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Innovative Strategies for Improving the Delivery of Substance Abuse Services in a Rural Area

Sylvia Wilber, B.S.E.
Program Director
Sigrid Congros, B.S.
Grant Writer
Maehnowesekiyah Treatment Center
Gresham, Wisconsin

The Maehnowesekiyah Treatment Center is the alcohol and drug abuse treatment and prevention agency for the Menominee Indian Tribe of Wisconsin. The center provides comprehensive services for the AOD treatment needs of the Menominee tribal members and others with unique strategies for efficient service delivery. Maehnowesekiyah (Mano-SAY-key-ah) is a Menominee expression meaning, "We will all feel better." It signifies the cultural sensitivity and goals for community wellness that are incorporated into the existing treatment programs at the Maehnowesekiyah Treatment Center.

Challenges Faced by a Rural Program

Rural program operators such as Maehnowesekiyah face many challenges, including client accessibility to services, the stigma and prejudice surrounding alcohol and drug treatment, and the maintaining of a sufficient client base with its interrelated financial stability. We also have a very important asset, which is knowledge and sensitivity concerning the local community and culture. Treatment providers must use this knowledge if they are to develop a successful program that comprehensively meets the needs of the people they serve. This can be accomplished by continually evaluating and upgrading the services provided, and by pursuing the resources necessary to meet the needs identified.

As written in our philosophy statement:

Maehnowesekiyah Treatment Center affirms that all people—red, white, black, or yellow—experience a unique culture based on their own values, history, and spiritual ways. We are witnesses to the destructive effects Alcohol and Other Drugs have on this culture and tradition. We realize that if abusers are educated on the effects and consequences of Alcohol and Other Drug Abuse, they will recognize that there is a better way of life, and they will desire that better way of life. We believe that a variety of approaches are successful in assisting our clients in attaining this better way of life, and recognize the individuality of our clients in walking down the path to recovery. Maehnowesekiyah strives to provide services to the client with respect, care, and patience . . . We seek to heal holistically by treating the chemical abuser and the family that the abuse affects.

Comprehensive provision of services and a sensitivity to community attitudes, customs, and beliefs are integral components of a rural treatment program. To provide clients with the tools to maintain a drug-free lifestyle, we must address their social, educational, medical, personal, interpersonal, and psychosocial areas. It is only by addressing the total person that we believe a drug-free lifestyle will be possible for our clients.

Maehnowesekiyah has won accreditation from the national Commission on Accreditation of Rehabilitation Facilities. In a rural area, the lack of options in choosing facilities and services necessitates high standards in available services. Maehnowesekiyah continually seeks to upgrade its services through staff training, program evaluation, and implementation of support services that are unavailable in the community.

The Staff Development Program was implemented in 1991 in cooperation with the University of WisconsinBStevens Point and Green Bay to serve the continuing education needs of our AOD staff. The program promotes teamwork among the staff while enhancing individual abilities. The ongoing education program provides continuing education credits for staff who are progressing in personal counseling skills and certification status, and exposes administrative and therapy staff to the operating concepts, problems, and importance of each individual area. The structure of the program has created a sensitivity and appreciation for the contributions of fellow staff and has enhanced staff abilities, motivation, and interpersonal relations. Training includes education on the Menominee culture and tradition to assist non-Native counselors in developing a sensitivity to the culture. It is helpful to the counselors to have this groundwork in order to separate the traditional cultural elements from the behaviors that have been precipitated by years of injury and damage to the culture.

Ongoing Program Evaluation

An ongoing system of evaluation is used to determine which services will be provided. These service decisions are based on a systematic process of objective evaluation, data collection, and program monitoring. The internal process evaluation at Maehnowesekiyah includes a weekly administrative review of the program in which counselor coordinators consult with chief administrators and other staff as requested. The counselor coordinators supervise progress on treatment plans and client file entries. Consultants used in this process include a clinical psychologist, who participates in bimonthly client staffing sessions, and the medical director of the Tribal Clinic, who conducts an assessment review. Additionally, counselor coordinators meet weekly with their respective department staff to discuss program procedures and issues, as well as client progress and changing needs of the individual. All meetings and consultant sessions provide direction for program services and activities, while monitoring the changing needs of the individual and the availability of community services to meet those needs.

The University of Wisconsin–Madison Center for Health Policy and Program Evaluation, a contracted consultant, has developed monitoring forms for a computerized data base system. Intake forms summarize the following:

• Demographic information
• AOD treatment history
• Assessment results
• Criminal justice history
• Mental health treatment history
• Source of referral
• Type of housing
• Source of income
• Primary and secondary drug choice with frequency of use

Client discharge forms document the following information:

• Type and frequency of services provided
• Units of service delivered
• Referrals to outside agencies
• Average time in treatment per client

These data are then entered into a specially designed computer program which has the capacity to provide up-to-date process information and periodic analysis of outcome information. Forms include all grantor reporting requirements.

Clients also complete a discharge survey that asks them to identify their perception of the strengths and gaps in the services provided to them during their course of treatment. This information enters the review process directly through discussion at the weekly administrative meetings and is also documented for further review upon tabulation with a larger number of clients.

Through the evaluation process, Maehnowesekiyah has identified several key problem areas commonly found among patients who present with AOD issues in the Maehnowesekiyah community. Service to these special needs has been responsible for the rapid growth in Maehnowesekiyah treatment programs since 1990. By the system of review already described, we identify client needs and make decisions about how those needs will be met. Since this policy of review was implemented, several dominant areas of client need have emerged, including family relationships and poor parenting practices, co-dependency, homelessness, domestic violence, independent living skills, and vocational rehabilitation. In its years of service to the reservation community, Maehnowesekiyah has identified certain universal factors contributing to the continued problems of alcohol and drug abuse. These include:

• Cultural identity issues
• Widespread generational problems of addiction
• Poverty

These factors must be addressed in order to successfully provide treatment to everyone in need.

The Maehnowesekiyah Treatment Philosophy

Maehnowesekiyah's core treatment program is a culturally sensitive adaptation of the Alcoholics Anonymous 12-Step program. The Native American Self-Actualization Process by Sidney A. Stone revolves around the resolution of cultural identity conflicts. Cultural identity conflicts are common among Menominees because of the confusion resulting from their forced relocation, termination, discrimination, and assimilation. Therefore, this method of conflict resolution is a culturally sensitive and appropriate approach.

Treatment concepts focus on the Rational Behavior Therapy (RBT) guidelines, which offer clients a means to think and behave rationally and eventually to solve/resolve their own emotional problems, using their ability to think. Counselors offer this therapy in two ways. First, for the duration of the client's treatment experience, the counselors demonstrate how the therapy works in day-to-day life in addressing the client's daily issues, life problems, etc. Secondly, by using the established 13-unit program that teaches clients very specifically how to manage themselves and their issues, these clients learn a skill they may use long after their treatment is completed. The counselors at Maehnowesekiyah have been trained to use these materials through the ongoing Staff Development Program.

Conflicts in Individual and Cultural Identity

The clients of our treatment program are unique in having individual identity conflict issues that arise because they are part of a minority group with varying levels of cultural identity. Our method of approaching and addressing the cultural needs of clients is to assess their cultural position and educate. Using the standard definition of culture to mean "socially transmitted behavior patterns, arts, beliefs, and all other products of human work and thought," we educate the clients as to their traditional and spiritual mores.

Native Americans often enter treatment as very wounded and violated individuals, and they seldom possess the strength necessary to stand up for themselves and/or set boundaries. Past generations of Native Americans were put down for being Indians to the point of becoming instantly ashamed any time they were in the presence of

non-Native people. This has become a multigenerational problem, since the perception of shame is passed from parent to child, even though the child may not have experienced shame directly. Consequently, clients often go along with group activities merely because they don't have the courage to decline or do not believe they have the right to. We do not, therefore, expose clients to situations or decisions which demand that they decline a practice possibly universal among their peers, especially when that practice is very much identified with "being an Indian."

All clients come with some degree of cultural identity that falls within a continuum of Native American identity. Education and discussion of what they discern as Indian values, beliefs, and practices helps them to identify their placement on the continuum. Clients begin to understand that they are "traditional" and they do possess "traditional values." This creates within each client a strong sense of pride for who and what they are, as they become better connected to their identity as Indian People.

Community Denial of Substance Abuse

The Menominee Indian Reservation has a significant problem with community denial of the substance abuse problem. The widespread problem of addiction within the local Menominee community presents a need to assist clients in seeking or developing a supportive environment for their continued recovery. After generations of AOD abuse, the problems and issues of alcoholism have become ingrained in the culture; these could take generations to remove. Maehnowesekiyah operates under the assumption that we do not have that much time. The ever-present damages from death by injury and illness continue to perpetuate problems associated with grief, denial, and self-destruction. In 1992, 12.4 percent of all hospitalizations were alcohol related. In 1990, 60 percent of all injuries requiring medical attention, including assault and suicide, were also alcohol related.

The reservation itself is considered a high-risk environment for abuse of alcohol and other drugs because of poverty, insufficient housing, and the community acceptance of alcohol and other drug abuse. This is substantiated by statistics on our youth population. A 1992 survey of Menominee youth (Teen Assessment Program) shows that by age 11B12, 49 percent of males and 61 percent of females use alcohol. According to Healthy People 2000 statistics, the average age of first use on a national level is 13.1 years of age.

Program Services

Maehnowesekiyah offers a comprehensive array of services for the Menominee community. These services, described below, include family therapy, parenting, support for children from substance-abusing families, treatment for pregnant and postpartum women, domestic violence therapy for perpetrator and victims, independent living skills, co-dependency and women's therapy groups, child care, and emergency housing and shelter.

Special Needs of Substance Abusing Families

Persons in the Menominee community have frequently been raised in an AOD environment and their families are not in recovery; this situation requires intensive reeducation in the family system. In response to this, Maehnowesekiyah has implemented a family therapy component within the treatment program and provides parenting classes to the community at large as well as within the treatment programs. During family therapy, significant others are brought into the treatment plan. Families discuss the effects of co-dependency, grief, and healing as they recognize family roles and age- and sex-appropriate responsibilities. They discuss family rules, communication within the family, and family contracts. During their treatment and recovery, they learn reorganization of the whole family and new expressions of love and anger as well as sober family fun. Tools used in this process include role playing, guided and self-directed imagery, play therapy, and transactional analysis focusing on inner parent, adult, and child interactions. Family groups are flexible, with priority given to issues requested by the family. Additionally, clients receive education and therapy in healthy relationships, sexuality, and health education.

The children of substance abusers have special needs which, if unattended, create an even higher risk for substance abuse problems in their adult life. It has been shown that adolescent children who have first- and second-degree alcoholic relatives have higher rates of alcohol and other drug use, begin using gateway drugs at an earlier age, and have more AOD problems.

Provision of Child Care Services

Child care services are available for all outpatient treatment programs and for the new treatment program for pregnant and postpartum women who are in treatment with their children. Children of treatment clientele benefit from improved family structure, day care, and school services that promote their physical, social, and cognitive development. The Child Care program follows a daily plan for development of the children's fine and gross motor skills as well as socialization activities. Our day care program is working toward licensure as a day care provider.

Implementation and review of the child care services has led to upgrading of staff qualifications in the program. The Child Development Coordinator has a B.S.E. with early childhood certification. This staff person keeps individual files on the children in our care and notes any unusual behaviors as well as changes in behaviors. The coordinator participates in staffing sessions with the child's parent(s) and assigned counselor; in these sessions, they discuss improvements made by the child and possible activities to meet the child's needs. Services have been expanded to include therapy groups for the children, enabling them to discuss the changes that occur as their parents progress through the treatment program. These services will increase the children's resiliency to AODA and enhance their adjustment in social and academic environments.

Parenting Education

Parenting education is available to clients in treatment as a tool for strengthening a lifestyle in recovery. Parents discuss their priorities in communicating ideas and lifestyles to their children and learn behavior management techniques that emphasize concepts of praise, encouragement, and consistency. The sessions explore realistic expectations for the child as well as the parent, and emphasize the impact of role modeling for the children. Upon our solicitation, the Tribal Courts are using our Parenting I curriculum of 16 sessions as a tool in sentencing cases of child abuse and neglect.

Therapy for Domestic Violence

Our domestic violence program also demonstrates our continual refining of services. To meet the needs of our predominantly male clientele, we initially addressed issues of anger and violence within the treatment program. Tribal Court officials inquired about the possibility of a prescribed course of domestic violence therapy which could be used for sentencing purposes by the court when adjudicating perpetrators of domestic violence. We structured the services to provide an open-ended course of eight therapy sessions.

Expanding treatment services to women through the Residential Treatment Program for Pregnant and Postpartum Women caused us to develop a similar therapy group for victims. Implementing this new service quickly led us to the realization that the women shared many of the perpetrator issues. We now operate a single domestic violence group, with men and women dividing into separate groups for the latter half of each session to discuss their gender issues.

Women's and Youth Groups

The themes of relationship, sexuality, and cultural identity are also presented to women's discussion groups, co-dependency groups, and the youth prevention/ intervention groups managed by Maehnowesekiyah prevention programs. The women's group is a nonthreatening discussion group utilized by women from the community who need support in pursuing positive solutions to problems of daily living. The co-dependency group helps women involved in a relationship with an alcoholic, women who may have an alcohol or drug problem of their own, or others who simply need support in taking independent action on their own behalf. Co-dependency and women's groups are open to the general public. Shelter clients frequently identify these issues as problems areas in their own lives.

Emergency Housing and Shelter

Problems with housing have been addressed by the creation and funding of an Emergency Shelter/Transitional Housing Program. Over the past 3 years, 43 percent of our residential treatment clients had no independent housing arrangement at the time they entered treatment. Upon completion of treatment, these same clients frequently accept shared housing with families and friends, linking them to the high prevalence of abuse of alcohol and other drugs in the community. The dysfunctional environments to which these clients frequently returned were interfering with successful recovery.

To address this need, a small start-up grant for Emergency Shelter/Transitional Housing was received in 1992. This has developed into a valuable resource for supportive service and treatment needs. Clients may use the shelter when they leave treatment, and it also stands as a separate service available to community members. Community members seeking shelter are expected to pursue a plan for resolving the problems that led to their homelessness and are frequently referred to the parenting, domestic violence, and/or co-dependency groups. They are encouraged to seek employment or further their education and, when appropriate, an AOD assessment is recommended. Statistics show that 80 percent of the shelter clientele have AOD abuse issues.

Independent Living Skills

Independent living skills are an important component of the treatment program, because these skills serve to reduce the stress in a recovery lifestyle. The social worker assists the clients on a one-to-one basis with money management, basic cooking and shopping skills, health and hygiene, transportation, job seeking/keeping skills, resources, social skills, legal issues, and overcoming housing problems.

While participating in these program areas, the client is making plans for discharge: housing applications, budgeting, and applications for financial assistance as necessary. Housing counseling is conducted with the families regarding renter rights and responsibilities, where to find rental opportunities, and budgeting the money to set up housing.

Education and Employment

Those who choose to further their education receive assistance through a staff social worker. This staff person works with the local technical school counselor (includes GED services), university admissions staff, and the local Menominee Community College to help the client pursue his or her career choice. Clients seeking employment are assisted with "personal data sheets" and with the job search process.

Strategies for Providing Comprehensive Services in Rural Areas

Our one-step approach to treatment and recovery needs is accomplished by referral and followup to available services, or through development and provision of the needed services. Efforts to meet the special identified needs have resulted in creation of several independent programs serving clients in treatment, including parenting education, family therapy, co-dependency, domestic violence therapy for perpetrators as well as victims, an emergency and transitional housing program, and transportation and child care services.

Provision of this range of services in a rural setting requires unique strategies for efficient service delivery. As compared with urban programs, the volume of services must be maintained by a limited number of staff for small numbers of clients. In order to make these services viable, we have linked them directly to the community. When possible, the supportive services developed to serve the clients offer a distinct curriculum that can also serve community members directly. Clients of the transitional housing program participate in the co-dependency, parenting, and women's groups, as well as in treatment programs. Tribal Courts use parenting and domestic violence groups for sentencing perpetrators of domestic abuse or child abuse and neglect. The parenting program is particularly active in recruiting community members for this education component.

The remote nature of a rural community creates greater challenges for treatment providers when they try to address problems concerning the stigma of treatment and difficulties in accessing treatment services. Because of the close-knit social structure that makes up these communities, the stigma and prejudice that surround AOD treatment can effectively stifle the provision of treatment services. Maehnowesekiyah is breaking the barriers to acceptance of treatment services through outreach and through providing related educational services within the community. The administrative and counseling staff team up to present informative sessions to staff and supervisors at area businesses and service agencies. These sessions cover such topics as:

• AOD symptoms as they present in the workplace
• Use of the Tribal Employee Assistance Program (EAP)
• General effects of AOD abuse on the community, youth, and families

These services have had a direct impact on utilization of the EAP, doubling the use of EAP treatment services in the first three quarters of FY94 as compared to all of FY93. The number of clients served by the EAP in FY93 (13) should not be underrated. This figure is quite respectable, since it represents the startup period for a functional EAP service that was meeting clients at all levels of need, not just the most desperate of situations.

Prevention/Education Services

As our education services became known, they inspired new requests for services specific to AOD-related problems at individual agencies, including client interview methods for problem areas and techniques for nonjudgmental enforcement of regulations. Maehnowesekiyah also responded to a request from the school system to provide options to expulsion for students who were disruptive in the classroom and/or at risk of failure. Although youth are referred because of behavior problems, a common thread among the majority of these students is use of alcohol and drugs. By the students' own admission, use of chemicals is contributing to their school adjustment problems.

ATOD education.

Through the program established, Maehnowesekiyah serves the alcohol, tobacco, and other drug (ATOD) health education and prevention needs of troubled Menominee youths referred to our services. We address three areas in this special component of the prevention programs, including:

• Basic ATOD education
• Strengthening the individual
• Assisting students to identify their support systems

ATOD education includes the physical and emotional effects of alcohol and drugs on the person's educational, family, and social environments. Individuals are strengthened as counselors explore the self-concept/self-esteem issues in AOD use/abuse and instruct youth in communicating their feelings and practicing assertiveness. This education enables youths to be more cognizant of factors in their family and social environment that may contribute to their potential for AOD problems, including family AOD abuse issues and social associations.

Counseling for Troubled Youth.

Identifying their support systems strengthens the individual, because this makes secondary support available. Individuals can be instructed to reason, look at available choices, and make positive decisions in their own best interests. Because some of these decisions may cause difficulty in a person's life situation (such as difficulty with friendships, peers, and/or family), counselors also help students to identify their support systems. For youth who are referred, our adolescent counselor provides counseling services on a one-to-one basis and also for family sessions.

The initial result of this intervention with youth showed fewer referrals to the office for participating students. This evaluative information is very encouraging. We have been requested to expand the services into lower grade levels, and also to assist with classroom ATOD education. Our community involvement on the prevention level establishes a direct link to early referral and intervention in an alcohol or drug abuse situation.

Our prevention program received State certification this past year as a provider of ATOD prevention services. This is based on comprehensive coverage of all alcohol, tobacco, drug, and mental health education activities. Safety, wellness, sexuality, culture, community, adolescent development, and family participation are also required elements of this education program. Activities must also be presented using age-appropriate materials. The prevention program utilizes three full-time staff with supervision provided by a certified AOD counselor and our consulting clinical psychologist. Maehnowesekiyah has also incorporated the prevention programs into its evaluation system.

The existing prevention programs at Maehnowesekiyah are funded by State and Tribal funds, with added support from the Indian Health Service. The Testing Realities and Investigating Lifestyles (T.R.A.I.L.S.) and adolescent health programs reach children aged 5 to 18 and provide health education (including AOD awareness) and alternative recreational activities. They operate their own youth group meetings in the four communities on the Reservation and also provide similar services to the Latch-Key Program within the school district.

New Volunteer Activities

This past year, Maehnowesekiyah developed the structure for a volunteer program that is beginning to accumulate volunteer hours. This activity further connects us to the community and provides an additional avenue for clients to identify positive activities for leisure time. Volunteers assist with planning and preparation for community events, food service, and as recovery witnesses.

Facing Barriers of Transportation and Financing

Maehnowesekiyah is addressing two distinct barriers to receiving treatment in this impoverished rural area—transportation and financing. Grant funds provide supplemental operating costs necessary to maintain vans that transport clients to treatment groups. Maehnowesekiyah provides transportation from the adjacent reservation communities and extended area for clients participating in support groups or continuing with other group treatment services. Clients schedule their individual therapy sessions in a manner that allows them to utilize Menominee public transportation. We also arrange for area medical transport services for our clients assessed as needing inpatient services. For the present, successful grant seeking and tribal support have alleviated the limitations that poverty imposes on our ability to provide treatment to individuals.

While we are able to collect third party reimbursement for services, the great extent of poverty in our community–combined with the numbers who are ineligible for medical assistance—demands that we find additional financial support for our programs. Otherwise, we cannot treat all who are in need. Last year we "wrote off" $947,000 in treatment services, but were able to maintain our momentum through diverse grant support at the Federal, State, and local levels. These sources include the Indian Health Service, the Center for Substance Abuse Treatment (CSAT), the Administration for Children and Families, four programs from the State Department of Health and Human Services, and the Menominee Tribe.

Diversity in client resources is another element in creating and maintaining stability in treatment services. A treatment center such as Maehnowesekiyah, dedicated to serving Native Americans, must also be creative in this approach. Through establishing itself as a Community Corrections Facility, Maehnowesekiyah has entered into service contracts with the Federal Bureau of Prisons. We accept clients of prisoner status through the Federal Bureau of Prisons, as well as State probation and parole clients who have AOD issues. Maehnowesekiyah maintains service contracts with the Veterans Administration for readjustment services related to posttraumatic stress disorder. We serve the Wisconsin Probation and Parole office with urinalysis testing services, and in turn receive referrals for treatment services. The Indian Health Service assists with intertribal referrals, and we also have service agreements with two neighboring tribes for residential treatment services.

The identification of community needs, combined with the achievement of top quality treatment services, has also enabled Maehnowesekiyah to receive grant funding for a new Residential Treatment Program for Pregnant and Postpartum Women funded through CSAT. This major component of our treatment funding would not have been possible without the knowledge of community needs and dedication to the achievement of high standards of treatment. CSAT has encouraged us to plan for an expanded program in FY95, by doubling our service capacity to pregnant and postpartum women.

The holistic array of services provided by Maehnowesekiyah assure the best chance for recovery that can be provided to our rural Native American population. Comprehensive provision of services and community support, together with effective blending of community needs with program needs and services, has brought about an increasing level of acceptance by the community for the Treatment Center and the healing community that it represents. In so doing, the community residents have gained an increased understanding of the commonalities between their personal issues and those who seek treatment for addictions. Reducing the barriers of treatment stigma through community education and interaction has made Maehnowesekiyah a dynamic force for change on the Menominee Indian Reservation.

Plans for the Future

Maehnowesekiyah has no plans for leveling off the growth in program services. The unprecedented level of tribal support has provided this agency with a new $1.6million office and therapy complex. By renovating our vacated office space, we are using this opportunity to expand the transitional housing units and also to serve the expansion of the Pregnant and Postpartum Women program. Maehnowesekiyah is pursuing available grant resources for assistance in construction of additional transitional facilities, and further support for the increase in supportive services that will be required of an expanded program.

We are currently planning an occupational therapy component for clients in all treatment programs. Staff training has been funded and scheduled for this fall. The role of occupational therapy can further assist clients to realize how their self-image has been affected by substance abuse, how the pattern of substance abuse has affected and even controlled their daily routines, and how to use the life skills they identify to support their recovery.

The treatment center has just contracted with an M.D. addictionologist from the Milwaukee area to serve as a medical consultant. The doctor will provide inservice training to staff and consult with our present medical director and clinical psychologist on a new area of health care that will promote physical healing from the damages of addictions. It is expected that these new efforts will enhance the recovery from addictions by addressing the physical needs of withdrawal, the nutritional losses suffered during the addiction, and the general physical condition.

The broad range of support therapy, services, and education offered at Maehnowesekiyah promotes wellness and reintegration skills as it provides clients with the needed strength to pursue recovery or prevent addictions. The holistic treatment program continues to evaluate program approaches with a focus on the client and his or her treatment needs. Maehnowesekiyah is constantly evolving, and will continue to do so until the alcohol and drug problem in our community is in hand. The energy created by the changes occurring in this community is self-perpetuating and continues to reward further effort at treatment improvement.

Last Updated 11-7-02