed and Sanchez, 1986:2). An examination of these two sources—the NCADI database and the NIAAA surveys of treatment units— shows that women and youth are the special population groups that have received the most attention since the early 1970s. What they do not reveal are the most effective ways to meet the needs of individual problem drinkers or how to identify factors germane to a special population that might affect treatment. The overviews are also unable to provide guidance on when treatment should emphasize an individual's special population membership to facilitate a successful outcome. Indeed, if these overviews tell us anything, it is that women and youth appear to be the special population groups that people are most concerned about. Given the historical dilemmas, variations, and inconsistencies in defining which groups should be considered as special populations in the planning, funding and evaluation THE TREATMENT OF SPECIAL POPULATIONS: OVERVIEW AND DEFINITIONS 352 Broadening the Base of Treatment for Alcohol Problems Copyright National Academy of Sciences. All rights reserved. of alcohol problems treatment, Lex (1985:90) has suggested that a special population be defined as any subgroup that is “special in terms of their uniformity on some dimension and their differences from more typical societal patterns and problems. ” The committee agrees with this definition. However, the definition does not fully capture the problems encountered in attempting to review existing knowledge on the value of special population programming. This review of the history of attention to special population groups suggests that their definition is often not only in terms of the unique biological and sociocultural characteristics that define a group with similar risk factors and drinking practices but also in terms of the momentary concern regarding access to appropriate services. Interest in each group has waxed and waned. There has been no systematic follow up to determine whether access has been improved or treatment outcome positively affected by these periods of attention. What is challenging, for both researchers and clinicians, is to determine where and how the emphasis on special population membership can best facilitate effective treatment for alcohol problems. Given this background, for the purposes of this report, a special population will be viewed as any subgroup that has been identified by the field as needing a specifically tailored “culturally sensitive” treatment program. The committee has chosen to look at developments and issues for only a few of the commonly identified special population groups and the evolution and effectiveness of treatment programs designed for them as portrayed in the research and clinical literature. It is important to note that these groups are by no means inclusive of all special population groups; rather, they have been selected as representatives of special populations as a whole. Chapter 15 considers these groups on the basis of structural characteristics (i.e., demographic characteristics); Chapter 16, adapts the perspectives of functional characteristics (i.e., circumstantial concerns) as a definitional framework. Chapter 17 presents the committee's conclusions and recommendations on the issue of treatment for alcohol problems among special populations.