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.

Broadening the Base of Treatment for Alcohol Problems

Using outcome data on a continual basis to monitor treatment progress has been identified as a way to enhance psychotherapy outcome. The purpose of this study was to investigate the use of a continuous feedback assessment system, the Partners for Change Outcome Management System (PCOMS; Miller & Duncan, 2004). Findings from 2 client samples that attended individual therapy at a university counseling center (N = 74) or a graduate training clinic (N = 74) indicated that clients who used PCOMS with their therapists (feedback condition) demonstrated statistically significant treatment gains when compared to clients receiving treatment as usual (no-feedback condition). Clients using PCOMS were also more likely to experience reliable change and in fewer sessions. A survival analysis demonstrated that approximately 50% of the clients in the feedback condition demonstrated reliable change after the 7th (graduate training clinic) or 9th session (university counseling center). Further findings, limitations of the study and ideas for future research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Does a continuous feedback system improve psychotherapy outcome

Using outcome data to monitor the progress of treatment and the therapeutic alliance, also known as "client feedback" or "patient-focused research," has yielded impressive results in individual psychotherapy. Client feedback has demonstrated reductions in premature terminations and improved psychotherapy outcomes. However, little research has been conducted using this paradigm with couples receiving therapy. The purpose of this study was to investigate whether the effectiveness of client feedback would extend to couple therapy. Results from a randomized couple clinical trial conducted in a naturalistic setting indicated that couples in a client feedback condition demonstrated statistically significantly more improvement compared with couples receiving treatment as usual and that improvement occurred more rapidly. Also, 4 times as many couples in the feedback condition reported clinically significant change by the end of treatment.

Effect of client feedback on couple psychotherapy outcomes.

Despite ongoing efforts aimed to improve treatment engagement for people with substance-related disorders, evidence shows modest rates of utilization as well as client-perceived barriers to care. Patient-centered care (PCC) is one widely recognized approach that has been recommended as an evidence-based practice to improve the quality of substance use disorder treatment. PCC includes four core principles: a holistic and individualized focus to care, shared decision-making and enhanced therapeutic alliance. This scoping review aimed to explore which PCC principles have been described and how they have defined and measured among people with substance-related disorders. Following the iterative stages of the Arksey and O’Malley scoping review methodology, empirical (from Medline, Embase, PsycINFO, CINAHL and ISI Web of Science) and grey literature references were eligible if they focused on people accessing treatment for substance-related disorders and described PCC. Two reviewers independently screened the title/abstract and full-texts of references. Descriptive analyses and a directed content analysis were performed on extracted data. One-hundred and forty-nine references met inclusion from the 2951 de-duplicated references screened. Therapeutic alliance was the most frequent principle of PCC described by references (72%); this was consistently defined by characteristics of empathy and non-judgment. Shared decision-making was identified in 36% of references and was primarily defined by client and provider strategies of negotiation in the treatment planning process. Individualized care was described by 30% of references and included individualized assessment and treatment delivery efforts. Holistic care was identified in 23% of references; it included an integrated delivery of substance use, health and psychosocial services via comprehensive care settings or coordination. Substance use and treatment engagement outcomes were most frequently described, regardless of PCC principle. This review represents a necessary first step to explore how PCC has been defined and measured for people accessing substance use disorder treatment. The directed content analysis revealed population and context-specific evidence regarding the defining characteristics of PCC-principles that can be used to further support the implementation of PCC.

/pdf/conceptualizing-patient-centered-care-for-substance-use-5e50x6a95c.pdf

Conceptualizing patient-centered care for substance use disorder treatment: findings from a systematic scoping review

Problems stemming from the misuse and abuse of alcohol and other drugs are by no means a new phenomenon, although the face of the issues has changed in recent years. National trends indicate substantial increases in the abuse of prescription medications. These increases are particularly prominent within the military, a population that also continues to experience long-standing issues with alcohol abuse. The problem of substance abuse within the military has come under new scrutiny in the context of the two concurrent wars in which the United States has been engaged during the past decade--in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom and Operation New Dawn). Increasing rates of alcohol and other drug misuse adversely affect military readiness, family readiness, and safety, thereby posing a significant public health problem for the Department of Defense (DoD).To better understand this problem, DoD requested that the Institute of Medicine (IOM) assess the adequacy of current protocols in place across DoD and the different branches of the military pertaining to the prevention, screening, diagnosis, and treatment of substance use disorders (SUDs). Substance Use Disorders in the U.S. Armed Forces reviews the IOM's task of assessing access to SUD care for service members, members of the National Guard and Reserves, and military dependents, as well as the education and credentialing of SUD care providers, and offers specific recommendations to DoD on where and how improvements in these areas could be made.

Substance Use Disorders in the U.S. Armed Forces

A client-directed, outcome-informed approach is presented that documents how this way of thinking about, and working with, problem drinkers facilitates better client engagement and improves treatment outcomes. As is true of the field of therapy, the history of drug and alcohol treatment has been marked by contention and debate. Popular assumptions and models since proven to be flawed include: the 'disease' model; that the problem ran in families; the need for expensive hospital-based detoxification; and that people can recover, but can never be cured. The authors highlight the movement of the field away from diagnosis and program-driven treatment towards 'individualised assessment-driven treatment'. Research has made clear that, regardless of type or intensity of approach, client engagement is the single best predictor of outcome. A format, designed by the American Society of Addiction Medicine, for an individualised service plan based on multidimensional assessment criteria is presented, in addition to a detailed discussion of how to implement an outcome-informed, client- directed method of feedback within a treatment service. (editor abstract)

D Mee-Lee

Papers

Making Treatment Count: Client-Directed, Outcome-Informed Clinical Work with Problem Drinkers.