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Center for Substance Abuse Treatment. Intensive Outpatient Treatment for Alcohol and Other Drug Abuse. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1994. (Treatment Improvement Protocol (TIP) Series, No. 8.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Intensive Outpatient Treatment for Alcohol and Other Drug Abuse.

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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.

Special Considerations in Providing IOT to Women

  • Advocacy for women's services
  • Psychiatric care
  • Child care
  • Abuse issues
  • Flexible program hours
  • Emotional issues (e.g., shame, anger)
  • Safe houses or transitional living
  • Family issues
  • Transportation
  • Self-help and peer support
  • Meals
  • Living skills
  • Medical care
  • Addiction during pregnancy.

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.

Special Considerations for Providing Culturally Competent IOT

  • Advocacy for special services
  • Unbiased assessment tools
  • Convenient program location
  • Staff with backgrounds similar to clients'
  • Staff training in multicultural issues
  • Specialized programming (including bilingual counselors)
  • Sensitivity to spiritual issues
  • Program assessment of special services.

Patients With Dual Disorders

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.

Special Considerations for Providing IOT To Clients With Dual Disorders

  • Additional treatment services
  • Linkages with mental health care providers
  • Specialized group sessions
  • Medication education
  • Attention to worsening symptoms
  • Coordination of care for patients with chronic psychotic disorders
  • Staff training in psychiatric disorders.

Potential Areas of Conflict

The AOD Field "Versus"

The Mental Health Field

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.

Exhibit 5-1 Selected Comparisons of Recovery and Mental Health Models.

Table

Exhibit 5-1 Selected Comparisons of Recovery and Mental Health Models.

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.

Special Considerations for Providing IOT to Homeless Persons

  • Linkages with shelters and public housing authorities
  • Need for food, medical care, and social services
  • Quality case management
  • Long-term rehabilitation goals (job skills, literacy)
  • Innovative strategies to engage chronically homeless (IOT programs in shelters)

People With HIV or AIDS

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.

Special Considerations for People With HIV and AIDS

  • Onsite medical and pharmacologic services
  • Access to psychiatric care
  • Special support groups onsite
  • Support and training for staff
  • Strong linkages to a range of services

Gay Men and Lesbian Patients

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.

Special Considerations for Gay Men And Lesbians

  • Broad definition of family
  • Special staff training
  • Gay and lesbian staff
  • Respect for clients' privacy
  • Close linkages with community support groups
  • Address HIV risk issues

Elderly 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.

Special Considerations for Elderly Persons

  • Stigmatization of AOD problems
  • Setting (convenient, safe)
  • Transportation
  • Cognitive impairment
  • Medication interactions (polypharmacy)
  • Close linkages with social services
  • Peer helpers
  • Provide meals onsite

People in the Criminal Justice System

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.

Special Considerations for the Criminal Justice Client

  • Location in corrections facility
  • Clarification and enforcement of rules
  • Day treatment model
  • Making AOD treatment a release or parole/probation condition
  • Close communication between program staff and criminal justice staff

Patients From Other Special Groups

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.

Making Treatment Comfortable

  • Nonjudgmental staff
  • Attention to patients rights
  • Staff reflective of the general population
  • Encouragement of patients respecting one another
  • Literature and art that demonstrates respect for different cultures
  • Promotion of emphasis on AOD treatment
  • Attention to barriers to treatment and recovery
  • Literature to educate staff and patients about each cultural and ethnic group
  • Self-help groups for patients from special groups
  • Attention to patients' special needs

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