Broadening the Base of Treatment for Alcohol Problems -- Copyright -- Contents -- Introduction and Summary -- The Study Process -- A Summary of the Text -- Our Vision -- Some Fundamental Questions -- Aspects of Treatment -- Special Populations in Treatment -- Aspects of Financing -- Guiding the Ongoing Effort -- REFERENCES -- 1 Our Vision -- A Brief History of Treatment -- Broadening the Base -- Toward Treatment Systems -- Advice to the Reader -- REFERENCES -- 2 What Is Being Treated? -- The Alcohol Problems Perspective -- Other Perspectives -- Alcoholism -- Alcohol Dependence Syndrome -- A Terminological "Map" -- The Heterogeneity of Alcohol Problems -- Heterogeneity of Presentation -- Heterogeneity of Course -- Heterogeneity of Etiology -- Implications of Heterogeneity for Treatment -- Summary and Conclusions -- REFERENCES -- 3 What Is Treatment? -- Refining the Definition of Treatment for Alcohol Problems -- Defining the Expanded Continuum of Care -- Defining the Elements of Treatment in the Continuum of Care -- Treatment Philosophy or Orientation -- Treatment Stages -- Stage 1: Acute Intervention -- Stage 2: Rehabilitation -- Stage 3: Maintenance -- Treatment Settings -- Treatment Modalities -- Summary and Conclusions -- REFERENCES -- 4 Who Provides Treatment? -- Describing the System to Treat Persons with Alcohol Problems -- Treatment of Alcohol Problems in the Nonspecialist Community Sectors -- Treatment in the Specialist Alcohol Problems Sector -- A State Perspective on Treatment Providers -- A Federal Perspective -- A National Perspective -- Treatment Personnel -- Summary and Conclusions -- REFERENCES -- 5 Does Treatment Work? -- Reframing the Question -- Answering the Reframed Question: Methods -- The Randomized Controlled Trial -- The Role of Quality Assurance -- Other Methods -- Answering the Reframed Question: Results.

Summary and Conclusions -- REFERENCES -- 6 Is Treatment Necessary? -- Improvement in Alcohol Problems Without Formal Treatment -- Deterioration in Alcohol Problems with Formal Treatment -- Coerced Treatment for Alcohol Problems -- Implications for Treatment -- Treatment Based on Knowledge of Improvement Without Treatment -- Summary and Conclusions -- REFERENCES -- 7 Is Treatment Available? -- Distribution of Resources for Alcohol Problems Treatment -- The National Drug and Alcoholism Treatment Unit Survey -- The Distribution of Treatment Capacity -- Expenditure Data -- American Hospital Association Annual Survey of Hospitals -- Relationship Between Treatment Availability and the Prevalence of Alcohol Problems -- Summary and Conclusions -- REFERENCES -- 8 Who Pays for Treatment? -- Who Are the Payers? -- Who Pays for Treatment in Specialty Programs? -- Sources of Funding in Public-Sector Specialty Programs -- Sources of Funding in Private Sector Specialty Programs -- Who Pays for Treatment of All Health Care? -- What Does Treatment of Alcohol Problems Cost? -- Summary and Conclusions -- REFERENCES -- 9 The Community Role: Identification, Brief Intervention, and Referral -- An Orientation to the Community Role in Treatment -- A Paradox and Its Implications -- Identifying People with Alcohol Problems -- Brief Intervention -- Efficacy of Brief Interventions -- Varieties of Brief Intervention -- The Target of Brief Intervention -- The Goal of Brief Intervention -- Referral -- Implementing the Community Role -- Settings -- Personnel -- Effects and Costs -- Conclusions and Recommendations -- REFERENCES -- 10 Assessment -- What Is Assessment? -- The Purposes of Assessment for Alcohol Problems -- Characterizing the Problem -- Characterizing the Individual -- Characterizing the Treatment Population -- Planning Treatment for the Individual.

Guiding Treatment for the Population -- The Structure of Comprehensive Assessment -- Sequential Assessment -- Multidimensional Assessment -- The Content of Comprehensive Assessment -- Content of Screening -- Content of the Problem Assessment -- Content of Personal Assessment -- Desirable Qualities of Assessment Content -- The Administration of Assessment -- Obtaining Valid Assessment Data: Problems in Providing Information -- Obtaining Valid Assessment Data: Problems in Gathering Information -- Methods of Obtaining Assessment Information -- Conclusions and Recommendations -- REFERENCES -- 11 Matching -- Studies of Matching in the Treatment of Alcohol Problems -- Examples of Matching Programs -- Specification of Treatment -- Specification of Matching Guidelines -- Therapist Selection -- Patient Selection -- Problem-Oriented Selection -- Theory-driven Selection -- Research-driven Selection -- Data-driven Selection -- Some Treatment Controversies as Matching Problems -- Conclusions and Recommendations -- REFERENCES -- Appendix: Excerpts From The Cleveland Admission, Discharge and Transfer Criteria -- Overview of Adult Admission Criteria -- Diagnosis -- Levels of Care -- Placement Criteria Consideration -- Dimensions for Making Placement Decisions -- LEVEL I: MUTUAL/SELF-HELP -- A. Brief Description of Treatment Level -- B. Programmatic Description -- C. Brief Description of Typical Patient -- D. Dimensional Admission Criteria -- LEVEL II: LOW INTENSITY OUTPATIENT TREATMENT -- A. Brief Description of Treatment Level -- B. Programmatic Description -- C. Brief Description of Typical Patient -- D. Dimensional Admission Criteria -- LEVEL V: MEDICALLY SUPERVISED INTENSIVE INPATIENT TREATMENT -- A. Brief Description of Treatment Level -- B. Programmatic Description -- C. Brief Description of Typical Patient -- D. Dimensional Admission Criteria.

ADULT DISCHARGE & TRANSFER CRITERIA -- Introduction -- Exceptions to Transfer Criteria -- Transfer to a Higher Level of Care -- Transfer to a Lower Level of Care -- LEVEL V: MEDICALLY SUPERVISED INTENSIVE INPATIENT TREATMENT -- LEVEL II: LOW INTENSITY OUTPATIENT TREATMENT -- 12 Determining Outcome -- The Rationale for Outcome Determination -- Some Examples of Systematic Outcome Determination -- A Major Caveat -- Implementing Outcome Monitoring -- Setting the Stage for Outcome Monitoring -- The Content of Outcome Monitoring -- The Process of Outcome Monitoring -- The Locus of Responsibility for Outcome Monitoring -- The Funding of Outcome Determination -- Conclusions and Recommendations -- REFERENCES -- 13 Implementing the Vision: Toward Treatment Systems -- Assuring Continuity of Care -- Feedback of Outcome Information -- An Audit of the Systems Approach -- Description of the Table -- Evaluation of the Systems Approach -- Conclusions and Recommendations -- REFERENCES -- 14 The Treatment of Special Populations: Overview and Definitions -- Defining Special Populations: A Historical Perspective -- The Research Perspective on Special Populations -- REFERENCES -- 15 Populations Defined by Structural Characteristics -- Women -- Adolescents -- The Elderly -- American Indians -- Asian Americans and Pacific Islanders -- Blacks -- Hispanics -- Summary and Conclusions -- REFERENCES -- 16 Populations Defined by Functional Characteristics -- Drinking Drivers -- Dual-Diagnosis Psychiatric Patients -- Homeless Persons: The New Public Inebriates -- College Students -- Children of Alcoholics -- Summary and Conclusions -- REFERENCES -- 17 The Treatment of Special Populations: Conclusions and Recommendations -- REFERENCES -- 18 The Evolution of Financing Policy -- Development of a National Policy.

The Establishment of the National Institute on Alcohol Abuse and Alcoholism -- Using Federal Grants to Increase Treatment Resources -- Efforts to Increase Public and Private Health Insurance -- The Current Situation -- The Shifting Leadership Role -- State and Local Government Activities -- Federal Government Activities -- Private Health Insurance Activities -- Mandated Private Health Insurance -- Changes in Health Care Financing Policy: The Recent Emphasis on Cost Containment -- Health Maintenance Organizations -- Preferred Provider and Managed Care Arrangements -- State Agencies -- Conclusions and Recommendations -- The Current Funding Environment -- The Need for Better Data on Funding and the Costs of Treatment -- REFERENCES -- 19 Cost-Effectiveness -- Studies of Costs and Cost Offsets -- Cost-Benefit and Cost-Effectiveness Analysis -- Matching and Cost-Effectiveness -- Conclusions and Recommendations -- REFERENCES -- 20 Paying for the Treatment System -- Financing the Current Treatment System -- Criteria for Evaluating Coverage Appropriateness -- Optimal Conventional Coverage -- Paying for the Current Treatment System -- Financing the Ideal Treatment System -- Financing the Vision: Paying for Specialized Treatment Services for the Poor and the Uninsured -- REFERENCES -- 21 Leadership -- Our Vision: The Committee's Recommendations -- Opportunities for Leadership -- The Leadership Opportunity for Congress -- The Leadership Opportunity for the States -- The Leadership Opportunity for Employers and Private Insurers -- The Leadership Opportunity for Treatment Providers -- The Leadership Opportunity for the Professions and Training Programs -- The Leadership Opportunity for the National Institute on Alcohol Abuse and Alcoholism -- The Leadership Opportunity for Voluntary and Community Organizations -- The Challenge for the Future -- REFERENCES.

Acknowledgments.