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Designing Effective Alcohol Treatment Systems for Rural Populations: Cross-Cultural Perspectives

William R. Miller, Ph.D.
Kamilla V. Willoughby, M.S.
Department of Psychology and Center on Alcoholism, Substance Abuse, and Addictions
The University of New Mexico
Albuquerque, New Mexico

Abstract Treatment delivery systems have often been based on a therapy ethos which assumes that people are unable to resolve their problems without professional treatment whereby a therapist uses special knowledge, insights, or techniques to change the recipient of services. This assumptive system poses a quandary in serving diverse rural populations with multiple barriers to intensive therapy. Recent substance abuse treatment findings, reviewed in this paper, question the validity of the therapy ethos, even in urban contexts. Alcohol problems occur along a continuum and respond to interventions that vary widely in intensity and content. In studies ranging across many cultures, relatively brief consultations of from one to three sessions have been shown to trigger change that may be similar in magnitude to the effects of more extensive treatment. Such consultation can be integrated into routine healthcare, employment, or pastoral care systems. Effective interventions through mail and telephone consultation have also been demonstrated. Contrary to stereotype, a warm and empathic counseling style has been found to be superior to more aggressive confrontational approaches. Consultation that is supportive and empowering may often trigger change, and can be delivered without the cost and disruption of removal to a remote treatment center. Research is needed to discover change strategies that are appropriate and effective for specific cultural populations. Relatedly, there is a need for greater attention to the community context within which substance abuse occurs, and to local culture-specific resources that can stimulate and support change.

Alcohol treatment delivery systems are changing rapidly in the United States. There has been a dramatic shift in professional conceptions of alcohol problems, emphasizing a continuum of severity rather than a distinct and unitary disease (Institute of Medicine 1990). Managed care and health care cost containment pressures have substantially shortened the average length of care, and required a rapid shift away from residential and hospital-based programs. The treatment of alcohol problems is more closely integrated with mental health services and is increasingly delivered by degreed professionals rather than recovering paraprofessionals. The rapid growth of scientific knowledge has contributed new treatment methods and information about their effectiveness (Hester and Miller 1995).

Greater attention is also being paid to the matching of individuals with optimal treatment approaches (Mattson et al. 1994). There is growing consensus that a "one size fits all" treatment is inadequate to meet the needs of diverse populations. Treatment systems offer targeted services and even separate programs for "special" populations including women, racial/ethnic minorities, gays and lesbians, adolescents, and the elderly (Erickson et al. 1996).

A difficulty here is that the current scientific literature provides few data to guide the tailoring of treatment to such special populations. A few studies reflect the potential benefit of specialized services for women (e.g., Dahlgren and Willander 1989; Sanchez-Craig et al. 1991). No controlled trials to date have demonstrated superior differential outcomes of certain treatments for specific groups defined by age, ethnicity, or sexual preference. How, then, should one proceed in designing treatment systems to serve specific or diverse populations?

The reflections contained in this paper were occasioned by an invitation to address a conference, "Addressing Alcohol-Related Problems in Alaska," convened in Anchorage in 1995 under the sponsorship of the National Institute on Alcohol Abuse and Alcoholism. The subject was, in a way, daunting, because virtually no outcome studies have been published on the treatment of alcohol problems among Alaskan people.

At the same time, the challenge proved stimulating, because it raised many questions about how the vast current literature on alcohol treatment effectiveness might be applied in developing optimal treatment systems for this relatively unstudied and largely rural/frontier population. That is the principal topic of this article. We first consider major trends in the clinical research literature that have implications for designing treatment systems for special or culturally diverse populations. These are then integrated to derive recommendations for serving rural populations in particular.

The Nature of Alcohol Problems

Before designing treatment, it is wise to consider the phenomenon being treated. There are major cross-cultural differences not only in patterns of drinking and its consequences (Helzer and Canino 1992; Maula et al. 1990; Single et al. 1981), but also in conceptions of the nature of alcohol problems (Bennett et al. 1993; Legge and Sherlock 1991; Sigelman et al. 1992).

From the 1960s through the 1980s, popular and professional conceptions in North America (and to a lesser extent in Europe) focused heavily on "alcoholism" as a unitary disease, qualitatively distinct from normality, consisting of an irreversible biologically rooted incapacity to regulate one's own use of alcohol (Heather and Robertson 1983; Milam and Ketcham 1981; Miller 1993).

A progression of symptoms of alcoholism was described by Jellinek in 1952, based on interviews with over 2,000 male members of Alcoholics Anonymous. Attempts to replicate Jellinek's syndrome met with some success when the population consisted of American white males (Park and Whitehead 1973). Greater divergence was found when males were studied in Finnish (Park and Whitehead 1973) and Navajo cultures (Willoughby 1995). When samples of women have been studied (all of Jellinek's respondents were male), convergence with Jellinek's progression has been modest at best for American women (James 1975; Piazza et al. 1986), and virtually zero with Navajo women (Willoughby 1995).

Jellinek himself renounced this unitary model of alcoholism in 1960, proposing instead a variety of kinds of alcohol problems, and supporting a broad generic definition of alcoholism as any drinking that inflicts harm—a definition ultimately adopted by the World Health Organization (1952) for its cross-cultural generalizability. It was, in fact, to the adverse consequences of excessive drinking that Magnus Huss (1849) referred in coining the term alcoholism.

The diagnostic label of "alcoholism" was formally replaced by "alcohol abuse" and "alcohol dependence" in 1980 and no longer appears in the Diagnostic and Statistical Manual of the American Psychiatric Association (1994), a change also reflected in the International Classification of Diseases.

Recent influential writings on prevention and treatment have favored the still more generic term "alcohol problems" (Institute of Medicine 1990). The picture that emerges is one of substantial diversity, continuously distributed along not one but several dimensions of severity of alcohol involvement (Miller, Westerberg, and Waldron 1995). It is reasonable to expect, therefore, that no single treatment approach is likely to suffice in addressing such diversity, and that is precisely what the outcome literature indicates.

The Efficacy of Treatment Modalities

No blanket pronouncement of treatment effectiveness can be given (Institute of Medicine 1990). Dozens of different treatment methods for alcohol problems have been tried, and many of these have been tested in formal clinical trials. The result is substantial evidence that some treatment methods are effective, others show promise, and still others seem to exert little or no beneficial impact on excessive drinking and related problems. The good news is that there is an encouraging array of different treatment methods with evidence of efficacy (Miller, Brown et al. 1995).

From a cross-cultural perspective, however, it is worrisome that the vast majority of treatment outcome studies have been conducted with urban white English-speaking populations of European heritage. A very few reports have provided systematic outcome data regarding the treatment of alcohol problems in Hispanic (e.g., Arciniega et al. in press; Szapocznik et al. 1986), Asian (e.g., Kua et al. 1990), black (e.g., Miller and Verinis 1995), Native American (e.g., Ferguson 1970; Shore and von Fumetti 1972; Wilson and Shore 1975) or other indigenous peoples (e.g., Kahn and Fua 1992). Similarly, few controlled trials have been conducted with rural populations (e.g., Sanchez-Craig et al. in press), or with adolescents (e.g., Carpenter et al. 1985) or elderly individuals (e.g., Frederiksen 1992; Graham et al. 1995). To what extent are findings from the large English-language mid-adult alcohol treatment outcome literature generalizable to other groups?

It seems at least reasonable, in searching for effective treatment methods to include in a service delivery system, to begin with approaches that have been shown to have specific efficacy in other settings. If one is treating pneumonia, established antibiotics are a good start even though controlled trials may not have been published for the specific subgroup to which the patient belongs. It seems improbable (though by no means impossible) that a treatment method with well-demonstrated efficacy for adults in their twenties, thirties, and forties will somehow lose its effectiveness with people younger than 20 or older than 50. Similarly, a treatment or medication found to be inert in two dozen controlled trials is unlikely to spring suddenly to life when applied with people from a different culture, though again it is not unimaginable.

Another fruitful avenue is to ascertain important causal factors in effective treatment. Why do apparently effective treatments work? An understanding of the mechanisms underlying efficacious treatment methods may suggest culture-specific strategies. For example, one of the most consistently supported treatments for alcohol problems is social skills training. The specific content of such training as practiced in urban North America is unlikely to transfer well to indigenous villages of Alaska, Fiji, Mexico, or Africa. Yet the underlying principle is more likely generalizable: that sobriety is promoted by having rewarding interpersonal relationships and ways of spending time that do not involve drinking (Meyers and Smith 1995). If this principle holds across cultures, then the question becomes one of how best to promote social support for sobriety and nondrinking activities within the local context. This may involve individual training, but might equally involve systematic changes in the social environment.

Evidence on Cost-Effectiveness

There is a surprisingly robust finding that is of immediate importance in designing rural treatment systems, and that seems to hold up well across cultures. This is the finding that even relatively brief counseling, when done properly, can have a beneficial effect on problem drinking. A rapidly growing literature, now numbering over three dozen trials from at least 14 different nations, shows encouragingly large changes in drinking after brief counseling of from one to three sessions (Bien et al. 1993; Miller, Brown et al. 1995). Brief, personally empowering counseling has been shown to be substantially more beneficial than placing a person on a "waiting list" for services (Harris and Miller 1990; Miller et al. 1993; Miller and Sanchez 1994). It appears, in fact, that putting someone on a waiting list is an implicit instruction to wait that is, not to change until services can be provided.

A puzzling finding is that when such brief interventions have been compared with more extensive forms of treatment, studies have often found relatively little difference in long-term outcomes (Bien et al. 1993; Holder et al. 1991). That is, the amount of benefit that follows from well-delivered brief counseling is often found to be comparable to that related to longer courses of treatment. This parallels the finding of few differences in the long-term overall effectiveness of more intensive (e.g., inpatient) versus less intensive (e.g., outpatient) treatment (Holder et al. 1991; Institute of Medicine 1990; Miller and Hester 1986). Though unsettling in a way, this finding is also encouraging because (1) substance abuse clients often fail to stay for more than a few sessions, even when more treatment is available; (2) public treatment systems are often unable to provide prompt extended treatment to all who present for services; and (3) managed care and other health economic constraints are reducing the length of service normally provided. Furthermore, some health service settings (such as employee assistance programs and primary care clinics) are inherently limited in the length of time that can be devoted to alcohol counseling. The hopeful message is that even within such constraints, it is possible to deliver beneficial services (Miller et al. 1994).

Cultural and geographic constraints may also favor relatively brief counseling. Sanchez-Craig and her colleagues (in press) demonstrated the feasibility and efficacy of brief telephone counseling for alcohol problems among rural residents of the sparsely populated province of Ontario. Brief consultation to reduce drinking and related problems can be effectively delivered by health professionals and integrated into routine health care (Heather 1995).

Again, a key question is why and how such brief interventions work. Although there is considerable consistency in the cross-national content of effective brief interventions studied to date (Bien et al. 1993), the mechanism of their efficacy remains unclear. One possibility is that such interventions trigger internally motivated change by helping the drinker to resolve ambivalence about alcohol and to reach a clear decision to change (Miller and Rollnick 1991). In our study of change strategies used by alcohol dependent Navajo people, the making of a clear decision to change emerged among the final (rather than early) steps, often years after sampling a variety of strategies including AA attendance, professional treatment, and hospitalization (Willoughby 1995). If a clear personal commitment is a key and decisive factor in triggering change, the efficacy of brief interventions (and the finding of similar impact to more extensive treatment) becomes more comprehensible. In designing intervention systems, then, it would be prudent to attend to this motivational issue as an important and early element of intervention, and the question becomes how best to do this within the local culture or target population.

The Impact of Therapist Characteristics

Another noteworthy finding in the planning of alcohol treatment systems is that caregivers have a substantial impact on outcomes. Early research on the determinants of client dropout ascertained that therapists vary widely in their retention of clients (Miller 1985). Some therapists lost few of their clients, whereas others accounted for a significant percentage of lost cases. The same turns out to be true of substance abuse treatment outcomes. Clients assigned at random to different counselors show markedly different rates of improvement (Najavits and Weiss 1994). It matters who is delivering alcohol services.

What accounts for these differences in therapist effectiveness? American programs have historically given priority to the hiring of counselors who identify themselves as recovering alcoholics. Is personal recovery status a predictor of therapists' success? Here we encounter another strikingly consistent finding. From more than 50 studies addressing this question, McLellan and his colleagues (1988) found no evidence that recovering counselors produce any better (or worse) outcomes when compared with therapists not in personal recovery. Health caregivers need not be recovering people themselves in order to be effective substance abuse counselors. Recovery status appears to be unrelated to counseling success, and it makes no more sense to rely upon former patients as counselors in this field than in the treatment of depression, schizophrenia, diabetes, or marital problems.

Level of empathic skill, however, does appear to be a robust predictor of therapist success. In a prospective study, Miller and colleagues (1980) found that therapist empathy accounted for two-thirds of the variance in client outcomes at 6 months, and even 2 years later empathic skillfulness significantly predicted greater improvement on drinking measures (Miller and Baca 1983). Valle (1981) similarly found that interpersonal skillfulness (e.g., warmth and empathic listening) accurately predicted relapse rates among clients randomly assigned to therapists. Conversely, confrontational counseling styles have been associated with increased client resistance and poorer client outcomes: The more a therapist confronts, the more the client resists change (Patterson and Forgatch 1985) and continues to drink (Miller et al. 1993). Confrontational treatments in general have compared unfavorably with other therapeutic approaches (Miller and Rollnick 1991; Miller, Brown et al. 1995).

The extent to which this finding will generalize across cultures remains to be determined. The current data at least suggest caution in exporting traditions of hiring former patients and employing aggressive confrontational intervention tactics. The selection of caregivers appears to be one of the more important decisions made in constructing treatment systems, and it is sensible to use, as criteria in hiring, those counselor attributes found to be associated with more favorable client outcomes.

Treatment Matching

In serving any diverse population, it is sensible to include a menu of different treatment strategies, emphasizing approaches with sound evidence of efficacy. Once one has a range of alternative services for diverse clients, however, how does one decide which methods to offer to which individuals? This is the challenge of client-treatment matching.

An encouraging literature already exists to suggest that different kinds of clients benefit from different treatment methods (Mattson et al. 1994). Relatively little is known, however, about the optimal strategies for matching individuals with options. As research evidence accumulates, some clear empirical guidelines may emerge for choosing among specific alternatives. Kadden and his colleagues (1989), for example, found that individuals with comorbid alcohol dependence and antisocial personality disorder responded more favorably to cognitive-behavioral coping skill training than to supportive-expressive psychotherapy. Yet the range of potentially relevant client attributes is vast, and there is a substantial menu of treatment options from which to choose (Hester and Miller 1995). It will be difficult indeed to establish objective matching criteria to address such complexity. Therapist judgment is notoriously unreliable in clinical prediction (Wiggins 1973), often heavily biased toward one approach (Hansen and Emrick 1983), and there is no persuasive evidence that therapist-mediated matching improves over chance or natural selection processes. An empowering alternative is to involve clients in the selection and design of their own treatment. There is evidence that when people freely choose a course of action, they are more likely to persist in and succeed with it (Deci 1980; Miller 1985).

Developing a Culture-Specific Knowledge Base

Treatment outcome research may have some important limitations when findings come from a restricted range of clients. What works well in one setting may be ineffective or inappropriate in another. The more that the studied samples differ in important ways from the population to be served, the greater the caution warranted in importing treatment approaches without specific further testing. The only way to know for sure how well a treatment approach works in a new context is to test it carefully and systematically. The subjective impressions of providers and clients are notoriously inaccurate indicators of actual treatment outcomes.

Furthermore, culturally appropriate interventions may not have been tested precisely because they are specific to an understudied population. Sweat lodges, vision quests, and ceremonial sings are traditional paths to healing among some Native American groups, but are unlikely to have been widely practiced and tested in other cultures (Manson et al. 1987). Acupuncture and meditation are commonly practiced in some Eastern cultures, but are only beginning to find their way into Western clinical trials (e.g., Bullock et al. 1987; Murphy et al. 1986). Such "alternative" (from the perspective of a different culture) treatments deserve consideration in the design of treatment systems, but like all therapies and medications should be carefully tested before being used routinely or preferentially.

These factors point to the importance of committing a portion of the resources of any service delivery system to careful program evaluation. This is also a reasonable self-defensive practice amidst growing economic pressure that require, as a condition for continued funding, demonstration that resources are being used fruitfully and wisely. Beyond such important pragmatic benefits, however, routine self-evaluation (for systems as for individuals) provides valuable feedback to be used in development. No learning occurs without knowledge of results. Reliable feedback helps a system keep growing and improving its services. In the absence of current research, a treatment program has to start somewhere, but without self-evaluation the program and the field are no better off 10 years later.

A common response is to acknowledge the value of program evaluation but to say, "That's just not our mission. Our mission is to provide services." But is it really? Does a program truly exist for the ultimate goal of providing services? In fact, the ultimate goal is usually to bring about some beneficial change, and the provision of services is toward that end. Funding sources are increasingly concerned with evidence that intended outcomes are being achieved, and the mere assurance that services have been provided is insufficient. To know whether a program is producing desired changes (or to discover how to do so more effectively) requires careful evaluation. Until such information is gathered by treatment systems serving specific populations, we remain ignorant of the cross-cultural effectiveness and generalizability of different approaches.

A truly effective treatment system therefore needs a built-in method for self-evaluation, by which services can be improved. In simplest form, this involves collecting reliable information about those things (e.g., drinking behavior) that the program is intended to change. A first step in that direction is to provide a consistent pretreatment evaluation of each and every client to be served. This need not be complex or terribly time-consuming, although there are certain benefits to a comprehensive assessment. It can and should be built into routine services. The point here is to collect the same reliable information about each person's status before services are delivered. Such information can, in turn, be useful in treatment planning, and in motivating clients for change (Miller, Westerberg, and Waldron 1995). The addition of systematic followup evaluations can then document changes related to services (Miller 1988).

Reflections on Serving Rural Populations

Our preparation for and experience at the Alaska conference caused us to step back and reflect upon implicit assumptions that have guided treatment delivery. Within the context of Western service delivery systems, there has developed a set of assumptions that could be termed a therapy ethos. These might be stated as follows:

1. People ("patients") who come for treatment are unable to resolve their problems on their own, and require professional help.
2. This involves a process of therapy whereby an expert (therapist) uses special knowledge, insights, and/or techniques to change the recipient of these services. Healing comes from the therapist to the patient.
3. The patient's role is to receive the therapist's expert help and to comply with the prescribed treatment. This often requires that the therapist confront and overcome a client's resistance.
4. The course of treatment would be expected to require a somewhat protracted period of time for therapy to take effect. The longer a patient gets to work with the therapist, and the more intensive the treatment, the greater the improvement.

Even within the Western scientific context of controlled clinical trials, the evidence seems to us to indicate that there is something fundamentally wrong with this psychotherapeutic way of thinking about change. Most tobacco and alcohol problems are resolved without formal treatment (Sobell et al. 1991; Vaillant 1995). Among those who do come for treatment, the degree of beneficial change is not found (in controlled trials) to be substantially related to the length of their exposure to therapy or to its intensity. Exposure to certain (e.g., more confrontational) therapists, in fact, is associated with a decreased likelihood of improvement (McLellan et al. 1988; Miller et al. 1980). When people are told to wait for professional treatment (being placed on a waiting list), they don't get better. When they are given one or a few sessions of brief, empowering counseling, they often show rapid and enduring change that may be similar in magnitude to that observed (on average) from more extensive treatment (an observation not dissimilar from anecdotal reports from Alcoholics Anonymous). When therapists (and presumably others) expect a person to recover, it tends to happen (Leake and King 1977). Treatments very different in their content often yield similar overall outcomes.

The chances of getting better in treatment are powerfully affected by the therapist to whom, by luck of the draw, one is assigned. Clients' "resistance" or "denial" appears to be an interpersonal phenomenon strongly influenced by the therapist, and counseling styles that increase client resistance produce little change, whereas empathic styles that minimize resistance are associated with relatively rapid change. People who faithfully do something to recover (even something that should not "work," like taking placebo medication) show better improvement. When people exercise control over their own treatment (such as choosing their approach to change), they fare better. People sometimes show dramatic and sudden bursts of change, usually outside the context of therapy, that are associated with broad and enduring transformation (Miller and C'de Baca 1994). A letter or a phone call can make a substantial difference in the course of treatment (Miller 1985). What happens after treatment, such as the extent of employment and social support (Moos et al. 1990) or Alcoholics Anonymous involvement (Montgomery et al. 1995), may be more powerful determinants of outcome than the events of formal treatment.

What's going on here? The pieces don't fit together neatly into the therapy ethos picture that says: "People must have treatment in order to recover, and the more they get the better they do." There is much to support a view that people have within themselves powerful resources for change, which are engaged by a firm decision and commitment. Personal empowerment communications, rather than those that foster reliance on an expert helper, may set change in motion. The interpersonal resources of the individual's community can also play a key role in recovery.

We certainly do not advocate the replacement of comprehensive treatment systems with brief interventions. There is need for a range of options among which the individual can find an avenue toward change. Yet we do see reason for caution, a danger in blindly accepting the therapy ethos and constructing treatment systems that imply and foster dependence on experts. Change happened and people recovered from alcohol problems long before there were professional addiction experts or treatment systems, and both individuals and communities contain within them many resources for change.

The implications of this different way of thinking, and of recent research reviewed above, are particularly provocative as one considers how to serve rural and frontier populations without ready access to complex treatment delivery systems. Brief motivational interventions, which are well-supported as triggering change in substance abuse, can be offered in various contexts accessible to rural populations: through one or two visits, or within the context of primary health care, or even by telephone (Sanchez-Craig et al. in press). Even mail contacts can have a beneficial effect on heavy drinkers (Agostinelli et al. 1995; Heather 1995). Thus, brief counseling, deliverable in a variety of forms, may suffice to trigger change in alcohol/ drug use, particularly when it occurs before the development of severe dependence.

When further support is needed for change efforts, what directions arise from research to date? One approach applied with rural populations has been to transport affected individuals to a distal treatment center, where they remain for a period of days or weeks before returning home. This "remove, rehabilitate, and return" model (reminiscent of automobile repair) assumes that the problem resides within the individual, and can be corrected by a stay in a therapeutic milieu. Yet drinking or drug use and related problems occur in a sociocultural and community context that is likewise quite important in sustaining change (Moos et al. 1990). Although changes (e.g., learning new coping skills) may occur in a distal treatment environment, they must ultimately generalize to the person's home environment. "Outpatient" treatment within the person's community context appears to be at least as effective as removal to an institutional center, with the additional benefits of being more cost effective and less disruptive (Holder et al. 1991; Institute of Medicine 1990).

How, then, can therapeutic services be delivered to rural populations? The concept of a "visiting therapist" may be workable with isolated individuals, but the intimacy of social life in most rural settings can pose substantial obstacles to confidentiality. Service delivery by correspondence or telephone affords greater privacy and may be more effective than previously assumed. It is also feasible to integrate screening and intervention for substance abuse into routine health care (Cooney et al. 1995), employee services (Miller et al. 1994), or even pastoral care (Miller and Jackson 1995), which can substantially increase identification while retaining confidentiality and intervening through natural helpers. In this context, individuals can be involved in selecting their own strategies for change, and choosing any forms of additional support that may be helpful to them in achieving their goals (Miller and Rollnick 1991). Change can also be accomplished by working confidentially through concerned family members (Meyers et al. 1995; Meyers and Smith 1995). All of this still assumes to some extent a caregiver model, and other approaches for using natural community resources need to be explored.

Finally, as stated above in the more general context of programming for special populations, it makes sense to begin with approaches that have worked in other settings. Although there are a few methods developed and tested with rural populations (e.g., Azrin 1976; Meyers and Smith 1995), those treatment approaches that have been found to be particularly effective in other settings represent a promising starting point in thinking through strategies for rural services. Adaptations are likely to be needed when established methods are applied in new cultural contexts, but approaches with demonstrated efficacy still constitute a sound beginning. Likewise, characteristics of more effective helpers may well be similar across settings, and it is sensible to take advantage of this knowledge in planning new service systems. Nevertheless, it is prudent to include in any newly implemented system the means to evaluate outcomes, both in response to accountability demands and as feedback for improving services.

In sum, there are many resources for change within individuals and their communities, and this should be remembered in developing new systems designed to alleviate the suffering related to substance abuse. This perspective holds particular promise when stepping outside the context of urban treatment systems. Exactly how to understand and engage natural change resources in rural and frontier settings is a puzzle well worth solving. Perhaps treatment system experience and research in such settings will provide new pieces of the puzzle, contributing to a more general understanding of how natural change occurs, and how it can be facilitated.

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Last Updated 11-7-02