Intensive Outpatient Treatment for Alcohol and Other Drug Abuse Treatment Improvement Protocol (TIP) Series 8
Chapter 5 -- The Treatment Needs Of Special Groups
Several groups of patients receiving treatment for alcohol and other drug
(AOD) use disorders may have distinctive treatment needs. These groups are
numerous and include:
Women -- particularly pregnant women and women with children
People from minority ethnic and cultural groups
People with combined psychiatric and AOD disorders
People who are homeless or who experience housing instability
People with HIV infection or AIDS
Gay men and lesbians
Elderly people
People involved with the criminal justice system.
While patients from a specific group may have several treatment needs in
common with other members of that group, each patient should be considered and
treated as an individual with a distinctive set of treatment needs. Thus, the
development of individualized treatment plans should include the consideration
of issues that are associated with special group status.
Because treatment resources are limited, patients with special needs usually
are integrated into generic intensive outpatient treatment (IOT) programs. The
following common or overriding themes emerge regarding the treatment of special
groups, both at a clinical and at an administrative level:
At a clinical level, client-counselor matching can be important.
Although not consistently or empirically demonstrated, matching should be made
along sociocultural lines whenever clinically appropriate and possible.
Educational and support groups and other programming designed to address
special needs should be developed. This may include a single, specialized,
weekly group during the standard program, a specialized treatment track with a
series of coordinated services, or a separate dedicated program that serves only
the target group.
The program mission and philosophy must reflect an openness and support for
the diversity represented in special groups. Ideally, the mission statement
should be developed with input from representatives of the special groups.
Program staff training should be designed to develop staff competency in
recognizing, supporting, and addressing the needs of special patient groups.
Community involvement in program goal development, networking, and patient
entry and retention are critical to the overall effectiveness of IOT.
Family members, patients' partners, and other significant others should be
actively involved in treatment. Program staff should be sensitive to cultural,
ethnic, and regional variations in family structures and the way that patients
define their family.
These broad issues will be further addressed within the following sections
on each special group. It will become apparent throughout this chapter that IOT
programs may be especially suited to the treatment of some special population
members because of the range and severity of treatment needs that can be met in
the IOT programs, as well as the availability of internal and external supports
in many regions of the country.
Whether these treatment needs can best be addressed within generic programs
that have services for specific groups or within programs that serve only the
specific groups is a complex issue. A variety of factors influence decisions
regarding the best placement.
Practically, these decisions may have to be based on the financial realities
of the program and the volume of patients available to participate in a
specialized program. Clinically, such decisions may be influenced by the
perceived severity and uniqueness of the treatment needs of the target group.
Similarly, these decisions may be influenced by the extent to which special
groups can benefit from specialized care and to what extent such services can be
offered without detracting from the services provided to other patients.
When the decision is based on the goals of recognition, appreciation, and
promotion of the diversity represented by the target group, such programming may
prove highly effective for patients and their respective communities.
The special groups identified in this chapter do not constitute an
all-inclusive listing of groups with special treatment needs. Rather, this TIP
addresses the needs of special groups that are most likely to be served by IOT
programs. Readers who want information that will more intensively address the
treatment needs of these and other special groups are recommended to review the
bibliography in the appendix of this TIP, as well as
the TIPs on Treatment of Alcohol- and Other Drug-Abusing Adolescents;
Pregnant, Substance-Using Women; and Improving Treatment for Drug-Exposed
Infants.
A Note About the Family
IOT program staff and program mission statements should understand and
embrace definitions of the family as described by patients. While one
definition of the family is a group of people who are related by birth and
marriage, there are many other definitions that are broader in scope and
influenced by ethnic, cultural, and regional factors.
For these reasons, IOT program staff and program philosophy should
acknowledge and accept patients' perspectives regarding what constitutes a
family. In a general way, the family can be understood as a primary group whose
members assume certain obligations for each other and often share common
residences.
For instance, the National Association of Social Workers Commission on
Families defines the family as two or more people who consider themselves family
and who assume obligations, functions, and responsibilities generally essential
to healthy family life. The functions of family life include such functions as
child care, child socialization, income support, long-term care, and other types
of caregiving.
Thus, it is important for IOT programs to be flexible when addressing family
issues. Some definitions of families are: 1) a mother and her child; 2) a
wife, husband, and children; 3) a woman, her children, and ex-husband; 4) a
large extended group that includes relatives and close friends; 5) same-sex
couples; 6) an individual with a domestic partner; and 7) a woman and her
significant other; and 8) relationships such as grandparent and grandchild.
Women
Women often require specialized or enhanced medical, psychosocial, family,
peer support, and other services. These services are often unavailable or
partially available in traditional AOD programs in which women typically
represent a minority of the patient population. This has led to the increasing
development of specialized women's services within mixed-gender settings and the
development of separate women's programs. Although not addressed in this TIP,
consideration should be given to the development of men's groups.
Because of the extended clinical contact that IOT programs can provide --
compared with traditional outpatient programs -- they offer an opportunity to
address a variety of women's needs. Ideally, IOT programs should be able to
offer a full, self-contained women's program. At a minimum, women-only groups
should be offered within the mixed-gender setting. Also, IOT program providers
should be sensitive to gender matching in making counselor assignments.
At the same time, IOT staff should recognize that women are not a
homogeneous group. Female patients have a variety of different treatment and
psychosocial needs, influenced strongly by their backgrounds, experiences, and
AOD problems. For instance, single career-oriented women without children may
feel that their needs are more similar to career-oriented men and women than to
single mothers -- who may perceive that child care, transportation, and help
with parenting are their most pressing needs. Although all women will have
gender-related concerns, the assessment process should identify which women or
men may benefit most from mixed-gender treatment or separate women-oriented
treatment. It should not be assumed that the needs of women and children are
the same, although they are frequently linked together by policymakers.
Enrollment Issues
The social stigma associated with AOD abuse inhibits women, more than men,
from seeking addiction treatment (Weisner and Schmidt, 1992).
Also, women are more likely than men to define addiction-related problems in
terms of health and mental health, while men are more likely than women to
describe their addiction-related problems as explicitly AOD-related (Thom, 1986). Thus, women are more likely than men to seek treatment for
the health or behavioral components of AOD use rather than specialized AOD abuse
treatment. This may lead women to obtain treatment later in the course of their
illness, perhaps at a point when their problems are more severe than those of
many men who obtain care (Beckman and Amaro, 1986; Blume, 1986; Furst et al., 1981; Horn
and Wanberg, 1970).
Although studies of the general population typically report higher rates of
AOD abuse problems among men than among women, some recent longitudinal studies
suggest that gender differences related to alcohol consumption are beginning to
converge, with disproportionately high rates of problem drinking in younger
cohorts of women. Despite this, male-to-female ratios in alcoholism treatment
programs have remained fairly consistent at 4 to 1.
Similarly, research suggests that women may be underrepresented in
traditional outpatient and inpatient treatment settings relative to the extent
of AOD problems in the general population (Institute of
Medicine, 1990). This problem may be even more acute for minority women
than for other women. This underrepresentation has been attributed to a number
of treatment-entry barriers that may be distinctive to women, including
financial limitations, inaccessibility of child care, and lack of services
tailored to their specific needs (Beckman and Amaro, 1986;
Blume, 1986; Institute of Medicine, 1990;
Reed, 1987; Roman, 1988).
If AOD providers are to be successful in attracting and retaining women in
treatment, these barriers must be reduced or eliminated. IOT treatment settings
may offer special advantages with regard to flexibility of programming, minimal
disruption to other life commitments, and a reduced experience of stigma.
Advocacy
There is a particular need for strong advocacy in developing IOT programs
for women. Women often experience increased social stigmatization as a result
of their AOD use. Such stigmatization may discourage a woman from identifying
herself as an AOD abuser, and may prevent others within the medical, social
services, and religious communities from identifying the problem. IOT programs
should develop targeted outreach campaigns to improve program recognition,
highlight the variety of services available within the setting, and encourage
referral of women.
Child Care
For some women, the threat or perceived threat of losing custody of their
children is a deterrent to residential treatment participation. IOT offers the
advantage of intensive treatment without removing a mother from her home. Thus,
the availability of child care services can be critical to the ability of women
to enter and remain consistently active in treatment. Women with children are
much more likely to participate in IOT if they know their children are well
cared for and safe. For example, a single mother who does not have an extended
family or other means of child care might not be able to sustain her IOT
involvement without child care.
At a minimum, linkages with local day care programs for child care should be
considered. In the ideal IOT program, services are provided on site. The
full-day schedule in some IOT programs may make the development of an onsite day
care program feasible and cost-effective. However, the inability to provide
child care should not be a deterrent to offering IOT to women, since
opportunities may develop to add such services through grant funding or budget
expansion. Programs can solicit the help of community volunteer organizations
for help with child care. In these instances, special care should be exercised
to protect the provider's liability and to ensure compliance with Federal
confidentiality regulations.
Flexible Programming
Optimally, IOT programs for women should offer both daytime and evening
treatment. While many women prefer daytime treatment because of the greater
ease of meeting child care needs, the availability of evening services may make
it possible for working women to take part in IOT. Family members and patients'
partners may be available in some cases during evening hours, and their
cooperation with the program should be considered in organizing child care
arrangements.
Safe Houses or Transitional Living Arrangements
Women sometimes experience homelessness or housing instability as a result
of AOD-related and non-AOD-related issues. For example, there is evidence that
AOD-abusing women are more often abandoned by their spouses or partners than are
AOD-abusing men. Some women become homeless because they have limited
employment skills and/or may be unable to work because of child care
responsibilities. Also, because of the high incidence of physical and sexual
abuse among AOD-abusing women, they may find themselves seeking alternative safe
shelter away from their spouse or partner. Thus, the ability of an IOT program
to offer services that relate to meeting their housing needs can help a program
attract and retain women in AOD treatment.
This task is at times made more difficult by the reluctance of women's
housing programs to accept women who are AOD abusers. As a result, specialized
transitional living facilities are sometimes needed for this group.
IOT programs that can align themselves with safe houses or other
transitional living arrangements offer an important group of services that are
often needed by AOD-abusing women. Ideally, such housing programs allow
children to continue to reside with their mothers. Onsite staff can offer
limited evening and weekend programming, while also ensuring the safety and
drug-free integrity of the housing facility. Ideally, services should be
available over several months to allow the woman's recovery and social problems
to stabilize.
Transportation
Lack of transportation to treatment may be a barrier to participation in IOT
programs. IOT programs should be sensitive to this issue, and should carefully
consider the location of the program in relation to public transportation.
Optimally, programs should provide assistance such as bus passes, tokens, and
stipends to cover travel expenses, provide direct transportation, or help
organize car pools.
Meals
Programs should also consider providing meals. This may serve several
functions, including attracting women AOD abusers into care, ensuring that their
nutritional needs are met, and introducing patients to meal preparation skills.
It can also provide an opportunity for social support, healthy bonding, and
drug-free companionship.
Medical Care
In general, the medical needs of women AOD abusers are undermet. Often,
AOD-abusing women experience more severe and more varied medical problems that
AOD-abusing men. For example, following the onset of heavy drinking, women are
known to develop alcohol-related liver disease more rapidly than men. Women
also experience a variety of other general medical problems including
infections, anemia, sexually transmitted diseases (especially gonorrhea,
trichomonas, syphilis, and chlamydia), hepatitis, and urinary tract infections.
Also, AOD-abusing women often report gynecological problems including amenorrhea
(the temporary absence of menstrual flow) and decreased fertility, which require
special attention.
It is critical that the distinctive and varied medical needs of women be
addressed in IOT. At present, these needs are often met through piecemeal
relationships between IOT programs and other aspects of the health care system,
rather than through integration of medical services into the IOT programs
themselves. One way to formalize health care services is through contracting
and by having explicit referral protocols.
It is vital that IOT programs establish strong, active, and formal linkages
with local and accessible health care services. At a minimum, these services
must include basic health care, STD treatment, and immunization of children.
For example, a cooperative agreement can be developed with a local community
health center. Such an agreement can specify arrangements to promote prompt
service delivery and continuity of care. If there is sufficient referral
volume, appointment slots can be reserved for program patients, and a
relationship can be developed with a single or small number of health care
providers. Also, such an agreement should stipulate that written documentation
of provided services, medications, and followup recommendations be provided to
IOT program staff with appropriate patient consent. This will ensure the
integration of medical needs into the treatment planning process and allow
program staff to facilitate the patient's compliance with ongoing care. Such a
connection with health care services can enhance patient retention in both IOT
and health care services.
Optimally, IOT programs should have onsite medical care. Services should
include those of a family practitioner or internist to address general health
needs and an obstetrician/gynecologist to address the more specialized
reproductive health needs of women. Also, for programs that provide onsite day
care, referral for medical, psychological, and developmental assessments of
infants and children should be available. Onsite day care programs often have
licensure requirements regarding referrals for assessments.
Psychiatric Care
Certain psychiatric disorders are more prevalent among female AOD abusers
than among male AOD abusers, or females in the general population. For example,
while rates of depressive disorders for male alcoholics are comparable to the
rates for males in the general population, female alcoholics are more likely to
have a diagnosis of depression than either women in the general population or
male alcoholics. Female alcoholics have also been found to have elevated rates
of abuse of other drugs and phobic and panic disorders. It has also been
observed that women experience a slower recovery from depression than men
following the cessation of AOD use.
Women patients with dual disorders may benefit from a variety of treatment
services including pharmacotherapy, psychotherapy, and close monitoring.
Ideally, a licensed mental health clinician such as a social worker, psychiatric
nurse, or a psychiatrist should be included on the IOT treatment team to fully
integrate patient care. However, it is not always possible for IOT programs to
provide such treatment services on site, and certain crises require aggressive
psychiatric intervention. Thus, IOT programs should establish close working
relationships with community mental health programs and other psychiatric
services. The access to and availability of a psychiatrist is essential for
consultation and medication evaluation and monitoring. Treatment services for
patients with dual disorders are further discussed later in this chapter.
Indeed, treatment issues relating to patients with dual disorders are discussed
in great detail in another CSAT Treatment Improvement Protocol, Assessment
and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other
Drug Abuse.
Abuse Issues
Women AOD abusers report higher rates of physical and sexual abuse than the
general population (Blume, 1986). Abuse should be
assessed across a wide spectrum: sexual, physical, and emotional abuse. For
example, evidence suggests that alcoholic women are more likely than
nonalcoholic women to have been sexually abused in childhood.
Managing issues of sexual abuse in IOT programs can be challenging. Because
of the special treatment needs of people who have been abused, it is often best
to contract with a specialized consultant to provide these treatment services.
If such an ongoing relationship is not financially possible, one or more staff
members should receive intensive specialized training in this area. IOT program
administrators should be careful in describing program services offered to
female abuse survivors. For example, some IOT programs may feel it is
preferable to describe an abuse treatment component as a "domestic violence
group" or "surviving abuse group," rather than a "sexual assault group" to avoid
labeling women as victims.
When providing treatment services for women who have been abused, it is
important that IOT programs create an atmosphere in which women feel comfortable
and will join and regularly participate in treatment services. It is also
important to consider the timing of these services to enhance the therapeutic
value and to diminish iatrogenic or clinician-induced problems. For example,
women should not be rushed into divulging a history of abuse or receive
treatment for abuse problems early in the AOD treatment process. Rather,
clinicians should first establish that patients are comfortable with the idea of
getting help for abuse issues and are ready to benefit from it, before they
receive treatment services for abuse.
Service providers should be sensitive to the fact that some women who have
been abused may be uncomfortable interacting with male staff members as a result
of earlier painful relationships. Finally, it may be worthwhile to reevaluate
other female patients for physical and sexual abuse history following AOD
treatment stabilization, since disclosure of such personal issues is sometimes
withheld until the patient is more comfortable in treatment.
Emotional Issues
Treatment needs of women with AOD problems are different from those of men
with respect to several emotional issues (Unterberger, 1989).
For example, AOD-abusing women are more likely to experience low self-esteem
than their male counterparts. AOD-abusing women with low self-esteem may
experience episodes of depression and self-derogation that, for some, may lead
to a feeling of purposelessness in life. More often than men, women AOD abusers
direct their anger at themselves rather than at others, prompting anxiety and
guilt.
It is important that IOT programs include women-only therapy groups that
specifically address the relationships between emotional issues (such as
self-esteem, shame, anger, and guilt) and AOD abuse and recovery. Programs can
provide communication skills education, empowerment sessions, and assertiveness
training. Expressive and nonverbal techniques, including art therapy, dance
therapy, and other creative therapies may be useful in the development of
self-esteem and the appropriate expression of emotions.
Family Issues
Family involvement should be an integral component of IOT for women.
Typically, family members have a poor understanding of the dynamics of addiction
and can become barriers to successful addiction treatment and recovery.
Many family members are weary of the addicted family member's AOD problems,
are frustrated because of past unsuccessful attempts to resolve the problems,
and may feel reluctant to participate in treatment due to lack of optimism about
the chance for success. Family members often need to learn that addiction is a
treatable disorder and that treatment can work. They also need to learn that
treatment is more likely to be successful if the entire family participates in
and supports the addicted family member's treatment and recovery efforts.
Family members should also learn that they may have significant problems
(such as anger, shame, guilt, resentment, or codependency) that relate to the
addicted family member's AOD problems. They should be encouraged to identify
and receive formal help for these problems. Family members should also learn
that: 1) the resolution of the addicted family member's AOD problems does not
ensure resolution of other family members' problems; and 2) family members can
receive treatment for their problems whether or not the addicted family member's
AOD problems are resolved.
The identification and engagement of appropriate family members and close
friends who are still involved with the patient are often critical for
successful treatment of the woman and her family.
Active addiction often prompts poor and inconsistent parenting, which in
turn promotes discord, miscommunication, and family dysfunction. Thus,
addressing parenting skills during AOD treatment can be a therapeutic strategy
that helps encourage family harmony, good communication, and the promotion of
health. Such programming may include identification of age-appropriate behavior
and developmental milestones in children, nutrition education, and appropriate
forms of discipline for children. One particularly important parenting skill is
effective communication with children regarding the parent's addiction and
recovery.
Self-Help and Peer Support Groups
Self-Help
Self-help groups, including mixed-gender and women-only 12-step groups, are
important components of IOT. In some localities, certain Alcoholics Anonymous,
Narcotics Anonymous, and Cocaine Anonymous group meetings are targeted to women
only. In larger cities, there are one or more Alcoholics Anonymous and
Narcotics Anonymous meetings for women every day or evening. However,
women-only meetings may not be available in some areas, and IOT programs can
fill the gap by sponsoring women-only 12-step meetings on site.
Where available, and depending upon the patient population, some IOT
programs may also want to recommend Methadone Anonymous for women. It is easier
to get Methadone Anonymous groups started in IOT programs when there are large
numbers of women enrolled in methadone programs. Such institutional meetings --
public 12-step program group meetings held on the premises of a treatment
program -- can be initiated by having alumni or other recovering individuals
contact the appropriate 12-step group and create a new meeting. The new meeting
will subsequently be listed in the local directory of meetings.
Another resource that is available in many areas of the country is Women for
Sobriety. This self-help organization has adopted a set of principles that
specifically address women's recovery needs through a monthly newsletter,
information and referrals, phone support, group meetings, pen pals, conferences,
and group development guidelines. Women for Sobriety addresses sobriety and the
need to overcome depression and guilt.
Rational Recovery is a self-help program that uses a cognitive and
behavioral approach to achieve recovery from AOD abuse and addictive behavior.
These groups teach and utilize the techniques of rational-emotive therapy.
Although there are very few women-only Rational Recovery groups, AOD-abusing
women may benefit from the emphasis on group process and self-reliance. While
the groups are considered self-help, they include the participation of an
advisor or a coordinator. An advisor is a licensed therapist who is aware of
community resources and is skilled in crisis intervention. While advisors do
not assume counseling or therapeutic roles within Rational Recovery group
meetings, they help demonstrate such techniques such as rational-emotive therapy
strategies.
In general, women should be encouraged to learn about and utilize the
variety of women-only 12-step meetings, mixed-gender 12-step meetings, and
alternative self-help models to establish a long-term program of recovery that
best fits their needs. These groups will grow commensurately with the growth in
women's programming initiatives. As with other treatment components, the
individual patient's needs should be considered in making the recommendation for
participation in women-only versus mixed-gender self-help groups. Given that
self-help meetings can be organized around a variety of special treatment
characteristics (gender, dual-diagnosis status, sexual orientation, and career
orientation), participation can be tailored to best meet individual patient's
concerns.
Other Peer-Support Programs
Compared with drug-free partners or peers, women with AOD disorders, perhaps
especially those with children, often have fewer opportunities for healthy
social support and may lack support from family or significant others. Thus,
peer support program opportunities should be an integral part of IOT programs.
An IOT program can provide the opportunity for an informal peer support
network within the context of a structured setting. For example, IOT programs
can organize or support women patients and/or alumni to organize a wide range of
social activities. These activities may include didactic presentations by local
experts on such topics as single parenting, nutrition, and recovery. Activities
may be educational and recreational, such as field trips to museums,
planetariums, and art galleries, or they may be exclusively recreational, such
as excursions to go bowling, dancing, and swimming. Activities may be practical
in nature, such as regular trips to the supermarket and other stores.
Ideally, such activities will provide an opportunity for women in early
recovery to meet and mingle with women who are in a later stage of recovery
(such as recovering alumni). In this way, female patients can learn from and
model the behaviors of other women in recovery and become exposed to women in
long-term recovery. Also, by creating or sponsoring a substantial pool of
recovering alumni, it becomes easy for recovering women to establish close
relationships with drug-free friends.
Living Skills
Ideally, IOT programs should provide training in basic living skills when
the targeted treatment group is deficient in these areas. Training should
include such topics as nutrition, child care, literacy, GED instruction,
vocational training, and other topics that have a self-help orientation. Such
training can help establish knowledge and skills that are critical for the
long-term maintenance of recovery gains. The "clubhouse" model -- in which
women work together and teach one another -- can be utilized for this training.
Such models are widely used in psychiatric day treatment programs and utilize
the skills and experiences of patients to teach and model behaviors for newer
program participants.
Addiction During Pregnancy
Pregnant women should not be denied AOD treatment or have treatment
postponed because of pregnancy. In fact, since the health and well-being of
both the mother and the fetus are at stake, efforts should be made to give
pregnant women priority access to AOD treatment services.
Indeed, such priority status is now a requirement for all programs receiving
Substance Abuse Block Grant funds from the Center for Substance Abuse Treatment.
Programs serving an injecting drug use population must give preferential
treatment in the following order: 1) pregnant injecting drug users; 2) pregnant
substance abusers; 3) injecting drug users; and 4) all others. These are
contained in the Interim Final Rules, Substance Abuse Prevention and
Treatment Block Grants, Department of Health and Human Services, 45 CFR Part
96.
The rules state that if a program receiving funds from the block grant does
not have the capacity to provide treatment services to a pregnant woman who
requests treatment, she must be referred to the State AOD agency, which
administers the block grant, which is required to refer the woman to a treatment
program that can admit her no later than 48 hours after seeking treatment.
A full range of support services may be needed by pregnant women with AOD
disorders. In particular, this group may have an even greater need for medical
and child care services, compared with other treatment patients.
AOD treatment must be modified in several areas to best serve pregnant
women. For example, some medications that are commonly used in outpatient
settings are contraindicated for pregnant women. If pharmacotherapy is to be
used, the IOT provider must identify which medications can be safely
administered during pregnancy. For example, commonly used pharmacological
blocking agents such as disulfiram and naltrexone should not be used during
pregnancy.
IOT providers should also consider that some pregnant AOD abusers may not be
well suited for initial management in the IOT level of care but may require
initial stabilization within a medical or residential setting. This high-risk
group can be difficult to manage exclusively in IOT settings, especially during
early stages of AOD treatment.
Some pregnant AOD-abusing women may not be able or may not choose to stop
using AODs while in IOT programs. For other women, being pregnant increases
their motivation to become or remain drug-free. Indeed, some women report that
they are able to diminish or discontinue their drug use only during pregnancy or
as a result of having children. In these instances, efforts should be made to
engage them in treatment, to assist them in receiving an appropriate level of
care, and to support their involvement with other prenatal support resources.
Pregnancy is a valuable opportunity for interventions related to AOD abuse and
other medical problems and prevention efforts. Many models of treatment have
been established that demonstrate the importance and value of linkages between
AOD treatment professionals and other health care providers and specialists.
Once they achieve the goal of delivering a drug-free baby, women who were
motivated to stop AOD use because of their pregnancy are susceptible to relapse
within the 6-week postpartum period. Postpartum mothers working with social and
child protective services to maintain or regain custody of their children may be
amenable to IOT. Overall, the complex issues of pregnant AOD-using women are
new to IOT treatment programs.
Minority Ethnic and Cultural Groups
IOT program staff should strive to increase their awareness and sensitivity
to the diverse cultures represented in their treatment population and community
at large. The attractiveness of IOT programs can be improved through staffing
patterns that reflect the cultural diversity of the population being treated.
This, along with enhanced program designs that are sensitive to the subtle
cultural nuances among different groups, will go a long way to remove barriers
to treatment. Enhanced program designs should include cultural competency in
content, the delivery of services, and philosophy. In order for a cultural
competency goal and/or approach to be successful, it must be supported on all
program levels, from administrative to clinical. Meeting program goals that
relate to cultural competency may require changes in program mission and
philosophy as well as staff enhancement.
Enrollment Issues
Advocacy
IOT programs should support a general openness to differences in background
among patients and staff. Further, this receptivity to differences should be
openly and actively communicated to both potential patients and referral sources
in the surrounding community. Outreach efforts should reflect the cultural
competence of the program. IOT programs that target specific ethnic and
cultural groups should actively promote and encourage community involvement. An
example of neighborhood community involvement is the establishment of advisory
boards. IOT programs should utilize community resources and community
networking, including churches, families, and employers.
Patient Assessment
IOT program staff should be sensitive to issues of cultural bias with regard
to assessment proceduresCwhere both standardized instruments and program-based
tools are used. To ensure appropriate test interpretation, instruments should
be selected for which norms are available for the ethnic or cultural groups that
are being treated.
Program Location
Whenever possible, IOT programs should be located in the community that they
are intended to serve.
Treatment Issues
Staffing
Programs should aggressively recruit staff who share a similar background
with the patients being treated. Some IOT programs target specific ethnic and
cultural groups and are successful in hiring clinical staff with the same
background. However, in areas where these ethnic and cultural groups constitute
a small percentage of the population, hiring qualified counselors from the same
backgrounds may be difficult. Therefore, IOT programs should establish and
maintain referral and consultation linkages with mental health and medical
professionals from the relevant ethnic and cultural groups.
When available, it is sometimes preferable to match clients and counselors
on the basis of shared background characteristics. However, other factors such
as gender, comorbid psychiatric disorders, and sexual orientation may also
influence the counselor assignment. While staff retain the final decision
regarding counselor assignment, client preferences should be considered in
making this match. Clearly, matching clients to the clinician who is most
competent to meet their needs is always the primary consideration.
Regardless of client-counselor matching availability, all IOT staff -- and
particularly counselors -- should receive specialized multicultural training in
order to be more responsive to the needs of patients from minority cultural and
ethnic backgrounds.
Programming
To the extent that it is economically and practically feasible, IOT programs
should provide groups on specific ethnic and cultural identity issues so that
these treatment issues can be addressed competently within a particular cultural
group. As with women's specific programming, such tracks may include a weekly
issues group, a regular coordinated group series, or a separate facility geared
specifically to address the treatment needs of a particular ethnic or cultural
group. Irrespective of the ethnic and cultural issues being addressed, the
overall focus should be on recovery and sobriety.
A program may be best able to consistently incorporate the norms and values
derived from the group's ethnic and cultural heritage into program content.
Similarly, the special language needs of different groups may be best met
through specialized programming. The availability of bilingual counselors must
be assured when treating patients who speak another language. The treatment
programs that have been developed in recent years for Native Americans represent
an outstanding example of the enhanced effectiveness that culturally competent
programs can achieve.
In some larger urban areas, AOD abusers have the option of choosing
culturally specific IOT programs. At a minimum, IOT programs can hold weekly
groups of special interest, which patients can elect to attend. In conducting
such groups, it is important to keep the content focused on the recovery issues
of the clients and to maintain a problem-solving orientation.
However, such groups can extend beyond problem solving and support to a
therapy orientation. This can be achieved by guiding the patient through the
therapy process starting with the issues the patient deems to be of most
immediate and primary importance to AOD recovery, and later broadening the scope
to include more group and community-oriented issues.
Whatever form treatment takes, it is essential that culturally competent IOT
services incorporate the concept of equal and nondiscriminatory services and
include the concept of culturally responsive services matched to the patient
group.
Treatment Planning and Goal Setting
Treatment planning and goal setting should be sensitive to the individual
patient's recovery goals in establishing expectations, planning content, and
incorporating values.
Family
As discussed more fully above in the overview of this chapter, IOT programs
should adopt a flexible definition of family, and accept the family system as it
is defined by the patient and influenced by ethnic, cultural, and regional
factors.
Other Modalities
Expressive, creative, and nonverbal interventions characteristic of a
specific cultural group can prove to be helpful in treatment. For example, in
one predominantly African-American AOD program, a choir has been developed;
members have chosen to emphasize traditional spiritual music.
Spiritual issues are often central to clients from some cultural groups.
They should be recognized and perhaps incorporated into programs. In programs
for Native Americans, for example, the integration of spiritual norms, customs,
and rituals enhance the relevance and acceptability of services.
Program Administration
Program Policy
Program policy should explicitly endorse and respect the cultural diversity
of program patients, staff, and the community. This should be reflected in the
development and enhancement of the program philosophy and mission statement, in
program outreach activities, in staffing, and in the tailoring of patient
services.
Program Assessment
Mechanisms should exist for programs to initiate ongoing self-assessments
regarding services for minority ethnic and cultural groups. The purpose of
self-assessments is to establish program goals and objectives in a manner that
reflects the cultural competency and concerns of the IOT program. One
particularly effective method of program assessment is to survey patients at the
time of discharge. Surveys of community members may help clarify the
accessibility and sensitivity of the program. For example, programs with
governing or advisory boards should recruit representative members that reflect
the cultural diversity of the community and who will have a role in the program
assessment process.
Patients who have a psychiatric and an AOD disorder can be described as
having dual disorders. A higher prevalence of psychiatric disorders is evident
among people with AOD disorders compared with the general population. People
with combined psychiatric and AOD disorders have special treatment needs,
requiring adjustments in treatment programming to adequately treat them. An
extensive discussion of the special treatment needs of patients with dual
disorders is available in a companion CSAT TIP -- Assessment and Treatment
of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse.
Treatment Systems
Patients whose psychiatric disorders are not severe can be treated
effectively in an IOT program as long as they receive additional treatment
services and medication for their psychiatric disorder as required. Since the
treatment needs of people with dual disorders are often complex and require an
intense level of services, a more intensive treatment placement should be
considered. Specialized psychiatric treatment can be provided in IOT programs
by staff or consulting psychiatrists, psychologists, and other qualified
clinicians.
As an alternative, IOT programs can establish an active relationship with
existing providers of mental health services. When so established, there should
be close coordination and strong linkages between the two (or more) programs and
providers. These linkages can be fostered through the efforts of a case manager
or a multidisciplinary team process involving staff from both programs.
If the single integrated program design is utilized, specialized group
sessions for patients with dual disorders are often useful to help them accept
the idea that while their recovery may not be as rapid and smooth as that of
uncomplicated patients, it is still possible. These patients can be taught
about the expected course of their progress in treatment and recovery and can
learn how to identify problems before they become clinically significant. Also,
education regarding medication maintenance may be particularly helpful.
Patients must be strongly cautioned about the dangers of using AODs in
combination with their prescribed psychotropic medication, and the need to
continue pharmacotherapy during their recovery. Patient education groups that
provide education about the purpose and function of psychotropic medication can
help clarify common misunderstandings about the use of medications by recovering
patients, increase medication compliance, and help patients participate more
actively in their treatment. Such groups can help prepare a patient to educate
recovering peers about his or her need for prescribed medication.
Patients With Nonchronic Symptoms
One practical way to classify AOD patients that have psychiatric symptoms is
with regard to changes in their symptoms following cessation of AOD use. Among
most AOD patients who experience psychiatric symptoms, when the symptoms are AOD
related, the symptoms diminish and fade following AOD cessation. However, for a
subset of patients, psychiatric symptom intensity remains stable or increases.
It is this subset of patients who are described as having dual disorders and who
require additional treatment for their psychiatric disorders.
Spontaneous Resolution
Symptoms of depression and anxiety will diminish or cease following
cessation of AOD use for some patients, and after the resolution of withdrawal
symptoms for others. For such patients, the use of psychotropic medication is
unnecessary beyond the medical management of withdrawal. These patients can be
successfully mainstreamed into the IOT program.
Persistent Symptoms
Coexisting mood and anxiety disorders are the most common reasons for the
persistence of psychiatric symptoms. These symptoms usually respond to
medication, psychotherapy, and other treatments such as biofeedback and aerobic
exercise. Antidepressant medication can be used by AOD patients in the same
manner as it is used by nonaddicted patients. However, benzodiazepines should
be avoided because of their abuse and addiction potential among people with a
history of AOD problems.
If a mood disorder persists and remains untreated, the patient has an
elevated risk of relapsing or dropping out of the AOD treatment program.
Clinicians disagree somewhat about the optimal length of time to wait before
prescribing medication for a mood disorder; the range is generally from 2 to 8
weeks after cessation of AOD use. However, it is particularly important to
determine early in treatment if depressive symptoms predated the AOD disorder or
if the depressive symptoms persisted during previous periods of abstinence. If
either of these is true, IOT staff may want to initiate early pharmacologic
intervention for current depressive symptoms. For these patients, assessment
followed by reassessment within 2 to 3 weeks is critical.
Symptom Reemergence or Worsening
Clinicians should be alert to the coexistence of AOD disorders and
dissociative post-traumatic stress, obsessive-compulsive disorder, or
attention-deficit hyperactivity disorder. For these patients, AODs are often
used for self-medication.
For example, patients with dissociative disorders may experience the
reemergence of traumatic memories and subsequently become psychotic, suicidal,
or frightened. Treatment is complicated by the necessity of avoiding
benzodiazepine medications that would ordinarily be beneficial. On the other
hand, there is evidence that stimulant medications can be safely used by some
AOD patients with attention-deficit hyperactivity disorder.
Because their discomfort and increased tendency to relapse can be disruptive
to other patients, AOD patients whose psychiatric symptoms worsen following
abstinence can often be very difficult to integrate into general IOT programs.
Furthermore, the usual program norms and expectations may need to be adjusted in
ways that are confusing and unacceptable to other patients. While some patients
with dual disorders may be clinically described as high functioning, their
behavior may be unpredictable and disruptive to the therapeutic milieu. Thus,
they often are better managed apart from other patients, with an emphasis on
individual counseling services.
Patients With Chronic Psychotic Disorders
Patients who have an AOD use disorder and a chronic psychotic disorder have
treatment needs that exceed those of the average patient with dual disorders.
Therefore, they require IOT programs that can provide specialized services to
address their needs, including those related to cognitive deficits, physical and
social problems, and medication.
The treatment progress of these patients may be slow and prolonged, often
compromised by their limited social and interpersonal skills. Also, since these
patients may be involved with several treatment and social service systems, they
often have numerous program demands placed on them, including attendance
requirements and separate treatment goals for each program. The coordination of
care and treatment goals is essential if treatment is to be effective. This
requires consistent collaboration among clinicians in the various settings in
which these patients receive treatment.
This group of patients may benefit from IOT programs that provide an
extended treatment day of perhaps 5 to 6 hours. IOT can become a major focal
point of their lives and provide structure to an otherwise poorly structured
lifestyle.
Like all AOD treatment programs, IOT programs for patients with dual
disorders should incorporate a multidisciplinary approach. Staff training
regarding psychiatric disorders and the use of medications for these disorders
is an important component. As discussed above, it may be necessary for some
patients to receive concurrent treatment from multiple programs. When this is
the case, it is critical that effective communication and collaboration be
established and maintained between providers.
While the length of stay at AOD treatment programs should always be based on
the treatment needs and progress of individual patients, some AOD programs
promote a fixed amount of time for care. In contrast, IOT programs for patients
with an AOD use disorder and a chronic psychotic disorder should always be
open-ended. The duration of treatment should be based on each patient's
treatment needs. The treatment team should describe clearly the patient's
coexisting disorders and explicitly describe treatment goals, progress, and
interventions to meet the patient's treatment needs.
Extended care plans should be anticipated and carefully developed.
Counseling should be proactive in planning postdischarge placements and
services. Despite complex psychiatric treatment needs, abstinence and other AOD
treatment goals are expected to be met.
The AOD treatment and the mental health treatment fields emerged from
different backgrounds. The two systems of treatment have somewhat different
theoretical bases and clinical approaches. For example, abstinence from AODs is
considered to be the starting point and an area of continual focus for most AOD
treatment programs and models, whereas abstinence may be a later goal and less
closely monitored by mental health clinicians. Other differences in orientation
and programming are outlined in Exhibit 5-1.
At times, these differences become barriers to integrating and linking AOD
and mental health services for patients with dual disorders. For example, there
is a potential for conflict regarding the optimal way to handle the failure of a
patient to remain abstinent. AOD treatment programs may have a tendency to
discharge patients who have episodes of AOD use, whereas mental health programs
are more likely to sustain involvement with the patient despite an absence of
progress or partial progress with regard to AOD recovery. AOD treatment staff
can be commended for a steadfast focus on abstinence. Similarly, mental health
staff can be commended for identifying and encouraging patients' progress
despite AOD use or in areas that do not appear to be directly related to AOD
use.
Further, some AOD professionals may mistakenly regard all psychotropic
medication as mood-altering drugs to be avoided because of the potential for
abuse. On the other hand, some mental health clinicians may prescribe
medications without recognizing that certain psychoactive medications are more
likely to be abused than others and that some people are at a higher risk for
abuse and addiction than other people. While problems remain, it is fortunate
that some conflicts are diminishing in part because of the increased
sophistication and integration of both treatment fields. A few recommendations
follow.
AOD treatment and mental health clinicians should become familiar
with the perspective, content, and mission of one another's discipline.
IOT programs should encourage and actively provide clinical cross-training
sessions. This can be accomplished through routine clinical supervision, onsite
inservice programs, and attendance at regional workshops and national
conferences.
The development of innovative integrated approaches should be encouraged by
both fields.
Medication Management
The treatment of patients with dual disorders at an intensive level of care
(such as medically monitored inpatient settings) is simplified greatly when the
physician prescribing psychotropic medications works on site. When this is so,
treatment services can be closely coordinated with all members of the
multidisciplinary clinical team. However, at the IOT level of care, some or all
of the medical care may be provided by physicians outside of the treatment
program. Such physicians include individual patients' primary care physicians,
part-time medical directors, and contract or consulting physicians. In these
cases, IOT staff must coordinate treatment services with these outside
providers.
Ideally, physicians who provide services for AOD treatment programs should
have experience and knowledge about addiction, such as physicians who are
addiction medicine specialists or who have addiction medicine as a secondary
area of expertise. For example, members of the physician organization American
Society of Addiction Medicine are often primary care physicians, internists, or
psychiatrists and also have a specialization in addiction medicine. In
practice, however, AOD programs, including IOT programs, must often utilize
medical and psychiatric personnel who have not developed specializations in
addiction medicine. Even without expertise in addiction, such physicians
provide valuable services such as physical examinations, withdrawal management,
and diagnosis and treatment of psychiatric symptoms and disorders.
However, when programs use such physicians, it becomes possible for the
medical and AOD treatment staff to have different treatment goals or different
approaches to the same treatment goals. For example, a primary care physician
and a psychiatrist who are not addiction medicine specialists may routinely
prescribe short-term courses of benzodiazepines for insomnia in their private
practices, since they generally obtain good results and witness few adverse
reactions among their nonaddicted patients. Unless they are made aware of the
explicit clinical goals and objectives of AOD treatment and recovery, medical
treatment recommendations may conflict with overall AOD treatment goals.
In situations where there is variability with regard to physician expertise
in addiction medicine, and when much of the medical and psychiatric work is done
by part-time consultants, programs should provide formal procedures that will
result in uniform philosophies and orientations regarding AOD treatment.
Also, while AOD treatment staff should be willing to educate medical and
other staff about the goals of AOD treatment, they should be willing to learn
about medical management. Importantly, AOD staff must be willing to learn that
exceptions to drug-free treatment goals will be appropriate for a subset of
dually diagnosed patients. AOD staff should receive ongoing education about
medical management including new pharmacotherapies that are prescribed for
patients.
Relations With Self-Help Groups
All IOT programs should establish linkages to various self-help groups and
to the recovering 12-step community through personal relations with alumni who
attend those groups. In particular, IOT programs that provide services for
patients with dual disorders should attempt to identify self-help group meetings
that welcome and are sensitive to the needs of such patients. In some areas,
there are special meetings for people with dual disorders. Such groups have
been affectionately called "double trouble" meetings. Patients with dual
disorders may need to be taught how to educate their self-help peers about their
special treatment needs, especially their need for medication. Patients with
dual disorders may benefit strongly by having a sponsor who has a thorough
understanding of recovery for patients who require medical management for
psychiatric disorder as well as addiction.
Homeless People
It is incorrect and counterproductive to assume that people who are homeless
or who experience housing instability cannot be successfully treated for their
AOD disorder until their housing needs are met. Rather, because of the
intensity of services available in IOT programs, these programs offer an
exceptional opportunity to initiate and maintain an element of stability in
homeless people's lives. Such stability may, in turn, enhance the opportunities
for addressing housing needs. To accomplish this task, IOT programs should work
closely with staff members at homeless shelters and with public housing
authorities.
Clinicians should be aware that an individual's resistance to treatment may
be related to the length of time he or she has been homeless. For instance,
longer periods of homelessness are often associated with stronger resistance to
using medical and mental health services. As a result, programs can encourage
engagement with the treatment process by helping people get their safety,
survival, and social service needs met. This may involve providing assistance
regarding housing, food, medical problems, and social services. Programs can
provide homeless people with some services on site and assist with access to
services off site.
As people begin to have their survival needs met, begin to feel safe, and
experience some degree of stability, they become increasingly likely to respond
positively to treatment. During the stabilization process, programs can provide
informal counseling and reinforcement and other services through case
management.
While the emphasis in IOT programs on addiction and recovery issues should
not be obscured by housing issues, it should be recognized that homelessness
often translates directly into an AOD relapse issue. That is, the ready
availability of AODs on the streets and in many homeless shelters, in
combination with the stress and poor quality of life that accompany
homelessness, often contributes to relapse. For homeless AOD abusers, these
issues need to be addressed as a part of effective case management. There is a
distinct need to address long-term rehabilitation goals for homeless people.
Additionally, since homeless people often experience several medical and
psychological problems, a thorough assessment should take such problems into
consideration.
The homeless population includes groups of people who can be described as:
1) living in transient situations, 2) recently displaced, and 3) chronically
homeless. These three groups arrive at treatment with distinct treatment needs.
Transient People
Some people have transient and unstable living arrangements such as
temporarily staying with others. For example, some individuals have a living
arrangement pattern that involves rotating among a group of friends, relatives,
and acquaintances. These people are at immediate risk of eviction at the will
of those with whom they reside. They are at high risk for suddenly having to
live in the street. They are particularly vulnerable to being exploited and
abused. For some, continued living in other people's residences may be
contingent upon providing sex or drugs. While they may not be living on the
streets, they lack a stable, secure, and safe living arrangement.
Recently Displaced People
Some people who experience acute housing instability may have only recently
become homeless. They may be employed but have been evicted or otherwise lost
their place to live. Sometimes housing instability relates to AOD-influenced
financial problems.
As one aspect of providing treatment, IOT programs have a responsibility to
help people gain access to temporary housing through such facilities as homeless
shelters and halfway houses, or to reestablish a permanent residence. In this
way, patients can continue to participate in treatment and remain employed.
Effective case management is a critically important way to address these issues.
Chronically Homeless People
Because of the difficulty of attracting chronically homeless AOD abusers
into traditional treatment settings, innovative strategies are needed to reach
and engage them in treatment. IOT programs cannot expect homeless AOD abusers
to negotiate the maze of social services or to identify and secure AOD
treatment. Rather, IOT programs must bring their services to the homeless
through a variety of creative outreach and programming initiatives. For
example, the location of the IOT intervention is of vital importance. One
strategy for encouraging homeless people to become engaged with the AOD
treatment process is to locate the programs within homeless shelters. Another
strategy is to place an AOD treatment specialist at the shelter as a liaison
with the IOT program.
For chronically homeless AOD abusers, IOT offers an opportunity for
habilitation, which is important for this group since many have not had an
opportunity to fully develop basic living and vocational skills. IOT programs
must offer linkages to job skills and literacy development services as well as
housing. To capitalize on this opportunity, case management must be available
to ease access to and coordinate participation in the variety of services needed
by homeless AOD abusers.
Medical care, including psychiatric care, should be coordinated for
chronically homeless patients. Ideally, it should be integrated with the IOT
program's services. This will enable staff to monitor followup care and, as
appropriate, medication compliance.
Some shelters will also provide comprehensive case management as well as
child care. At a minimum, IOT programs can provide the core elements of IOT in
a shelter. However, the location of treatment services is not as important as
the coordination of AOD treatment with other medical and social services for
homeless people. Thus, IOT programs should establish cooperative programming
with homeless shelters and their associated provider networks.
Inadequate access to health care is a major obstacle confronting many AOD
abusers with HIV infection or AIDS. Health care facilities in some areas of the
country are so overwhelmed that people with HIV or AIDS often cannot gain
admittance to clinics that could provide them with the wide range of services
needed to sustain or prolong their health.
One of the advantages of the IOT setting is its ability to offer diverse
services, particularly when services are incorporated into standard IOT care.
Thus, it can provide a greater breadth of care to HIV-positive AOD abusers.
Specifically, for patients with HIV or AIDS, IOT programs can provide onsite
medical and pharmacologic services as well as access to psychiatric care. These
services are essential, since there are significant medical and psychiatric
problems in this group -- greater problems than those found in the population of
people with AOD use disorders.
In IOT, retention of HIV-infected and AIDS patients can be especially
challenging without the advantage of residential structure. HIV-infected
patients may at times lack motivation to pursue treatment, struggling with a
commitment to recovery in the face of perceived imminent sickness and death.
Counselors should be prepared to deal directly with this issue and to encourage
patients to openly address their ambivalence about recovery. Participation of
patients in special support groups dealing with HIV and AIDS should be
encouraged when available. To this end, IOT programs should sponsor onsite
support groups for people with HIV infection or AIDS. These support groups
should address such issues as AOD recovery within the context of AIDS, social
isolation, bereavement, fear, and stress.
The HIV/AIDS issue should not be overlooked in IOT and requires special
training efforts for IOT staff. Indeed, some AOD treatment certifying bodies
require training in this area. There may be a tendency by counselors to refer
HIV-related issues to medical providers. However, support, supervision, and
training should be available within the IOT setting for all staff members who
will encounter such issues. There should be built-in procedures to address the
fears, discomforts, and grief resolution associated with working with HIV/AIDS
patients. Moreover, it is imperative that the IOT program staff receive
training to effectively deal with the issues of death, dying, grief, and
bereavement.
Each IOT program will have limitations with regard to the number and types
of services provided. At the same time, patients with HIV and AIDS will require
more types of treatment and social services than the average patient being
treated for AOD problems. For this reason, IOT programs that treat patients
with HIV and AIDS have the responsibility to establish and maintain strong
linkages to a wide range of services. These linkages must be characterized by
ongoing relationships among providers, easy access for patients, and broad
scope. They must not simply be passive referrals.
Whether services are provided by the program or through linkages with
outside programs, IOT programs should aggressively address a broad scope of
issues related to patients' physical, cognitive, psychological, emotional,
social, and spiritual health.
Gay men and lesbian patients may identify certain issues that make their
recovery difficult. IOT programs will be more effective in their treatment of
gay men and lesbian patients if they recognize these issues and observe the
following guidelines:
IOT programs should have broad definitions of the family and of
relationships. It is important to understand that sexual behavior occurs within
a context of other life issues, and that defining people solely on the basis of
their sexual orientation is never appropriate.
IOT program staff need sensitivity training around gay and lesbian issues.
Having openly gay and lesbian staff in the IOT program may be particularly
empowering to gay and lesbian patients as well as educational for heterosexual
staff.
IOT staff should establish an atmosphere in which gay and lesbian patients
can feel comfortable. The establishment of this "comfort level" should begin at
intake. For example, in obtaining information on sexual orientation, it is
important to be nonjudgmental and supportive of whatever information patients
provide.
Gay and lesbian patients should not be compelled or coerced to reveal their
sexual orientation to other patients. This is abusive and disrespectful of
patients' rights. Further, focusing on sexual orientation is a distraction from
the primary focus of treatment for and recovery from addiction to AODs.
However, for some patients, issues related to sexual orientation are central
to understanding their patterns of drug use, addiction, recovery, and relapse.
For these people, avoiding discussions of sexual orientation may represent a
reluctance for self-disclosure relating to addiction in general.
If patients decline to disclose their sexual orientation to other
patients, exploring their reasons for not doing so may be helpful in individual
counseling sessions. For example, it may reveal their perception of the program
environment as unreceptive to gays.
The needs of gay men and lesbians also reflect the gender differences that
exist among heterosexual men and women. In addition, since the dynamics of gay
male and lesbian relationships are different, there may be differences in the
way the addicted person's partner responds to addiction, prompting the need for
different treatment strategies.
In larger urban areas, the gay and lesbian communities often have
sophisticated support structures, many of which have developed in the context of
AIDS advocacy groups. IOT staff should identify these groups, establish
linkages, and work closely with these important resources.
In areas where needed support services are not available, IOT programs
should consider establishing support groups for gay men and/or lesbians,
depending upon the patients' needs. IOT programs can also sponsor or encourage
12-step group meetings (such as AA) that focus on recovery for gay people.
Irrespective of sexual orientation, the primary focus of AOD treatment
should remain on AOD issues such as sobriety, relapse prevention, and recovery.
Regardless of clients' sexual orientation, HIV risk issues should be assertively
addressed during treatment. These issues include the high-risk behavior of
engaging in sex during episodes of
AOD use, since safer sex is not as consistently practiced when participants
are intoxicated or high.
It is worthwhile to have appropriate literature for gay men and
lesbians, especially gay recovery literature and local gay newspapers and
magazines where available. It is helpful to have literature on homophobia and
homosexuality available for education of heterosexual staff and patients.
Overall, elderly people constitute a small portion of patients receiving AOD
treatment, especially IOT treatment. In defining special treatment needs based
on age, a cutoff of 55 has generally been adopted. When establishing guidelines
for older patients, programs should consider special groups where elderly
patients can deal with issues specific to their life circumstances. These
groups can help prevent isolation, promote social interaction, and enhance a
feeling of togetherness. To ensure effective treatment, the following key
issues also need to be addressed.
Stigmatization
Elderly people, perhaps especially from minority cultural and ethnic groups,
often have stereotypical ideas about AOD abuse and feel especially stigmatized
when they have AOD problems. As a group, they tend to be reluctant to seek out
AOD treatment. They may require especially sensitive approaches to engage them
in treatment.
Setting and Transportation
Ideally, a special setting such as a Veterans Administration Hospital or
senior center works best for IOT programs exclusively treating elderly people.
Such settings afford an increased mix of older people, enabling elderly patients
to more readily identify with the treatment group. While program content may
not be particularly different in IOT programs that include elderly people, a
safe location is vital.
Transportation can be an issue with elderly people as well, particularly for
evening programs. If patients cannot provide their own transportation, family
members, public transportation, or senior citizen transportation services should
be explored.
Cognitive Issues
Cognitive impairment is a more common problem among elderly patients than
among others in the IOT program. Some elderly patients may be confused,
particularly early in treatment while still recovering from AOD withdrawal.
They may be especially demanding of staff time and require attention for their
fears and anxieties. The logistics of handling this group can be demanding.
Because of cognitive problems secondary to alcohol use, withdrawal, or resulting
from the interaction of prescribed medications with alcohol, a subset of these
patients may first require medically monitored or managed inpatient treatment.
This will provide a more protected environment for patient care and will
facilitate closer patient monitoring by program medical staff.
As part of the assessment process, it is important for IOT staff to
distinguish between chronic physiologically based impairment and acute
impairment related to AOD use. A comprehensive medical history, physical
examination, and AOD history are necessary to help clarify patients' needs.
Medication
Medication is a critical issue for elderly people with AOD problems.
Physiologic changes in the elderly affect AOD metabolism and tolerance. Also,
alcohol can interact with prescribed medications and lead to confusion or
toxicity. Elderly patients are more susceptible than other patients to the
effects of consuming multiple medications. However, it is common for elderly
patients to take multiple medications for several illnesses.
Similarly, elderly patients often receive treatment and medication from
several physicians and specialists. Often, this care is not coordinated or
supervised by a single treatment provider. Without coordination and
supervision, the risk for prescription medication toxicity is heightened.
Similarly, when prescription of psychoative medications is not monitored, the
risk of physical dependence and addiction increases.
Cognitive impairment resulting from poor medication management or the
interaction between alcohol and prescribed medication can affect the ability of
elderly people to take part in IOT. Thus, medication monitoring and management
should occur directly within the IOT program whenever possible.
Social Support
Social support is particularly critical for elderly people. In cases of
late-onset AOD abuse, the abuse is often related to a recent traumatic life
event such as the loss of a spouse or other loved one, or retirement from
long-term employment. Since IOT provides a structure for daily living and
offers intensive levels of support, it may be of particular benefit to older
patients who have experienced a traumatic event.
Depending on local resources, there are often several community support
services with which IOT programs can establish linkages. Community support
services include medical and other health services, education and recreation
activities, and services for daily living. Health services include medical day
care centers and clinics that provide health screenings. Services for daily
living include homemaker and home health aide services. Other services include
senior day care centers, meal delivery services, phone call-in or visiting
services, and transportation services. Linkages with churches and senior day
care centers can provide patients with a wide variety of activities.
Other Services
Peer helpers for elderly patients can be beneficial. As with other
patients, when elderly AOD abusers are accepted by their peers, the progress of
their treatment proceeds more rapidly and smoothly. AA groups targeted for
older patients represent a partial solution to help meet this need. Exercise,
such as weightlifting, stretching, aerobics, or certain martial arts, should be
an integral element of the program. Moreover, providing meals helps people meet
their nutritional needs and also provides an opportunity to socialize.
The Center for Substance Abuse Treatment is preparing several Treatment
Improvement Protocols relating to criminal justice issues. These include Screening
and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal
Justice System; Planning for Alcohol and Other Drug Abuse Treatment for Adults
in the Criminal Justice System; Combining Substance Abuse Treatment With
Intermediate Sanctions for Adults in the Criminal Justice System; and
Integrating Alcohol and Other Drug Abuse Treatment With Alternative Case
Processing in the Justice System.
Many people in the criminal justice system have AOD use disorders and
require treatment. Intensive outpatient treatment can be adapted to various
criminal justice settings and can be used to target a number of criminal justice
populations, including: 1) incarcerated people, 2) people receiving alternative
sentences, and 3) people on parole and probation. These groups often differ in
their treatment needs.
Location of the IOT Program
For incarcerated patients, the IOT program is located within the corrections
facility, with program staff having reasonably ready access to patients. The
corrections facility may have a dormitory arrangement where IOT patients live
apart from the general prison population.
Program Rules and Regulations
There is a high prevalence of antisocial personality disorder among AOD
patients in the criminal justice system. Thus, behavioral management strategies
may be particularly useful for treating incarcerated AOD abusers.
Clarification and enforcement of IOT unit rules and regulations are
particularly critical. Through a team effort involving treatment and
correctional staff, well-detailed program policies and procedures should be
developed before the program becomes operational. Program policy and procedures
must clearly reflect the requirements and restrictions of the correctional
setting. For example, disclosure of a patient's threat to facility security is
not prevented by program confidentiality guidelines. There are other
confidentiality guidelines regarding criminal justice system clients. These
guidelines should be communicated to clients.
Treatment Modeling
IOT programs in the criminal justice system can be organized using a day
treatment model of care. Also, the duration and scheduling of care can be
tailored to patients' length of stay in prison and anticipated release date.
Indeed, successful IOT completion can be made a prerelease condition.
In some States, patients on parole will come to IOT directly from AOD
treatment units within Federal or State correctional facilities. For these
patients, IOT will be perceived as a form of continuing care. Regular
participation in an IOT program might be a requisite of their parole; this can
promote their retention in the program. Participation of the criminal justice
professional in supervising this stage of treatment can be helpful in applying
appropriate leverage when patients become unmotivated or unwilling to commit to
the treatment plan.
Likewise, it is important that patients not be inappropriately considered in
violation when experiencing setbacks in treatment. Communication and
coordination between IOT program staff and the relevant criminal justice
professionals are important elements in the successful treatment of criminal
justice system clients.
Transitional Issues
For clients in the criminal justice system, making the transition back to
society (to community, family, and peers) can be extremely challenging. Since
they face a twofold integration, people who have been participating in an IOT
program with only their incarcerated peers may experience a difficult
reintegration with the broader recovery community. For this reason, linking the
patient with aftercare AOD treatment services as well as community-based
prisoner support services can be beneficial.
There are a number of other patients for whom specialized IOT tracks can be
developed. For instance, people in certain occupations (such as health care
professionals, airline pilots, lawyers, and long-distance truck drivers) are
special groups that, in large urban centers, already have IOT programs
specifically tailored to their singular needs. These programs are often
designed so that participants can continue to pursue their occupations while
receiving treatment. These groups are often highly motivated to abstain from
AOD use because of oversight by their licensing organizations. People with
disabilities or cognitive impairments or who are illiterate also require special
administrative and clinical considerations. IOT program policies should address
the special needs of such clients.
Although there may be concern that such patients may see themselves as
"different" or less troubled than the general population, it is generally useful
to support involvement in homogeneous support groups while facilitating
concurrent interaction with other AOD patients. Other special groups may be
identifiable in certain regions and communities. IOT programs are encouraged to
consider the special patient groups in their area and evaluate the usefulness of
targeted services.
Summary
IOT is becoming an increasingly important level of care for the treatment of
AOD problems. This level of care can be adapted to several models and programs
that treat patients from special groups. There are several practical and
philosophical issues that need to be considered prior to developing IOT services
that treat specific groups. Such considerations include the treatment goals and
mission of specialized services, counselor sensitivity toward special groups,
access to training regarding special population needs, aggressive integration
with other services for the target population, patient volume, and financial
support.
When these considerations do not support the development of a separate
specialized IOT program, enhancement of more general IOT services with special
groups and tracks should still be considered. Only by organizing clinical
services to be more responsive to the special needs of patients they treat will
IOT programs be able to attract, retain, and have an impact on the diversity of
patients who are in need of treatment.
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