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16 Populations Defined by Functional Characteristics The special populations discussed in this chapter are those who share a common social, clinical, or legal status. There has been general agreement in the field that these groups have been seen to require Culturally sensitive" specialized treatment services that also take into account the unique characteristics that distinguish the members of a particular group, even though these individuals may not identify themselves with the group. The groups used as examples in this chapter are people referred to treatment as a result of a drinking-and-driving arrest; the homeless and chronic public inebriate; the person with a coexisting psychiatric condition; college students; and children of alcoholic parents. Other groups that have been identified as special populations on the basis of a functional characteristic include the physically impaired, the deaf, and inmates of correctional facilities. Occupational groups (e.g., military personnel, physicians, migrant workers) have also been seen as socially defined special populations, and there are specialized programs which have been designed to meet their unique needs. For some of these functionally defined special populations (e.g., drinking drivers and skid row public inebriates), specialized agencies have developed and form a discrete subsystem within the specialist alcohol treatment sector described in Chapter 4. Drinking Drivers Drinking drivers, a special population defined solely in terms of their common legal status, are those persons who have been arrested for an alcohol-related driving offense. Most often, the offense is a violation of a driving-under-the-influence statute, although at times a vehicular homicide charge is also involved. A nationwide network of drinking-driver assessment and case management programs has been created to identify, classify, and refer drinking drivers to intervention and treatment; generally these programs use the methodology developed under the Alcohol Safety Action Program (ASAP), a joint effort of NIAAA and the National Highway Traffic Safety Administration (NHSTA) (Kisko, 1976; Fridlund, 1977; U.S. Department of Transportation, 1979a; Reis, 1984~. A network of specialty alcohol education and treatment agencies for drinking drivers has also been developed. Concerns have been expressed that the influx of drinking drivers into communi~-based treatment settings have shifted their orientation away from working with persons who have severe and substantial alcohol problems and converted community-based agencies into extensions of the criminal justice system (Weisner and Room, 1984; Weisner, 1986~. Whether these concerns are justified is open to question because there has been no recent review of the structural and operating characteristics of these individual state "DWI program" networks across the nation or any recent comprehensive evaluation of their effectiveness. There is no doubt that drinking drivers are a heterogeneous lot, and there have been numerous efforts to define subtypes as a way to improve treatment matching (e.g., Seizer et al., 1977; Steer et al., 1979; Zung, 1979; Donovan and Marlatt, 1982; Donovan et al., 1985; Snowden and Campbell, 1986; Wells-Parker et al., 1986; Mann, 1988~. Arrestees typically have been divided into two groups-problem drinkers and social drinkers-on the basis of their drinking behavior and problem status. Problem drinkers were those offenders who had lost control of their drinking and suffered severe social, physical and psychological consequences. Social drinkers were those offenders who drank occasionally but suffered no 3X!
382 BROADENING ITIE BASE OF TREATMENT FOR ALCOHOL PROBLEMS undue consequences as a result of their consumption prior to their arrest for driving after drinking (U.S. Department of Transportation, 1979a). Following these characterizations, drinking-driver rehabilitation programs were differentiated into a short-term, didactic, lecture-oriented component for social drinkers and a treatment component for problem drinkers. The educational components were usually based on the original ASAP model and consisted of a limited number of sessions (usually 4 to 8) in which information on alcohol effects, traffic safety, and alcohol problems was provided in small group or lecture formats (Malfetti and Winter, 1976~. The treatment components were most often short term, fed-length group counseling (12 to 16 sessions). Progress was monitored by the courts, generally by a specially trained probation officer. Initial evaluation data on the ASAP suggested that for social drinkers minimal intervention consisting of educational presentations of factual information, discussions, and the threat of future punishment if rearrested was effective in preventing repeat arrests; for problem drinkers a more intensive treatment experience was required involving affective education, individual and group counseling, and other therapies and supportive services if change was to be effected in their drinking-and-driving behaviors (Scores and Fine, 1977; U.S. Department of Transportation, 1979a,b). Today, the program's treatment component continues to include didactic information presentations, but these presentations occur in smaller, interactive discussion groups rather than in large lecture sessions. Additional differentiation has taken place, such as the development of long-term individually oriented counseling programs and more intensive residential treatment programs targeted at multiple offenders (Mann et al., 1983; Wells-Parker et al., 1986; McCarty and Argeriou, 1988~. From 1971 until 1982 NIAAA sponsored a categorical grant program to serve drinking drivers; the program ended with the advent of the block grant. Although the federal policy emphases have changed, states have continued to support these programs; however, the focus has shifted from the state or local government directly funding education or treatment (or both) to its licensing programs that are supported by court-mandated fees and fines and its provision of financial assistance for indigent offenders (Weisner and Room, 1984~. The system in most states is very similar to that described for Minnesota in Chapter 4: DWI programs provide intervention and treatment according to protocols that are often codified in legislation and licensure standards. The precise nature of this network of DWI programs varies from state to state and has not been studied recently. There is evidence that suggests that this rapid increase in treatment programs dependent on the courts for ~coerced" referrals has markedly changed the nature of treatment for alcohol problems as many agencies become more involved in the criminal justice system than they are in the health care system (Weisner, 1986; see Appendix D). In a typical DWI referral network, drinking drivers are classified into three subgroups: (1) social drinkers; (2) incipient problem drinkers; and (3) problem drinkers. (This categorization uses the methodology originally developed for the ASAP projects.) Screening is done either by court personnel or by the licensed program using a combination of interview data, driving history data and screening instruments, most often the Mortimer-Filkins Interview (Filkins et al., 1973; Wendling and Kolody, 1982) or the Michigan Alcoholism Screening Test (Seizer et al., 1977), or both (Mann, 1988~. Some jurisdictions have modified the methodology extensively (e.g., Pisani, 1986), while others have maintained or added to it (e.g., Booth, 1986~. In some jurisdictions, drinking drivers are beginning to be classified at the initial screening as either first offenders or repeat offenders; repeat offenders are more likely than first offenders to be referred to intensive treatment (Reds, 1984; Hagen, 1985; McCarty and Argeriou, 1988; Mishke and Venneri, 1987; Beerman et al., 1988; Mann, 1988~. Jurisdictions also vary in who carries out the screening and referrals; sometimes an employee of the court functions in a modified probation officer role, and sometimes this task is handled by a contract agency. Jurisdictions vary in the amount of discretion given
POPUIATIONS DEFINED BY FUNCTIONAL CHARACTERISTICS 383 to the court to use in referrals to assessment and treatment as a sentencing option. There has been a move toward increasing the severity of DWI penalties, particularly for multiple offenders, led by such advocacy groups as Mothers Against Drunk Driving (MADD) (Ungergleider and Bloch, 1987) and the Presidential Commission on Drunk Driving (1983~. Despite the increased focus on the deterrence of drinking and driving which led to the initiation of the ASAP and similar programs, this behavior persists as a major social and public health problem. Primary and secondary prevention efforts with young drivers, the subgroup with the highest risk of a DWI offense, have been relatively ineffective (Donovan, 1988~. Driver training programs that attempt to provide young drivers with better driving skills appear to have little or no impact in reducing the number of accidents per licensed driver. In fact, such training programs, by encouraging youth to become licensed at an earlier age, may increase their exposure to driving risks and inadvertently lead to an increase in accidents. Educational counseling programs that focus on drinking and driving among youth have had mixed results, and it is not yet possible, no matter how promising they seem intuitively, to state with any certainty how effective they are. The most effective method of reducing alcohol-related accidents appears to be to increase the legal age at which alcohol can be purchased. Well-designed studies indicate that increases in this age are associated with notable decreases in accidents in the affected age groups; furthermore these reductions have been found to persist over periods of up to six years. The upper limits of this intervention may now have been reached because all of the states have increased the legal drinking age to 21. One strong incentive for such action was provided by the federal government: states that failed to raise the legal drinking naP ri~kP.~1 ~ loo of in of federal highway funds (Donovan, 1988~. ,. . . - Am- A- --a D -DO Kiev ~^ ~ v it_, _,,, ~;wnuaIy prevenuan attempts using general deterrence strategies also have been of limited success. The general deterrence model is based on the assumption that the penalties contingent on the arrest for a drunk driving offense will be swift, certain, and severe. The clearest finding related to this approach is that if the perceived risk of arrest and punishment for drunk driving is sufficiently increased, there appears to be some deterrence of drinking-driving and a reduction of accidents that appear to be related alcohol (H. L. Ross, 1984; Wailer, 1985; Donovan, 1988~. These reductions appear to be relatively short-lived, however, and rates return to or sometimes exceed preintervention baselines over time. The least costly and most effective specific deterrents appear to be license suspension and revocation (Hager, 1985~. Although a large number of individuals who have lost their licenses continue to drive, they drive less frequently, for fewer miles, and more cautiously. Studies comparing license actions with rehabilitation programs have suggested that the licensing actions are more effective in reducing subsequent DWI recidivism and accidents. Such findings question the rationale for and effectiveness of "diversion" programs (e.g., deferred prosecution) that allow DWI offenders to seek treatment as a substitute for court-ordered punitive sanctions (e.g., jail, license suspension). Indeed diversion programs may be similar to a double-edged sword. On the one hand, they encourage offenders to enter treatment. On the other hand, by allowing the offender to avoid or circumvent what appear to be particularly effective deterrent licensing sanctions, the programs may actually be counterproductive. It has been argued that alcohol education and rehabilitation should be used in conjunction with and not as a substitute for licensing sanctions, that is, as a complementary rather than a competing approach (Hager, 1985~. Hagen's conclusions from his review of the research on the effectiveness of education and rehabilitation as a "sanctions" for reducing recidivism (i.e., reducing repeated offenses of driving while impaired) are consistent with those of other reviewers (i.e., Vingilis, 1983; Mann, 1988~. These investigators argue that too much emphasis had been
384 BROADENING THE BASE OP TREATMENT FOR ALCOHOL PROBLEMS placed on this sanction (i.e., education and treatment) alone and that it should be conceptualized in conjunction with other sanctions, particularly license suspension. Referral to education for social drinkers or to treatment for problem drinkers remains an important and widely used countermeasure to reduce drinking and driving, even though it cannot be said to be a particularly effective means to achieve this purpose. Indeed without more research, no approach can be viewed as preeminent; more systematic studies are needed on the effects of the different penalty and referral systems now in place and on the different strategies for matching DWI referrals to appropriate settings, modalities, and intensities of treatment. Hagen (1985) vividly described the multiplicity of prevailing approaches for solving this particular alcohol problem: Sanctions for the drunken driving offender vary throughout the world, ranging from the typical monetary fines, jail sentences and licensure controls to a variety of options collectively called education and rehabilitation. The latter may range from a 2-fur didactic education course to a full blown alcoholism treatment involving psychotherapy. The orchestrater for the administration of this elaborate permutation of sanctions lies with the judiciary, with the application being the responsibility of the service providers-be it a correctional facility, licensing agency or the treatment-educational facility. (p. 79) . In contrast to these more negative findings regarding the effectiveness of education and treatment for DWI offenders, evaluation reports from state programs continue to emphasize the successes that have been achieved (e.g., Booth, 1986; Hoffmann et al., 1987; McDonnell and Fortinsky, 1987~. The evaluation of the effects of educational and rehabilitation programs on treatment outcome has been plagued by an array of methodological problems that make unequivocal interpretation of the results difficult (Mann, 1988; Donovan, 1988~. Even more recent treatment outcome studies that have provided more appropriate experimental control, such as those conducted by Reis (1984) in California and by Landrum et al. (1983) in Mississippi, have led to equivocal results. One important aspect that must be taken into account in such evaluations is that the DWI population is not homogeneous in nature. Rather, this population appears to consist of a number of groups whose distinguishing characteristics may have meaning for determining the most effective way to prevent DWI offenses. Subtypes have been identified through analysis of arrest histories, personality assessments, and other data. ~ ,r dimensions, including sociodemographic variables, personality structure, anger and hostility, driving- related attitudes, psychopathology, drinking-behavior-related variables, and both general and driving-related arrest records. Current research efforts focus on determining whether treatment (education or rehabilitation) outcomes among DWI offenders may be enhanced by more effective matching of differential interventions to such legally defined or empirically derived subtypes. For example, McCarty and Argeriou (1988) have recently reported initial positive results for an intensive short-term residential primary treatment jail alternative for multiple offenders. The most elaborate drinking driver classification system yet proposed for differential treatment planning includes seven groups or subtypes (Steer et al., 1979~. Using four indexes of alcohol impairment, records for a pool of 1,500 male DWI arrestees that had been seen in NIAAA-funded treatment programs were cluster analyzed. Clinical experience and knowledge of the literature led the investigators to describe suggested interventions and treatment regimens for each of the seven groups. The groups varied in severity of impairment; the intensity of the interventions varied concomitantly, from license ~ ~_ - Sub~rnes have been based on a number of
POPUIATIONS DEFINED BY FUNCTIONAL CHARACTERISTICS 385 restrictions plus instruction in safe driving skills to license revocation plus court-mandated hospitalization for forced withdrawal followed by probationary supervision and psychotropic medication. Although there has been no definitive experimental evaluation of the effectiveness of drinking driver programs, most of the studies that have been conducted support their general effectiveness in decreasing abusive drinking and improving psychosocial functioning; they cannot, however, shed light on whether such programs reduce drinking-related traffic violations. Additional studies are needed where different types of drinking drivers are assigned to different tailored treatment modalities on the basis of pretreatment assessment (U.S. Department of Transportation, 1979a,b; Swenson et al., 1981; Wells-Parker et al., 1986; Donovan, 1988; Mann, 1988~. Evaluation of efforts to date suggests that treatment of the drinking driver is clearly not a substitute for civil sanctions and criminal penalties, but that treatment is a valuable supplement, although perhaps only for clearly specified subgroups. Further progress depends on developing better subgroup classification systems, better referral and matching procedures, better follow-up procedures, and more specific treatment methods. Dual-Diagnosis Psychiatric Patients A special population that has been receiving a great deal of attention recently is the so-called "dual-diagnosis" patient (Harrison et al., 1985; Blume, 1987; Galanter et al., 1987; Rounsaville, 1988~. Advocates of the "disease model" of alcoholism totally rejected psychiatric concepts and methods of treatment during the initial effort to distinguish alcoholism as a primary disorder in and of itself (see Chapter 3~. They rejected the conceptualization that alcohol problems were merely a symptom of an underlying psychiatric condition requiring psychoanalytically oriented dynamic psychotherapy or psychopharmacological treatment. Initially, many of the recovering alcoholics who were involved in developing what was then the "news Minnesota model intensive residential and hospital-based treatment programs and specialist halfway houses avoided any relationships with psychiatrists and the specialty mental health system. This avoidance came in part as a reaction to a history of ineffective psychotherapy and the use of drugs that were themselves addictive (Rounsaville, 1988~. "Alcoholism is not a Valium deficiency was a common critique heard of the psychiatric approach to treatment of long-term alcohol problems. The recent attention to the "dual-diagnosis" patient has resulted from the recognition of both alcohol and mental health specialist groups that there was a subgroup with whom neither sector worked well and a concern that the number of individuals in this group was growing (Galanter et al., 1987; Penick et al., 1988~. These individuals often require treatment for the use of other drugs as well as alcohol, and mention increasingly is made of the "mentally ill chemical abuser" who is disruptive to the milieu of a standard treatment program (e.g., New York Division of Alcoholism and Alcohol Abuse, 1988~. Persons with mental illness in addition to alcohol problems have seldom found a ready welcome in the specialty alcohol treatment sector. Minnesota model programs have tended to exclude those with overt psychopathology, whereas those working in the traditional mental health sector either referred persons with alcohol problems to a specialty agency or continued to treat them. When mental health practitioners did treat persons with alcohol problems, they used either the older, symptomatic approach or one of the newer treatment methods that blend psychodynamic approaches with approaches that focus specifically on drinking behavior (e.g., Khantzian, 1981, 1985~. There has been continuing interest in the relationships between specific psychiatric syndromes and alcohol problems, primarily depression and antisocial personality disorder. As one means of differentiating which
386 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS individuals should be seen in which sector, Schuckit (1985) has made a distinction between those persons with an alcohol problem who were found to have a preexisting psychiatric condition and those whose psychiatric problem emerged subsequent to the onset of heavy drinking. As with other special populations, many of the available studies on dual-diagnosis patients have focused on epidemiological and diagnostic considerations-that is, on determining how many of the persons seen in various community and treatment settings have concomitant DSM-III diagnoses of alcohol dependence and "another psychiatric disorder, including dependence on other drugs (Hesselbrook et al., 1985; H. E. Ross et al., 1988a,b). The development of more precise diagnostic criteria and assessment instruments have helped to identify those persons entering treatment who are experiencing both an alcohol problem and a psychiatric condition. Estimates of the size of the population being seen in each treatment sector vary, ranging from over 5 percent of those entering standard alcohol treatment programs to over 70 percent of those entering psychiatric programs. The conditions that have received the most attention are depression (affective disorders), antisocial personality disorders, and schizophrenia. The prevalence of antisocial personality disorders has been reported as ranging from 20 to 79 percent in persons treated for alcohol problems (Hesselbrock et al., 1985; Rounsaville, 1988~. The prevalence of antisocial personality disorder and alcohol problems in the general population has been estimated to be about 7 percent. Anxiety disorders in combination with alcohol problems have also been found in high numbers, especially panic and phobic disorders; however, the prognostic significance of this combination for either condition is not clear (Rounsaville, 1988~. Major depression also has been reported as having a wide range in samples of persons being treated for alcohol problems, with lifetime rates ranging from 18 to 52 percent and current rates of 9 to 38 percent; these findings contrast with community rates which are around 6 percent to 7 percent for lifetime and 2 to 3 percent for current status. Studies are now being carried out to determine whether there are any systematic differences in outcome using different treatment protocols (e.g., treatment of the depression with an antidepressant drug and targeted psychotherapy) to determine whether methods that have been shown to be effective in treating depression alone can be used with dual-diagnosis patients. Efforts have been made to develop specialized treatments for each of the dual-diagnosis subgroups (e.g., depression plus alcohol problems) as well as separate treatment units (Harrison et al., 1985), because the standard psychiatric approaches have had a high success rate (Galanter et al., 1987~. Several states (e.g., Illinois, New York, New Jersey, Colorado) have developed special funding categories, but there are still numerous unanswered questions about diagnosis and treatment (Rounsaville, 1988~. Several studies have shown that adding psychotherapy, when it is carried out by an experienced psychotherapist, as a component in a more standard alcohol/drug counseling program can improve the chances for successful outcome in those persons who have been assessed as having severe psychological problems (McLellan et al., 1983; Rounsaville et al., 1987~. It has been suggested that psychiatric diagnosis can be an important matching variable even if no specific treatment for that combination is found. For example, an individual with alcohol problems and antisocial personality disorder might respond better to an alcohol problems treatment program that uses very structured limits-setting than to a more open, less rigorously structured treatment environment even though there is currently no demonstrated effective treatment for antisocial personality disorder.
POPUIAIIONS DEFINED BY FUNCTIONAL CHARACTERISTICS Homeless Persons: The New Public Inebriates 387 Concern for the homeless person with alcohol problems has replaced concern for the chronic public inebriate, although they may truly be the same individual (Finn, 1985; Shandler and Shipley, 1987~. The current status of treatment availability has been partially reviewed in a recent IOM report (1988), which distinguished among the temporarily homeless, the episodically homeless, and the chronically homeless. The third group were most likely to comprise either chronically mentally ill persons or Chronic substance abusersn in the committee's terms, a person with chronic disabling alcohol problems. There are no well-defined surveys of the homeless population, but it is estimated that 30 to 40 percent are persons with chronic alcohol problems (IOM, 1988~. The likelihood of a comorbid psychiatric disorder is also very high, placing a large number of the homeless within the dual-diagnosis special population. The recent literature on alcohol problems among the older inhabitants of skid rows and the "new homeless" was reviewed by Fisher (1987~. With the disappearance of skid rows in the 1970s, the termination of the NIAAA categorical grant program, and the deinstitutionalization of chronically mentally ill and alcoholic persons, concern with the chronic public inebriate at the national level of public policy began to dissipate. The public inebriate problem had not been resolved (Scrimegour and Palmer, 1976a,b; Diesenhaus, 1982; Finn, 1985), but it apparently was not seen as needing continued national focus. This view is supported by the lack of designated set-aside funds in the block grant. Efforts to deliver services within the fragmented services network continued in major cities with state and local support but without the resources considered necessary by those working with this special population (e.g., Finn, 1985; Sadd and Young, 1986; Shandler and Shipley, 1987~. The hub of these efforts was the network of nonhospital, nonmedical detoxification centers that replaced "drunk tanks" for public inebriates in the early 1970s. These centers were established following a state's passage of the Uniform Act or its enactment of a change in policy to come into conformity with court decisions decriminalizing public intoxication. The increase in the "recovery rates that many thought would result from moving the "processing of the public inebriate out of the criminal justice system and into the health care system did not occur. The expectation that such recovery could take place was challenged on theoretical and practical grounds by some (e.g., Room, 1976; Pisani, 1977; Pittman, 1977~; and it was verified empirically by others (e.g., Annis and Smart, 1978~. The detoxification center had merely replaced the drunk tank as a Revolving door." The explanation given for the failure to see dramatic change in public inebriety was the inadequacy of the resources committed to meeting the extensive needs for health care, supportive living arrangements, gradual but consistent engagement in treatment by meeting survival needs as well as treating the drinking behavior (Blumberg et al., 1973; Finn, 1985~. Gradually, agencies serving public inebriates began to develop the added social support, health care, and vocational counseling services required to supplement the specific treatment modalities they offered to reduce problem drinking (e.g., Moos et al., 1978~. Thus, the current emphasis in this area of alcohol problems treatment appears to be on developing a comprehensive treatment system that deals with all of the health care and social support needs of homeless persons, including alcohol problems (Breakey, 1987~. A design for the integrated continuum of care thought to be needed to provide such services has been summarized by Shandler and Shipley (1987~; it comprises emergency medical care for the intoxicated, hospital or nonmedical detoxification, psychosocial evaluation, inpatient or residential formal treatment that focuses on developing job skills and on seeking housing, outpatient treatment, partial hospitalization, and aftercare. Detoxification lasts five to seven days, inpatient/residential treatment lasts about four months and outpatient or partial hospital treatment lasts six months. The model
388 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS anticipates the need to repeat the full cycle of treatment several times before success is achieved, and clients are urged to return if they lose control of their drinking. This model is based on over 20 years of experience gained by the Philadelphia Diagnostic Center, one of the nation's pioneering public inebriate programs. Such programs are designed to break through the disaffiliation, or lack of personal linkages to social and family groups, that is a crucial characteristic of the chronically homeless. Distrust of authority, another key characteristic of homeless people, is also seen as complicating the development of a sustained treatment relationship. Homeless persons and chronic public inebriates move in and out of treatment for alcohol problems; services must be designed with due recognition of this characteristic (Morgan et al., 1985; Pagan and Mauss, 1986; Fisher, 1987~. There is some debate as to whether homelessness is a cause or consequence of being on the street (Dennis, 1987~. It is likely that it is both. Therefore, another important aspect of treatment for the homeless is the provision of long-term supportive living arrangements in an alcohol free living environment (Fisher, 1987; Korenbaum and gurney, 1987~. At present, there is a major NIAAA initiative under way to evaluate effective treatment for the homeless person with chronic alcohol problems (Lubran, 1987; NIAAA, 1987~. Although a number of descriptive studies have been performed, there have been no clinical trials to establish which treatment methods have the most success in moving an individual out of both the homeless and the problem drinking conditions. The specific configuration of services needed, the possibility that different configurations are necessary for different subgroups, and the effectiveness of involuntary commitment have not been empirically tested despite the almost 20 years of identification of the public inebriate and skid row alcoholic as a special population. College Students Recently, college students as a subgroup of adolescents have become identified as a new special population. The common characteristics are age, life situation, and legal status. There are several reasons for this development. First, the focus on drinking and driving with attention being drawn to the high incidence of alcohol-caused accidents among adolescents and young adults has led to federal and state legislation raising the legal O ~, ~ drinking age to 21. This change has created even more dissonance and concern on college campuses, which already had trouble enforcing the laws on underage drinking within their mixed-age populations. Second, an increase in the number of highly publicized tragedies associated with on-campus parties and fraternity hazing has led universities to review their policies and practices. Third, although there have been some encouraging results from the studies on primary prevention strategies, primarily those using education and awareness campaigns (Goodstadt and Caleekal-John, 1984; USDHHS, 1987), there have been questions raised about the effectiveness of these efforts, both from a methodological and practical perspective (e.g., Moskowitz, 1986~. Finally, the college campus is in many respects a closed community with many unique aspects; one of those aspects is that the student is a transient member who becomes the responsibility of the permanent administration and faculty functioning in loco parent) for many aspects of daily living. For example, on February 18, 1988, the New York Times published an editorial entitled "Drinking Themselves to Death. The editorial described the recent death of a freshman at Rutgers University who suffered an overdose of alcohol at an initiation party. This death followed by less than a week a near fatality at Princeton University, in which a student drank himself into a coma during an initiation party at an eating club. The editorial quoted Rutgers' president, Edward Bloustein, who observed that there appears
POPUIA1IONS DEFINED BY FUNCTIONAL CEIARAC1*ERISIICS 389 now to be Ha growing trend of abusive use of alcohol" on campuses, in part, according to some experts, because alcohol is seen by students as a safe and generally legal alternative to illicit drugs. The editorial concluded that most universities have adopted a "hands-off" attitude toward student drinking, particularly when it occurs in off-campus facilities such as fraternity houses. "Except where they are hosts or landlords, institutions cannot do much except advise and educate their students on the responsible use of alcohol. Whether to follow the advice is for the students to decide," the editorial concluded. Growing concern over college student drinking has been expressed in colleges and universities all over the country. Newspaper articles document the increasing number of alcohol-related accidents and overdose fatalities. To take still another example, at the University of Washington in Seattle, several students have died of alcohol-related accidents (e.g., falls from fraternity house windows) in the past several years (Marlatt, 1988~. Research efforts in this area to date have primarily focused on surveys of drinking practices and the distribution of problems (e.g., Engs and Hanson, 1985; Anderson and Gadeleto, 1985; Saltz and Elandt, 1986) and the evaluation of primary prevention strategies. A recent assessment of student drinking patterns in one University of Washington fraternity found (after evaluating two weeks of daily self-monitoring of alcohol intake by fraternity members) that the average house member consumed 16 drinks per week with an average maximum blood-alcohol level (BAL) of .16 percent, well above the legal intoxication level of .10 percent. In addition, the average member reported being intoxicated (BAL > .10 percent) for 8.4 hours per week. Another sample of heavy-drinking college students reported driving an automobile while under the influence of alcohol an average of 7.5 times in the past year (Marlatt, 1988~. These findings are representative of other college drinking studies. In a review of 38 studies published between 1976 and 1985, Saltz and Elandt (1986) reported that 47 percent of the students surveyed reported being at risk of a DWI or driving under the influence (DUI) citation; 24 percent reported injuries or alcohol-related injuries. Data reported in the same review showed that the prevalence of college student drinking appeared to be growing in recent years. Compared with data reported by Straus and Bacon in their classic 1953 study (showing that 80 percent of college men and 61 percent of women were drinkers), Saltz and Elandt (1986) indicate that the range of reports on the incidence of male college drinking was 81 to 98 percent, whereas that of female college drinking was 78 to 98 percent. As described by Marlatt (1988), the college-age drinker is unique in several respects. First, most college students who drink are engaged in an illegal activity to the extent that they are under the legal drinking age of 21. Their drinking behavior is often excessive and uncontrolled because many students are ~naive" and inexperienced drinkers. However, their legal status presents a problem for programs that attempt to teach responsible drinking behaviors for this age group. Opposition to "responsible drinking" as a goal for underage drinkers has been stated by several national groups, including the National Council on Alcoholism and the National Institute on Alcohol Abuse and Alcoholism. Second, college students have flexible class and work schedules and are under minimal supervision while on campus. Most of their drinking occurs in social or Party" situations, frequently associated with bouts of heavy drinking over relatively short periods (e.g., weekend evenings). As a result, their drinking is influenced primarily by peer behavior and attitudes toward drinking. Prevention programs geared toward influencing peer drinking norms would seem to be most appropriate in this regard. Third, although many college students drink very heavily, most do not qualify as ~alcoholics" in the traditional sense; they do not usually show sign of physical dependence on alcohol (e.g., withdrawal symptoms). As a result, most students reject the idea that their drinking behavior can be described as a "disease" and that abstinence is the preferred solution to
390 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS this problem. Therefore, they do not seek help from traditional intervention and treatment programs. These characteristics suggest that college-age problem drinkers may respond more positively to brief interventions that are geared toward a goal of moderate or safe drinking. Studies that have followed students longitudinally from college on to post-college life show that the vast majority "mature out" of their heavy drinking patterns as they become more involved in family and employment roles (e.g., Fillmore et al., 1979~. Programs designed to inculcate moderate or safe drinking practices for the college age drinker can be considered attempts to "speed ups this natural process of maturity and increased personal responsibility. The college campus which is concerned with drinking among its students becomes a natural community setting for testing the system of generalist and specialist treatment outlined in Chapter 13. Because few students see themselves as having a problem with alcohol, the main problem facing the administrators of alcohol prevention, intervention, and treatment programs targeted at the college-age population is one of motivating students to participate. Marlatt (1988) has described what may be the necessary characteristics of a college intervention program, identifying possible ways to enhance motivation and to carry out the brief intervention component of a comprehensive program by tying the intervention to ongoing campus primary prevention efforts: . Programs should be based on an educational approach rather than on a medical or disease model of alcoholism because students are more likely to attend a class or course on alcohol issues than they are to attend a "clinic for alcoholics. . . Programs should reach out to students who are children of alcoholic parents, have a special interest in the topic of alcohol education, and are at particular risk for developing problems. Educational and prevention programs should employ student-peer leaders and invite the participation of interested student groups and campus leadership. ~ College alcohol education programs should recognize that alcohol affects males and females in different ways and work with gender differences. Materials distributed by these programs should focus on the role of alcohol in social and sexual behavior, including risk behavior associated with sexual aggression and sexually transmitted diseases (especially AIDS). . Rather than adopting a moralistic approach, prevention and intervention programs for college drinkers should provide students with personalized feedback concerning their drinking behavior and associated health risks that contains non- judgmental normative information indicating the student's drinking level and the risks that go along with a particular level. ~ The "tone" of educational programs should be one of optimism and the opportunity to acquire self-mastery and self-management skills. Approaches that are primarily negative and attempt to increase fear of negative consequences (e.g., becoming an alcoholic in the future) are unlikely to motivate student participation. College students can be considered a unique high-risk special population for alcohol problems. They are, however, heterogeneous on the other key variables that have served to identify special populations (gender, race and ethnicitr, social class, living situation, personality type), and this heterogeneity must be considered in program planning
POPUIAIIONS DEFINED BY FUNCTIONAL CHARACTERISTICS 391 (White and Mee-Lee, 1988~. The majority of college students would probably be assessed as having only mild or moderate alcohol problems and would benefit the most from brief intervention efforts which use an educational model and a moderation approach. Indeed this population presents a unique opportunity for utilizing and evaluating-the brief intervention strategies described in Chapter 9 and the comprehensive system described in Chapter 13. A program based on these principles is now being tested at the University of Washington (Marlatt, 1988~. Other colleges and universities have already established primary prevention programs, and a few have established their own special population treatment programs (e.g., Rutgers). Such programs may take several forms, ranging from courses offered for academic credit to self-help materials and specialist led group therapy. There is an opportunity to introduce secondary prevention programs as well as treatment programs for students who show signs of substantial or severe alcohol problems. However, as a newly recognized special population, there have been few studies evaluating the effectiveness of either singular or comprehensive strategies. To avoid the problems that have occurred in defining treatment models for other special populations, recent concerns over college drinking should lead to rigorously evaluated demonstrations of alternative models before recommendations are made that all colleges invest in such efforts. Children of Alcoholics The special population group most recently singled out for attention is children of alcoholics (USDHHS, 1983, 1987; Children of Alcoholics Foundation, Inc., 1984; Waite and Ludwig, 1985~. Children of persons with alcohol problems are considered to be at increased risk of developing alcohol problems both because of possible genetic linkages and environmental influences. The major assumption underlying the identification of this group as a special population is that parental alcohol problems and family dysfunction create an environment that can lead to psychosocial problems for children and to abusive drinking at an early age, even in the absence of a genetically transmitted susceptibility (USDHHS, 1987~. Interest in providing prevention and intervention services to children of alcoholics has grown rapidly among people working in the field, and there are increasing numbers of articles on this subject in the popular literature. In addition, a strong and vital national advocacy movement has been created to lobby for increased services and research (Woodside, 1988; Blane, 1988~. The Children of Alcoholics Foundation and the National Association for Children of Alcoholics are prominent advocacy and educational organizations in the field. Differentiations are made among the needs of child, adolescent, and adult children of alcoholics (Blane, 1988~. The Children of Alcoholics Foundation estimates that there are 28.6 million children of alcoholics in the United States and that 22 million of them are adults (Woodside, 1988~. Self-help and group therapy approaches predominate at the adult level; for children and adolescents, two general approaches are the most used: school-based primary prevention and secondary prevention efforts and treatment-based interventions. School-based efforts are focused on identifying children of alcoholics and the interventions are targeted at them. Treatment-based interventions tend to be targeted at the family, with the youth participating in family therapy. Other treatment activities such as peer support groups are also used in both environments. The advocacy movement noted earlier has a strong self-help ethic and borrows many of its principles from Alcoholics Anonymous, Al-Anon, and Alateen. It includes a national network of author-lecturers who have written popular books aimed at children of alcoholics and who present their strategies for prevention or treatment at professional and popular workshops (Blane, 1988~. There has been an increasing demand for specialized
392 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS treatment for adult children of alcoholics, with the emphasis on group therapy. A variety of intervention and specialized treatment strategies and programs have been developed using clinical experience rather than research (Russell et al., 1985; Waite and Ludwig, 1985; Cermak, 1986; Brown, 1988~. The Children of Alcoholics Foundation recently identified 235 programs in 34 states that had been specifically designed to serve either young or adult children of alcoholics. The programs were small and relatively new-approximately three-fourths had been in operation less than four years (Woodside, 1988~. The concern for children of alcoholics is one aspect of the more general concern for the families of persons with alcohol problems. This concern arose from the conceptualization that "alcoholism is a family disease" and that the same principles of recovery apply to all members of the family. In the early years of development of treatment for alcohol problems, there was a movement toward requiring participation in formal treatment or self-help efforts, or both, by all family members as essential for recovery. This emphasis has led to an increase in the of treatment services offered to other family members, even when the person with the identified problem is not engaged in treatment. The justification for treatment for these groups is based predominantly on their risk of developing problems with alcohol themselves and the potential detrimental effects that may be incurred from their involvement with a person experiencing problems with alcohol. This new-and growing-treatment focus has been labeled codependency, the term now in frequent use for the psychological and adjustment problems of other members of the family of the person with alcohol problems. The concept of codependency seems to be fairly well established. Representatives of many of the states who attended the Joint Federal and State Agency Meeting on Alcohol and Drug Data Collection, conducted by the National Association of State Alcohol and Drug Abuse Directors in March 1989, indicated that agencies in their states were identifying codependent persons as primary clients and including them in their reports to federal and state agencies, including the SADAP and the NDATUS (see Chapter 7~. The recommendations from those meetings were to include codependency status as part of the national uniform minimal data set. In the private sector, the area is sufficiently established that there are specific codependency treatment programs and codependency units in alcohol programs (Cermak, 1984, 1986~. Yet, the treatment of children of alcoholics and other codependents is an area where definitions are unclear and research pertaining to etiology or outcome is lacking. Martin (1988) found a wide variety of conceptualizations in her review of the popular literature on codependency. Some writers in the field advocate an independent official diagnosis of codependency personality disorder be recognized (Cermak, 1986) as well as a biological model of the condition (Laign, 1989a). The main body of research on treatment outcome to this point comes predominantly from clinical practice and frequently consists of case study reports that focus on model building, personality profiles, or treatment strategies (Brown, 1988; Cermak, 1986; Wegscheider-Cruse, 1985~. There are only the very beginnings of a research-based literature. For example, Parker and Harford (1988) have analyzed national survey data on adult children of alcohol abusers, Cutter and Cutter (1987) have studied adult children of alcoholics in Al-Anon groups, and Ackerman (cited in Laign, 1989b) has recently conducted a survey of adult daughters of alcoholics. What many of these studies show is that the same methods used to treat the person with alcohol problems are being used to treat codependents. Yet the appropriateness of these methods has not been justified, nor has the differential (marginal) effectiveness of these specialty approaches been evaluated in a series of clinical trials. There have also been no studies that compare specialized programs for adult children of alcoholics with standard programs that incorporate specialized techniques as suggested by
POPULATIONS DEFINED BY FUNCTIONAL CHARACTERISTICS 393 Russell and coworkers (1985~. A number of the problems involved in developing a body of research (e.g., the lack of retrievable data sources) have been identified by Woodside (1988) and Roman (1988~. Because an ir~vesti~ion of codependen~ whether spouses or children of alcoholics was not specifically part of the committee's mandate, it has chosen not to make a specif c recommendation about this issue. However, the committee is concerned about the lack of Claris that such reporting practices create (jr' terms of who is being I and the effects on the access to treatment for persons with alcohol problems of the increasing numbers of codependents who are being seen as primary clients. Clarification arid improved defu~ifions are no before pony recommendations can be made. Summary and Conclusions The conclusions that emerge from a review of the literature on the treatment of special populations defined by functional characteristics are not substantially different from those reached by looking at groups defined by structural characteristics. Again, however, the committee cautions policymakers, program designers, and clinicians to be wary of defining a given person only in terms of his Or her special population group membership. Members of each of these functionally defined special populations also vary on other important dimensions that have implications for treatment outcome-including those structural characteristics discussed in the previous chapter. Despite the importance that has been attached to the defining characteristics of a special population in developing treatment strategies based on clinical experience and theories about the etiology and maintenance of alcohol problems within each population, there have been few studies that test the differential effectiveness of these approaches. The conclusion that there is an inexcusable lack of systematic research on the application of specific treatment approaches holds for those special populations defined by functional characteristics as well as for those defined by structural characteristics. Again, the recurrent interest in legislation, clinical practice, and program development for these populations is not followed by tests of the comparative effectiveness of the various approaches that have been advocated. Without such test polipymakers are at a loss for the empirically based guidance necessary in making needed refinement and improvements. REFERENCES Anderson, D. S., and A. F. Gadaleto. 1986. College alcohol surrey: 1985, 1982, and 1979. Alcohol Health and Research World 9:4647,71. Annis, H. M., and R. G. Sman. 1978. Arrests, readmissions, and treatment following release from detoxication centers. Journal of Studies on Alcohol 39: 1276-1283. Argeriou, M. 1979. Reaching problem drinking blacks: The unheralded potential of drinking driving programs. International Journal of Addictions 13:443459. Beerman, K A, M. M. Smith, and R. L. Hall. 1988. Predictors of recidivism in DUIIs. Journal of Studies on Alcohol 49:443449. Berkowitz, ~ D., and H. W. Perkins. 1986. Problem drinking among college students: A review of recent research. Journal of American College Health 35:21-28. Blane, H. T. 1988. Prevention issues with children of alcoholics. British Journal of Addiction 83:793-798. Blumberg, L., T. Shipley, and I. W. Shandler. 1973. Skid Row and Its Alternatives. Philadelphia: Temple University Press.
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