Interventions in individuals with specific needs.

With the growing understanding of substance use problems among special populations like women, gender minority groups, as well as in the geriatric population, there is a drive to develop sensitive interventions catering to their unique needs. This chapter is a short review of psycho-social interventions targeted towards these individuals with specific needs.

INTRODUCTION

Traditionally, substance use has been seen as a phenomenon among adult males. Until recently, addiction research and services suffered a scarcity of intervention and outcome related data for women or sexual minorities like LGBT, extreme age groups and other minorities. These groups often pose unique treatment challenges due to the obvious differences in the interplay of various bio-psychosocial factors relating to substance use. However, with the emergence of evidence on increasing substance use among women, sexual minority groups, decrease in the age of initiation of substance use and problematic substance use among older adults, the specific treatment needs of these groups are being assessed and interventions are being planned during the recent three decades. Apart from the pharmacological treatment for substance use, these population groups in question often benefit from psycho-social interventions. Many of these interventions are developed taking into consideration the theoretical underpinnings and epidemiological evidence related to bio-psychosocial factors associated with substance use among these populations. In this chapter, the psycho-social interventions developed or modified so far for these special population groups for substance use problems would be discussed.

Women

With the emergence of understanding of gender difference in substance abuse, there has been a drive for developing gender-sensitive interventions/programmes for substance use problem among women and sexual minorities. Certain psychosocial antecedents have been found more likely to be associated with substance use by women. These include comorbid psychiatric disorders1, significantly more physical and sexual abuse and domestic violence, victimization,23 and deficits in social support.4 Nearly half of the women treatment-seekers in tertiary addiction treatment centres or community clinics in India also report similar psychosocial issues for initiation of substance use.567 Treatment seeking and retention are usually poor among women all over the world including India.56 Studies indicate that women face various systemic, structural, social and individual barriers in treatment seeking and retention in treatment for substance abuse.8 These include lack of appropriate gender responsive treatment models, lack of services for pregnant women; rigid programme schedules, lack of safety at treatment centres; inadequately trained staff for handling gender sensitive issues; fear of losing custody of children; lack of childcare outside of treatment. disadvantaged life circumstances; stigma, shame and guilt; lack of support from family; decreased perception of need for treatment are few of the socio- cultural and personal barriers reported in the literature.9

A gender sensitive intervention ideally should systematically integrate the gender dimension into every step of the process, from defining the problem, to identifying potential solutions, in the methodology and approach to implementing the intervention.1011

The theoretical underpinnings for gender-sensitive interventions developed for women take into account the addiction theory, women's psychological development, the trauma theory and the factors associated with substance use among women discussed earlier.1011121314 Apart from the emotional, psychological, spiritual component, the addiction theory takes into account the environmental and socio-political dimensions into the disease model of addiction.15 The next important component is a theory of women's psychological development, The Relational Model, (developed by the Stone Centre, Wellesley College) which posits that the primary motivation for women throughout life is establishing a strong sense of connection rather than separation. Women disconnected from others, or involved in abusive relationships, experience disempowerment, confusion, and diminished self-worth, all of which predispose them to substance abuse. On the other hand, in a growth-fostering relationship, a woman develops a sense of mutuality that is “creative and empowering” and essential for psychological well-being.12 Understanding of trauma is also essential. Trauma not only includes suffering violence, but also witnessing violence, and trauma of stigmatization because of sexual orientation or other reasons like poverty etc., Women use substance in order to self-medicate the suffering of trauma which often produces bias in woman's relational experience and poses as barrier for psychological development.16

Based on the theories and available epidemiological data, gender-sensitive interventions, the following gender-sensitive principles have been developed:1418

Gender: Acknowledge that gender makes a difference

Environment: Create an environment based on safety, respect, and dignity

Relationships: Develop policies and practices that are relational promote healthy connections to children, family, significant others and the community.

Services: Substance abuse, trauma, mental health issues addressed in a comprehensive, culturally relevant fashion

Socio-economic status: Opportunities to improve socioeconomic conditions

Community: Establish comprehensive and collaborative community services

Gender sensitive interventions of varying intensity have been implemented in various settings (Out-patient, residential, mixed-gender and single gender). In general, the women only treatment settings reported better treatment utilization, greater benefit for women with special need. Gender-specific programming, programmes with provision of child care had better rates of treatment retention.19

In 2008, Covington developed a comprehensive Women's Integrated Treatment (WIT) model based on the theoretical framework discussed above, and multidimensional therapeutic interventions. Till date, seven theoretically supported and trauma-informed manualized curricula were designed. “Helping Women Recover: a programme for treating Addiction” is one such curriculum which is widely used in addiction treatment programmes, mental health clinics for women. It uses cognitive-behavioural, relational, mindfulness, and expressive arts techniques. It covers self, relationships, sexuality, and spirituality as key triggers for relapse.

The content focuses on self-esteem, sexism, family of origin, relationships, domestic violence, and trauma. Better in-treatment performance has been reported with these models.20 However, effectiveness of such models is yet to be studied systematically.

Among the behavioural treatment approaches that have amassed empirical support include: cognitive behavioural therapy (CBT), motivational enhancement interventions, and contingency management. Yet most behavioural therapies have been developed generically and they have not been examined to see how they can be specifically tailored to women's treatment. CBT for relapse prevention, interventions using workbook-based psychoeducation approach appear to be promising, encouraging retention while delivered in women-specific group.20 Brief intervention providing information regarding foetal health hazards among pregnant alcohol users has been reportedly effective in reduction of drinking.11 Contingency management alone or in combination with BI have some evidence of effectiveness in reduction of substance use and psycho-social needs.20 During the last thirty years, Therapeutic Community approaches have been modified to incorporate empowerment and supportive rather than confrontational approches for women. However, the effect of such modifications has not yet been tested formally.1

LGBT

Emergent research (both cross-sectional and longitudinal) has consistently reported a greater likelihood of substance use among sexual minority youth as compared to heterosexual youth.2122 The odds of substance use among sexual minority youth was found to be at nearly twice than that of heterosexual youth.23 Similarly, lesbian and bisexual female youth are more likely to exhibit substance use problems when compared to heterosexual females2425 and sexual minority males.23 Lesbian, gay, bisexual, and transgender (LGBT) populations often enter treatment with more severe substance misuse problems, have a greater likelihood of experiencing a substance use disorder in their lifetime, and initiate alcohol consumption earlier than heterosexual clients. Thus, developing effective treatment programmes that address the specific needs of these populations is critical.26

The reasons for higher levels of substance use among sexual minority youth are largely unknown. However, the association between various stigma (related to sexual orientation) –related stressors, including gay-related stressful life events (e.g. identity disclosure), victimization at school, verbal/physical abuse and substance use has been documented.25 The available evidence of a strong association between sexual behaviours and substance use, and use of substances to cope with marginalisation indicates the need to pay attention to the relationship between sexual behaviour or orientation and substance use treatment.27

With regard to substance use among LGBT population, the stages of ‘identity development’ Fontaine and Hammond (1996)28 and the disclosure of sexual identity described as “Coming out” have been discussed in literature. Given the higher rates of victimisation amongst LGBT, there are strong arguments that victimization should be addressed for prevention of drug use.2930

For all practical purpose, prevention is set as a priority principle while dealing with substance use problems and its treatment for the LGBT population.2931

SAMHSA (2001) and recently APA (2012) published treatment guidelines for substance abuse treatment for LGBT (2001). Both these guidelines highlights the importance of ‘cultural competence’, confidentiality and non-discrimination while dealing with LGBT individuals. APA additionally emphasizes the need for community-based programmes specifically for LGBT adolescents and young adults. These are particularly important given the enhanced need to assist this young group with (1) disclosing their sexual minority identity, (2) issues of family rejection, (3) lack of housing and other stability factors (particularly those experiencing family rejection), and the (4) need for a safe environment given extreme levels of abuse and harassment due to their gender expression. Meagre literature treatment programmes with specialized groups for gay and bisexual clients have shown better outcomes for men compared to gay and bisexual men in non-specialized programmes.21 However, till date this population is being treated in mixed substance abuse treatment setting that serves both LBT and heterosexual persons.

Apart from the substance use treatment per se, issues like the coming out process; families of origin and families of choice; capacity building among professional have been discussed at length.31 Factors such as transphobia or homophobia (both internal and societal), violence, family issues, and social isolation, among other problems, may also need to be addressed.29 Pregnancy and parenting issues should be addressed while treating LBT women.32

Regarding the mode of delivery and type of services to this population, the need for a LGBT-informed care has been underscored by various authors.2932 LGBT-informed treatment includes asking clients the pronoun that they prefer to go by and encouraging other clients to use the pronoun of choice. Treatment workbooks and other programme materials generally use heterosexual examples, thus conscious revisions to treatment curriculum materials are called for. The counselling staff may not make assumptions regarding health risks and social norms associated with the identifying as an LGBT person. Avoiding use of disrespectful language is an important aspect of treatment and may enhance treatment retention. A thorough assessment that is non-judgmental, inclusive of sexual orientation for new treatment entrants in a non-judgemental fashion, is the essential pre-requisite of a successful treatment. Enquiry regarding sexual identity alone increases the probability of treatment drop out by 30%. Initial and on-going assessment should also include should also include questions about the positive and negative experiences specifically related to their sexual minority identity. In-depth understanding of these issues helps in developing a comprehensive need based treatment plan.

To address the need of this population, treatment services which are LGBT-sensitive and LGBT-specific services have been developed. Based on the available literature various authors have proposed checklist of requirements for LGBT-sensitive interventions. These include the way in which language is used (partner versus girlfriend/boyfriend); counsellor self-awareness, acceptance and affirmative approach, and engagement of family and significant others.32 The importance of a non-judgemental, sensitive, ‘gay-affirming and respectful attitude of the therapist/clinician have also been underscored.3334.

On the other hand, LGBT-specific services are culturally adapted to address the unique needs of the LGBT population.35 Cultural adaptation attends to the beliefs, norms and context for the minority group, applies relevant examples and materials that match with the group's norms and values, and attends to sexual behaviour as it pertains to the intervention being adapted. Ratner (1988)36 described a 12-Step focused model (Pride Institute) with the following LGBT-specific features: positive and affirmative environment that acknowledges the LGBT lifestyle; a focus on self-acceptance and self-awareness; strategies for coping with stigma, discrimination, stress; affirming the non-traditional “family” network, integration of sexuality into the treatment; and the presence of LGBT role models. Many of these interventions are run by LGBT individuals themselves.

Modified CBT to take into account LGBT issues, including case formulation and functional analysis, are considered as helpful therapeutic approaches when working with LGBT individuals.32 Effectiveness of the Community Reinforcement Approach (CRA) for LGBT youth living on the streets have been reported.37 Morgenstern et al. (2007) found that four sessions of brief Motivational Interviewing (MI) for alcohol-dependent MSM (Men having Sex with Men) populations with co-occurring problems who are contemplating moderation can reduce drinking for sustained period of time, compared to MI plus CBT (12 sessions).38 Most of such interventions have been done on people who are HIV positive and gay, among whom the rate of HIV seropositivity is high. Brief interventions have also been found effective in reducing consumption of club drugs over a one-year follow-up period among men MSM using smaller drug amounts. However, it was not effective in reducing club drug use amongst those with moderate levels of drug use. (2009)39

APA also has emphasized the need to enrich service providers, especially psychologists, with regard to their knowledge and understanding of homosexuality and bisexuality. The need for medical providers on the signs and symptoms of AOD abuse and the specific health care needs of LGBT populations through incorporation of chapters in the medical curriculum has also been emphasized in the literature.26

Both women and LGBT population using substances are defined by their unique psycho-social needs. Engaging these people in treatment has always been challenging. With advent of emerging research on the nature of their problem and their specific needs, gender-sensitive interventions are being developed and existing interventions are also being modified to address their need. Although the effectiveness of such interventions have not yet been thoroughly examined, these interventions have definitely shows a ray of hope.

Geriatric population

Substance use in the geriatric population is one of the fastest growing health problems and it is probably a silent epidemic. Older substance users can be categorised as early onset users (survivors) or late onset users (reactors). Early onset users typically have a long history of substance use which persists into old age. Late onset users often begin using because of stressful life events, including retirement, social isolation or bereavement. Significant clinical differences resulting from the age of onset in alcohol users have been reported in the literature. The latter group has a better prognosis for recovery. Older adults take more prescribed and over-the-counter medications than younger adults,40 increasing the risk for harmful drug interactions and dependence. Although illicit drug use is less frequent among older adults than younger people, its prevalence is increasing all over the world and at a higher rate in the western part of the world.41

Identification and diagnosis of problematic substance use following the formal diagnostic systems may be challenged by age related biological changes and psycho-social functioning.

There is an overall dearth of literature on effective interventions (both pharmacological and non-pharmacological) tailored towards this population.

As far as the assessment of an old individual about substance use is concerned, some general considerations should apply. Older adults are known to respond more to a supportive, non-judgmental and non-confrontational approach than more assertive styles of assessment and intervention. Discussions of alcohol and other substance use should occur in the context of an overall assessment and in reference to the presenting problem with the goal of health promotion and a complete understanding of their health behaviours.4042

There is a dearth of rigorous, internally valid intervention studies involving psychosocial interventions for the geriatric population. Based on the little research available, older adults have demonstrated comparable or better treatment outcomes than younger groups4344 and factors like erroneous perception of severity, a foreshortened sense of future, low self-efficacy and physical limitations have posed as common barriers to reduce substance use.4546

Three psychosocial and psychotherapeutic approaches, namely cognitive-behavioural therapy (CBT), supportive therapy models (STM)474849505152 and Brief Intervention (BI) have been studied for this population. CBT focuses on identifying and altering sequences of thinking, feeling, and behaving that lead to problem drinking or drug use.53 There is strong evidence for positive outcomes across populations and age groups including older adults.4849505152 The Substance Abuse and Mental Health Services Association published a CBT treatment manual specific to substance-using older adults. The highly structured, didactic approach taken in CBT may be particularly helpful to older adults because of the tendency to present with memory difficulties.54 Finally, CBT interventions have outperformed nicotine replacement therapies among older adults participating in a smoking cessation programme.55

Traditional STM approach has been reframed to address the unique issues faced by older individuals, including health conditions, depression comorbidity, and social isolation. STM focuses on developing a culture of support and successful coping for older-adult substance abusers. Treatment is planned taking a holistic bio-psychosocial approach through addressing multiple issues in the individual's life. Supportive therapies concentrate on building social support and improving self-esteem.56 There is at least some evidence that older adults demonstrate better outcomes in these settings than in non-adapted settings.

The most common brief intervention practised for older adults is a combination of normative feedback, in which a patient's drinking is compared with his or her peers and brief advice and seems to be highly effective for them.445758 Most of the brief interventions use either motivational interviewing (MI)59 or motivational enhancement therapy (MET) as the key element.60 Both MI and MET takes a non-confrontational, non-judgemental supportive approach to discussing substance use and healthy changes in the individual's life. However, there is little evidence to suggest that formal MI works with older adults with regard to substance use.6061

Apart from the interventions discussed above, case and care management models have been indicated as important tools in working with this population. These models work through the primary care settings or community-based agencies56 and address the array of psycho-social problems common in this population in a comprehensive manner.6263 Besides, they also attempt to connect isolated older adults to community resources.54

Traditional Self-help groups like Alcoholics (AA) or Narcotics Anonymous (NA), if modified keeping in mind the cognitive changes and physical limitations of the aging population, may be useful in reducing isolation, shame, and stigma.56 However, there have been no systematic studies regarding this.

With increase in life expectancy, geriatric substance use problems have gradually became emergent along with obvious psycho-social issues of old age. However, attention to the aging population is a relatively emerging area. Developing holistic, age appropriate services for the older population to cater to their physical and mental health needs under one umbrella is currently in focus and expected to expand further in the coming years.

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Conflicts of interest

There are no conflicts of interest.