Friday, December 08, 2006

A Critique of Alcohol Abuse Prevention & Rehabilitation: How Current Program and Policy Interventions Lack Behavioral Change Components-Mariah Archer

Past and most current public health approaches to alcohol prevention and rehabilitation do little in terms of incorporating mechanisms of behavioral change to create effective interventions. A look at the Transtheoretical Model (TTM) and Environmental Management Approach show the need of involving stages-of-change behavioral modification and comprehensive programming in the public health agenda. With the use of these models could come a better functioning system of treatment, and also long-term changes in the behavior of people who suffer from alcohol abuse.

Policy as Prevention and Treatment

While many prevention programs use policies to curb the use of alcohol, they often are not well enforced. Mitchell, Toomey, and Erickson (2005) found in a review of current college campus policies, that although all surveyed colleges said they wrote policies to restrict the use of alcohol, the number of implemented policies varied among those respondents. Policies can reduce the ability to obtain alcohol, perhaps preventing some of the negative outcomes that could occur from its use, if the regulations are realistic and capable of being followed and enforced. However, regulations, punishments, and even many prevention programs that focus primarily on prohibitory methods often are not enforced or well regulated. These methods rely on minimizing opportunity to use alcohol, but do not address the negative behaviors associated with use. Our society puts a fair amount of effort into preventing alcohol use and punishing alcohol abuse, yet we do little to try and teach proper consumption or ways to truly recover from abuse.
The use of the TTM’s behavioral change models at northeast university proved to be highly more effective than policy or programming alone. The model used in conjunction with previously used tactics showed that restricting the availability was not the only or best way to change behavior, resulting in increased awareness of policies, decline in binge drinking and alcohol poisonings, and decreased violations among many other behavioral and social improvements (Prochaska, Prochaska, Cohen, Gomes, LaForge, & Eastwood, 2004).
Policy can also play a key role in the process of rehabilitation; however, programs need to be a combination of behavioral rehabilitation and policy interventions in order to fully encompass the needs of the community (Gebhardt, Kaphingst, & DeJong, 2000). Some policies may have an initial effect of prohibiting consumption, but it is important to look at the other underlying factors that may cause prolonged abuse. This is demonstrated when many psychotherapy designs have been combined to create inclusive policy and effective programming, shown with the support of the Educational Development Center’s proposition that policies should not be instituted alone, but as comprehensive programming (The Science of Healthy Behavior, 2001). This encourages intentional change, rather than typically used imposed change that stems from purely politically motivated interventions (Prochaska, DiClemente, &Norcross, 1992).
Policies may discourage repeat behaviors, but they do not necessarily create fewer relapses. One might think in terms of the Health Belief model that an individual would weigh the advantages and disadvantages of relapsing into alcoholism, and realize it is to their advantage to overcome any desire to relapse, but this simply does not hold true in reality. People act on desires, impulses, irrational judgments, and to best overcome these, behavioral modification is necessary (Velicer, Prochaska, Fava, Norman, & Redding, 1998).

Stages of Change

The TTM helps to alleviate the punitive aspects of current programs and policies that do not recognize the addictive nature of the negative behaviors involved in alcohol abuse. Also, it shows there are stages people suffering from alcohol abuse must overcome in order to recover. To successfully reach this state of recovery, each of the “stages of change” must build upon the process that preceded it (Prochaska, DiClemente, &Norcross, 1992).
Traditional interventions are often based as “action oriented” programs that discount many in the treatment population who are not at a stage where they are willing or able to change behaviors (Prochaska, DiClemente, &Norcross, 1992; Ginter & Hensley Choate, 2003).
Current programs of treatment tend to include the 12-step model often used for rehabilitation, non-clinical services such as drug testing, drug education, and self-help, and legal programs such as drug courts that offer an integration of the court system and alcohol abuse programs. However, these programs have been found to be unsuitable for the varying needs of each individual (Taxman &Bouffard, 2003). The 12-step model based on “natural recovery” and its techniques of acceptance of powerlessness, forgiveness, and reliance on a higher power fails to encourage participation and motivation to recover (Laudet, 2003), and is found by Bouffard and Taxman (2004) to be inferior to the effective approaches presented in the model of the stages of change and other cognitive-behavioral techniques.
Programmers and policy makers tend to forget that many people are ordered into these treatments, or if they do participate by choice, they assume that individuals are capable of an immediate, exact, or absolute reversal of their behaviors, and require more than the traditional disciplinary, therapeutic, educational, or libertarian patterns (Peteet, Brenner, Curtiss, Ferrigno, &Kauffman, 1998; Velicer, Prochaska, Fava, Norman, & Redding, 1998).
People needing to enter an intervention will often not require the same type, amount, or stage of rehabilitation. Behavioral treatment based on stages of change would allow for those at all levels to benefit by having the freedom to begin at the stage appropriate for them (Velicer, Prochaska, Fava, Norman, & Redding, 1998). If the individual feels that the program is not at a level they can identify with, they are likely to drop from the program.
A specific use of the TTM is outlined in Marden Velasquez, Gaddy Maurer, Crouch & DiClemente’s (2001) treatment program that not only allows for the stage of change to fit each person’s needs, but also to have the flexibility of time and ability. This treatment program was designed to be able to mold to each individuals’ needs in order to provide a tailored intervention that would help them to succeed at moving throughout the stages of change.
This and other studies suggest that success should also not be based on an absolute (Amaria & Tartaglia, 2002). Rather, it should be based on progress that measures an individual’s ability to successfully move through the stages of change. Traditional programs and policies often jump directly to maintenance or to the end result to “create a [substance]-free environment”, not taking into account the steps that need to come before recovery can occur (Peteet,, Brenner, Curtiss, Ferrigno, & Kauffman, 1998). Following the stages of change can help to discourage relapse as well. The TTM embodies these principles and helps to show that change is a process, and that current public health practice and societal policies ignore this important factor (Amaria & Tartaglia, 2002).
The TTM describes a mechanism of behavioral change that also identifies the process of change as an event dependent on time (Peteet,, Brenner, Curtiss, Ferrigno, &Kauffman, 1998; Velicer, Prochaska, Fava, Norman, & Redding, 1998). Past change models used in various prevention and rehabilitation programs lack this time component, viewing change as a single occurrence rather than a process, a crucial misunderstanding when dealing with behavioral modification. Hospitals, court systems, and some facilities that may be designed specifically for rehabilitation work only to temporarily remove the negative behavior, in this case alcohol abuse, but do not address the factor of change across time as well.

Environmental Approach

The model also looks to include both the social and biological components that make up behavior outcomes (Velicer, Prochaska, Fava, Norman, & Redding, 1998). Many models fail to acknowledge the internal and external forces that work against efforts to change negative behaviors into positive ones, and this is especially true among addictive behaviors. Because of the array of risk factors that can lead to alcohol abuse— to name a few, family history of disease, length and severity of exposure, social influences and pressures, access to substances, presence of support systems, exposure to prevention strategies, ability to receive treatment when needed—intervention approaches must be prepared to deal with all of these sources of abuse (Mitchell, Toomey, and Erickson, 2005)
The Environmental Management Approach also supports the need for more behavioral interventions in alcohol prevention and management. The approach takes the principles of the TTM and applies them in a way that change is made at the individual, community, and societal levels (Prochaska, DiClemente, &Norcross, 1992). A problem with many existing programs is that they are very one-dimensional. They ignore the multilevel interventions that can have an affect on an individual’s ability to permanently change their behavior (Amaria & Tartaglia, 2002).
The EDC has worked to implement several areas of programming, particularly involving alcohol prevention and abuse treatment that embody a type of Environmental Management Approach. They look to establish programs with multiple pronged approaches, including aspects related to education, community, and policy interventions (The Science of Healthy Behavior, 2001). By implementing three to four of these approaches in the intervention, it is able to encompass an individual’s environment, enough so that they have a strong base for change. By changing the environment, overall health as well as negative behaviors can be achieved.
The Albany, New York, Committee on University and Community Relations used this approach in terms of the way decisions were made by students in relation to their drinking habits and the behaviors that result from this use (Gebhardt, Kaphingst, & DeJong, 2000). As a result of their efforts to combine community-based interventions with individual treatment and environmental change, declines in complaints due to student drinking, noise reports, and alcohol related arrests occurred.
In order to best serve this population, one that often needs urgent, continual, specialized, and all encompassing assistance, the integration of theories to build the most effective approach must be designed and implemented. The immediacy of this need is crucial because of the ramifications of the negative behaviors and the severity of problems that can stem from relapse or lack of appropriate rehabilitation. This is why, as public health officials, we must devote our efforts and improve current work to ensure that people get the adequate care they need.

References

Amaria, H., & Tartaglia, D. (2002). Dr. James Prochaska: Changing the Way We Think About Substance Abuse. Princeton, NJ: UMDNJ School of Public Health.
Bouffard, J., & Taxman, F. (2004). Looking inside the "black box" of drug court treatment services using direct observations. Journal of Drug Issues, 34(1), 195-218.
Gebhardt, T. L., Kaphingst, K., & DeJong, W. (2000). A Campus-community coalition to control alcohol-related problems off campus: An Environmental management case study. Journal of American College Health, 48, 211-215.
Ginter, G. G., & Hensley Choate, L. (2003). Stage-matched motivational interventions for college student binge drinkers. Journal of College Counseling, 6, 99-113.
Laudet, A. B. (2003). Attitudes and beliefs about 12-step groups among addiction treatment clients and clinicians: Toward identifying obstacles to participation. Substance Use & Misuse, 38(14), 2017-2047.
Marden Velasquez, M., Gaddy Maurer, G., Crouch, C., & DiClemente, C. (2001). Group Treatment for Substance Abuse: A Stages-of-Change Therapy Manual. New York: Guilford Press.
Mitchell, R. J., Toomey, T. L., & Erickson, D. (2005). Alcohol policies on college campuses. Journal of American College Health, 53(4), 149-157.
Peteet, J. R., Brenner, S., Curtiss, D., Ferrigno, M., & Kauffman, J. (1998). A Stage of change approach to addicition in the medical setting. General Hospital Psychiatry, 20, 267-273.
Prochaska, J.O., DiClemente, C.C. & Norcross, J.C. (1992). In search of how people change: Applications to addictive behavior. American Psychologist, 47, 1102-1114.
Prochaska, J. M., Prochaska, J. O., Cohen, F. C., Gomes, S. O., LaForge, R. G., & Eastwood, A. L. (2004). The Transtheoretical model of change for multi-level interventions for alcohol abuse on campus. Journal of Alcohol and Drug Education, 47(3), 34-50.
The Science of Healthy Behavior: Using Research-Based Policies and Strategies to Promote Health and Safety. (2001).). Newton, MA: Education Development Center, Inc.
Taxman, F., & Bouffard, J. (2003). Drug treatment in the community: A Case study of system integration issues. Federal Probation, 67(2), 4-14.
Velicer, W.F., Prochaska, J.O., Fava, J.L., Norman, G.J. & Redding, C.A. (1998). Smoking cessation and stress management: Applications of the Transtheoretical Model of behavior change. Homeostasis, 38, 216-233.

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  1. This is an excellent, and very interesting critique. While the stages of change theory has been used extensively in smoking cessation programs to try to target the appropriate subpopulations of smokers with stage-specific interventions, this approach has not generally been used with alcohol treatment interventions. You make a compelling argument why this should be done. This is a very important paper for practitioners in this field to consider.

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