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Table of Contents

• Foreword

• Award for Excellence Review Panel

• Guide to Treating Alcohol and Other Drug Abusers in Rural and Frontier Areas

First Place Award

Steve Riedel, Tim Hebert, and Paul B. Byrd

• Inhalant Abuse: Confronting the Growing Challenge

Second Place Award

Tanya Tatum

• >Rural Women's Recovery Program and Women's Outreach . . . Serving Rural Appalachian Women and Families in Ohio

Third Place Award

Raymond Daw and Herb Mosher

• The Bridges of McKinley County: Building Rural Recovery Coalitions

Kathleen M. Adams and Colin C. Ward

• A Case Management Model Utilizing In-Home Treatment Services for Rural AODA Clients: The Family and Children's Center Model

Jim Armstrong

• Strategies for Building Rural Coalitions and Networks

Ernest Bantam and Paul Higbee

• Collaborative Strategies for Reaching At-Risk Youth in a Frontier Setting

Kristine A. Bricker and Michael G. Bricker

• A Rural, Community-Based Program of Day Treatment "Wraparound" Services for At-Risk Youth

Michael G. Bricker

• The STEMSS Supported Self-Help Model for Dual Diagnosis Recovery: Applications for Rural Settings

Marie E. Cowart and Mary Sutherland

• Late-Onset Alcoholism: Gaining Understanding

Jim Lohmeyer

• Providing Needed Treatment Options in the Face of Managed Care

Dan Malesevich and Tom Jadin

• Of Huffers and Huffing: A Survey of Adolescent Inhalant Abuse

Teri L. Nelson and Kimberly Brockman

• Case Management With Maternal Substance Abusers in Rural Communities: The "WRAP" Experience

Jack Peterson

• Alcohol Recovery Center Intensive Residential Treatment Program

Donna Pinter

• Identification and Treatment of Senior Citizens With Addiction Problems

Boyd D. Sharp and Kathi J. Beam

• Treatment Perspectives on Criminal Personalities in a Rural Setting

Patricia Jean Tikkanen

• Continuum Development Through Coalition Building: A Survival Technique for Rural Programs

Sylvia Wilber and Sigrid Congros

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

Colleen Zielinsky

• Intensive Outpatient Vocational Rehabilitation Program

Treating Alcohol and Other Drug Abusers in Rural and Frontier Areas

1994 Award for Excellence Papers

Technical Assistance Publication Series

17

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment

Rockwall II, 5600 Fishers Lane
Rockville, MD 20857

This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except quoted passages from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.

This publication was prepared for publication under contract number 270-93-0004 from the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration (SAMHSA). Richard Bast of CSAT served as the Government project officer.

The opinions expressed herein are the views of the authors and do not necessarily reflect the official position of CSAT or any other part of the U.S. Department of Health and Human Services (DHHS).

Foreword

The Center for Substance Abuse Treatment (CSAT) and the National Rural Institute on Alcohol and Drug Abuse (NRIADA) are pleased to jointly sponsor this publication, which is a compilation of papers submitted to the 1994 Award for Excellence contest. The Award for Excellence called for papers addressing the special challenges of providing quality treatment services to substance abusers in rural and frontier areas.

Papers were particularly solicited in the following areas:

• Experiences, ideas, practical measures, and recommended actions for implementing health care reform initiatives in rural areas (such as regional cross-State provider arrangements)

• Innovative strategies, policies, and programs for improving the delivery of substance abuse, health, and public health services in rural and frontier areas

• Proposals for political and economic solutions that would expand the development of services in rural/frontier areas

• Strategies for building rural coalitions and networks

• Approaches for special issues related to substance abuse, such as rural crime, gangs, and violence, including family violence

• Research studies and needs assessment data showing the prevalence of AOD abuse problems in rural and/or frontier settings, as well as their effects on rural crime, family life, and social, cultural, and economic conditions

• Cost-benefit analyses showing the impact at the Federal and State levels from resolving substance abuse and public health needs of rural and frontier communities

The papers presented here are a remarkable portrait not only of the daunting AOD problems that face rural and frontier America but, more importantly, of the viable approaches to those problems that are being created in rural and frontier areas.

The top three winners of this contest illustrate three successful approaches to helping substance abusers in rural and frontier areas deal with their problems. Riedel, Hebert, and Byrd describe an innovative program in their paper, "Inhalant Abuse: Confronting the Growing Challenge." Our Home, Inc., in Huron, South Dakota, has unlocked the doors of treatment to rural, inhalant-abusing youths—mostly American Indian youths—who did not before have access to treatment. This comprehensive residential treatment program provides a length of stay between 90 and 120 days. The treatment gives these young inhalant abusers, who are an average of 13 years old, the opportunity to detoxify, reduce impairment in neurocognitive functions, improve academic performance, and stabilize emotionally and behaviorally.

Tanya Tatum describes two substance abuse programs designed to address the needs of Appalachian women in Ohio. "Rural Women's Recovery Program and Women's

Outreach . . . Serving Rural Appalachian Women and Families in Ohio" is designed to take advantage of the strengths of these women, as well as their wealth of culture and spirit of perseverance. Appalachian women have specific cultural barriers, which include "a mistrust of outsiders, fear of the 'system,' the conscious exclusion of specific groups in a bureaucracy, a tradition of self-sufficiency and taking care of one's own, and geographic and social isolation." Tatum's group found that the key to delivering effective programs was to gain acceptance from the community and client population. They built on the personal and collective strengths of individuals and of the communities to be served.

A successful rural coalition in Northwest New Mexico is the subject of a paper by Raymond Daw and Herb Mosher. "The Bridges of McKinley County" describes a county that had the highest composite rate of alcohol-related problems of all counties in the United States from 1975 to 1985. The rural coalition that Daw and Mosher describe initiated The March of Hope, a journey made by a group of citizens who walked 200 miles in 10 days from Gallup to the State Legislature in Santa Fe. This rural coalition has been the catalyst to a regional response that has closed drive-up liquor windows, built a detoxification and assessment center, reformed State driving-while-intoxicated laws, and offered new prevention and treatment services.

Successful strategies and insights into the AOD problems facing rural and frontier Americans are mirrored in the other papers submitted to the Award for Excellence. These papers illustrate the difference that can be made for people suffering from alcohol and other drug problems in rural and frontier America.

Award for Excellence Review Panel

Barbara Groves, M.M.
Regional Coordinator
Oregon Office of Alcohol and Drug Abuse Programs
Salem, Oregon

Vicki L. Lentz
Green County Mental Health Services, Inc.
Muskogee, Oklahoma

Larry W. Monson, ACSW
Coordinator
National Rural Institute on Alcohol and Drug Abuse
Tony, Wisconsin

Leon PoVey
Director
Utah Division of Substance Abuse
Salt Lake City, Utah

Peggi White, R.N., C.S.
Family Nurse Practitioner
New Choice Drug and Alcohol Recovery
Champaign, Illinois

Inhalant Abuse: Confronting the Growing Challenge

Steve Riedel, M.S. Ed.
Associate Director
Our Home, Inc.

Tim Hebert, M.S.
Paul B. Byrd, Ph.D.
Our Home, Inc.
Huron, South Dakota

Inhalant abuse has been an overlooked and severe form of substance abuse in rural catchment areas. Youths with inhalant abuse problems can be identified, referred to, and retained in treatment. Treatment participation results in positive and objective outcomes. It is recommended that the current policy of nonintervention should not continue. This growing inhalant abuse problem must be challenged. The problem should be given the consideration of governmental, planning, and service providing entities, so that comprehensive approaches responsive to inhalant abuse can be implemented. Finally, the programs implemented should be objectively evaluated, so that comparisons among approaches can be made.

Purpose of the Project

The purpose of the Our Home, Inc. Inhalant Abuse Treatment Program is to challenge the problem of inhalant abuse by making a comprehensive treatment program available to affected youth.

In 1987, H.G. Morton wrote that "solvent abuse appears to be an embarrassment to children's services; rather than accepting the challenge of inhalant abuse, a policy of nonintervention exists and this policy is unacceptable." Dyer (1991) noted that "treatment facilities set up for inhalant abusers are nonexistent." Jumper-Thurman and Beauvais (1992) noted the "lack of even a rudimentary treatment model." Despite such commentaries in the literature, adolescent inhalant abuse has by and large been underacknowledged by the prevention and treatment delivery systems. A specific void has been particularly evident in comprehensive inhalant abuse treatment services.

In an attempt to fill this service void, Our Home, Inc. successfully sought an Office for Treatment Improvement (now the Center for Substance Abuse Treatment [CSAT]) grant. The project sought to "unlock the treatment doors to a population of moderate and severe drug users (inhalant abusers) whose treatment needs have been ignored at national and local levels." This mission continues to be the project's primary purpose.

A critical but coexisting purpose also existed. This second purpose was to develop an inhalant abuse treatment model that would address the wide range of social, psychological, academic, and neuropsychological deficits associated with inhalant abuse. Developing a program in the absence of other models also called for objectively measuring treatment outcomes as part of the model implementation process.

Methods

The discussion of methods addresses two areas. First, we discuss the distinctive treatment and patient identification methods utilized in the project. Second, we review the specific methods applied in measuring treatment outcomes.

Initial Steps

The following steps were taken in establishing the project:

1. First, it was necessary to create a treatment facility. An increased treatment capacity was created through the CSAT grant application process and through support from community economic development funds. A facility with a potential 16-bed capacity was obtained and renovated. As a step toward financial independence, the bed capacity has been managed so that a percentage of the beds are available as prepaid slots and a percentage are available under purchase-of-service agreements.

2. To stimulate systemwide prevention and intervention responses, it was necessary to increase professional awareness of the inhalant abuse problem. Increased awareness was promoted through a variety of methods, including:
   • Formulating an advisory board that represented the service delivery systems which would be impacted.
   • Conducting subject matter workshops at local, national, and international events.
   • Arranging for news releases and media awareness activities throughout the region. Because the program has a target population requirement of 75 percent American Indian youth, a specific radio station targeting Indian audiences was involved.
   • Developing and distributing (via training-of-trainer workshops) a comprehensive educational video curriculum about inhalant abuse and its dangers. As there was a void in resources, this was also done to place an educational resource in the hands of varied professionals across the region. Approximately 300 video curriculums have been released.

3. It was necessary to develop and implement a comprehensive treatment model designed for the inhalant abusing patient. Programmatically, this entailed considering the patients' unique needs and problems, especially with regard to neurocognitive functioning. The unique methods ultimately incorporated have been numerous. The provision of individual/group counseling, a history and physical examination, psychological evaluation, balanced diet, recreation, family programming, and aftercare coordination are assumed to be routine and are not discussed in this paper. This discussion is confined to the most distinctive methods implemented and includes:
   • Providing an extended length of stay, allowing for a minimum patient stay of 90 days that can be extended to 120 days.
   • Providing complete neurocognitive assessment based on the procedures and instruments included with the Halstead-Reitan Neuropsychological Test Battery (Reitan 1959). This assessment is given at the approximate 2-week point after intake and is used to assess neurocognitive impairment and to develop an individual prescriptive neurocognitive rehabilitation program. The assessment is repeated at discharge for outcome evaluation purposes. The Kaufman Test of Educational Achievement (K-TEA) is used to assess and retest academic skills.
   • Providing neurocognitive rehabilitation—Reitan Evaluation of Hemispheric Abilities and Brain Improvement Training (REHABIT) (Reitan and Senac 1983)—to those assessed as in the "impaired" range of neurocognitive functioning and to those assessed as in the "normal" range but who may have a specific impairment.
   • Providing a full academic day during the course of treatment. Academic programming has the patient participating in school at any of the three individually assigned levels. Academic attendance assigned levels are assigned as "does not attend school," "attends school part time," or "attends school full time." Another specific method is "video group," in which patients and counselors watch prerecorded classroom behavior in order to assist in behavioral classroom adjustment.
   • Providing specialized inhalant abuse education with other comprehensive health/drug and alcohol education.
   • Providing cultural activities and ceremonies within the customs and beliefs of the American Indian population. In doing so, the first step was to appoint advisory board members reflecting the interest of the Indian Health Service System and the Tribal Court System. Other multiple activities were also undertaken. A consultant was employed to initiate a process of cultural growth and enhancement. Periodic consultation visits stimulated programming. Activities such as "sweat ceremonies," smudge purification rituals, and the use of elders and daily prayer were incorporated. Staff recruitment and employment practices have been enhanced to culturally complement the program.

Enhanced methods applicable to family services, transitional care, community-based aftercare, abuse and neglect counseling, and patient supervision are also used.

Test and Retest Procedures

Objective treatment outcome data have been obtained by test and retest procedures. The methods used, as well as the data handling procedures, are briefly outlined here. A Halstead-Reitan Neuropsychological Test Battery (HRNTB) is administered to all patients at approximately the 14-day point. The Intermediate Booklet Category Test (Byrd 1985) and Booklet Category Test (DeFelipis and McCampbell 1979) are used as opposed to the electromechanical slide versions of the category tests. Through this battery, a Neurocognitive Deficit Score (NDS) (Reitan and Wolfson 1988) is determined for each patient. The NDS reflects the extent of the neurocognitive impairment that each patient is experiencing at admission and discharge. The NDS for each patient population is tabulated and converted to a mean NDS for the total patient population. The difference between the intake and discharge NDS is derived and recorded as improved or regressed neurocognitive functioning. HRNTB norms require that subjects ages 14 and younger be considered "children," and subjects ages 15 or older are considered "adults." Data for each classification are separated by age group. The project restricts admission to those ages 10 through 17.

In addition to the two age groups, clients are also classified as "impaired" or "nonimpaired," based on their NDS. The pretreatment and posttreatment NDS scores for each age group and diagnostic classification (impaired/nonimpaired) are also compared. These comparisons allow the program to assess the differences in the response to treatment between and within the age and diagnostic groups.

A Kaufman Test of Educational Achievement (K-TEA) is also administered at intake and discharge. The individual age-equivalent achievement results are converted into a mean achievement for the patient group. The results reflect the improved or regressed level of academic achievement. Data are handled so that results are presented for the two age groups.

Finally, the project reviews patient functioning at 6 and 12 months after discharge. This followup collects subjective and anecdotal data regarding posttreatment functioning. Inhalant use, other alcohol and drug use, school attendance, legal contacts, and living arrangements are monitored. Data are collected by personal contact, by telephone interview, or in writing. Data are accepted from the patient, the parent/guardian, or the referral/aftercare worker.

Content Area

The 1993 National Institute on Drug Abuse Monitoring the Future Study announced a shifting trend in the drug use patterns of the nation's youth (NIDA Capsules 1993). Between 1992 and 1993, use of inhalants among the nation's eighth graders increased from 17.4 percent to 19.4 percent. Inhalants are now the "most widely abused substance (after alcohol and tobacco) among this age group," and it is now estimated that one in five eighth graders has used inhalants such as glues, aerosols, gasoline, and solvents. The deadly and destructive nature of inhalant abuse is well documented throughout the literature. Death can result from "sudden death syndrome" and other direct causes.

The Situation in Rural South Dakota

While the national trend toward increased inhalant use should serve as a call to attention, the problem has been a longstanding one in many rural areas; this was the case within the project catchment area. In 1990, the South Dakota Senior Survey indicated that 18 percent of the Caucasians and 22 percent of the American Indians surveyed had lifetime experience with inhalants. Also in 1990, 55 percent of the youths in the South Dakota Juvenile Correction System had a history of inhalant use. Eighty-five percent of the youths within the State's most restrictive correctional facility (the South Dakota State Training School) had a history of inhalant use. Finally, given that seven reservations fall within the geographic boundaries of the target area, the estimated inhalant exposure among American Indian populations may be nearly double the national average (Beauvais and Oetting 1985).

Despite such data, professional services directed toward the problem within the catchment area were at best limited. Treatment services were nonexistent and, consistent with Morton's 1987 observation, a policy of "nonintervention" applied. Our Home, Inc. perceived that a significant population of moderate to severe substance abusers were being overlooked and sought to help them.

Record of Unsuccessful Treatment

As early as 1979, Mason suggested in a NIDA monograph that when inhalant abusing patients did enter treatment, they tended to perplex the system rather than be successfully served by it. Specifically, the monograph indicated that "inhalant abusers constitute the greatest dropout rate among substance abusers served." Smart (1986) noted that "probation, foster homes, and training schools were found to be unsuccessful for four of five male sniffers." Dyer (1991) noted that generally "counselors are not equipped to deal with the wide range of problems" presented by inhalant abusers. Jumper and Beauvais (1992) indicated that programs were not adapting to meet the needs of inhalant abusing patients. Our Home, Inc. acted on the need to develop specialized programming conducive to patient retention and successful treatment.

It was also recognized that other sociodemographic factors were likely to affect the delivery of care. These factors were: age (the average age of the patient admitted to date is 13.2 years); income levels (48 percent of the patients have annual family incomes of $5,000 or below); geographic isolation; and the racial composition of the patient population.

Clinical Issues In Providing Treatment

Beyond demographics were clinical issues that raised questions about the delivery of treatment services. Fornazzari (1988) noted that "lack of treatment effectiveness is due to lack of parent/family support, but also because the inhalant abuser is started too early in treatment programs. Detoxification of 2 weeks is recommended to allow for neurocognitive repair." Referring to chronic solvent abusers, Fornazzari stated, "Our experience suggests that the detoxification period be as long as possible. At least 2 weeks of close observation is necessary for the brain of these young persons to be rid of the effect of the solvent." A need for extended lengths of stay was indicated and implemented in the specialized programming.

Mason (1979) estimated that 30 percent of experimental users and 60 percent of regular inhalant users presented with measurable neurocognitive impairment. Other authors, such as Cooper and colleagues (1985), Ron (1986), Allison and Jerrom (1984), and King and colleagues (1985) have acknowledged neurological and neurocognitive consequences of inhalant abuse. Evidence of such neurological and neurocognitive symptoms suggested that any treatment approach developed must consider such matters. In response to this background context, the Our Home, Inc. program incorporated neurocognitive assessment and rehabilitation services.

The neurocognitive implications also held implications in relation to the young person's ability to perform academically. Mitic and McGuire (1987) cited school as a main source of stress for inhalant abusing youths. In 1990, Our Home, Inc. did an internal comparative analysis of 16 patients who had an inhalant abuse history, compared with 16 other substance abuse treatment patients without such a history. The comparison indicated that patients who had an inhalant abuse history came to treatment at a younger age (3.3 years younger than other substance abusing patients). They were also more than 1 year further behind in comprehensive academic achievement as tested by the K-TEA. It was apparent that academic adjustment and academic deficits needed to be considered in the treatment approach.

Objective Measures for Monitoring Outcomes

Finally, and since this project stood as the most comprehensive treatment effort pursued with this special population, Our Home, Inc. sought to evaluate treatment outcomes objectively. Changes in patient neurocognitive functioning and academic achievement were selected as the most objective measures. More subjectively, routine data reflective of patient posttreatment functioning have been pursued. Thus, questions about the benefits of treatment and the project might be considered.

In summary, a variety of questions were evident around the issues of patient treatment readiness and receptiveness. Our Home, Inc. sought to address these questions by modifying the treatment protocol and evaluating objective treatment outcomes.

Findings

The findings must be considered within the context of the patient population served. The following introductory and definitive information about the project catchment area and the patient population provide this context.

While the project's referral base has included a limited number of patients from across the United States, most of the patients served have been from the project's primary catchment area: South Dakota. CSAT defines South Dakota as a "Frontier State." (Note that the terms "frontier" and "rural" are used interchangeably throughout this paper). Seven Indian reservations have boundaries that overlap with South Dakota, and some of these reservation communities constitute the most impoverished areas in the United States.

Referral patterns suggest that older and chronic inhalant abusers have not been referred to the treatment program. Rather, younger patients who have a less progressed but regular pattern of use have been referred. In the process of determining intake appropriateness, the histories of all patients admitted have been compared to the American Psychiatric Association's Diagnostic and Statistical Manual criteria for inhalant abuse or dependence. The patient sample has been 75 percent male and 25 percent female.

Finally, because of project funding mandates, the findings are based on an 85 percent American Indian sample. Sample size is 101 unless otherwise specified. Project findings are presented below in general as they relate to the identified project purposes.

Project Findings

Section 1

Purpose 1. "Unlocking the treatment doors to a population of moderate to severe drug abusers" (inhalant abusers).

Program utilization findings.

During the initial 25-month project period to date, the project has provided treatment services to 101 youths. The utilization of the 16-bed capacity has progressively increased. For years 1, 2, and 3, respectively, the average census has been 10.0, 11.4, and 14.1.

It should be noted that we have received numerous generic program inquiries. During the 25-month project period, the project has handled 344 documented inquiries from across the United States and Canada. The patient treatment retention ratio for the project has been 80 percent. The most often-noted deterrent to patient retention has been parents' withdrawing of voluntary placements. This withdrawal takes place after the patient has disclosed a pretreatment history of physical or sexual abuse (usually inflicted by a family member). While this trend is difficult to quantify objectively, it is estimated that it applies in 50 percent of the nonretention cases. By the time treatment is completed, 60 percent of the patients have reported a pretreatment history of physical abuse and 52 percent a history of sexual abuse. Average length of treatment stay has been 97 days.

Severity of drug use patterns.

The severity of the patient drug use patterns also needs to be defined. Indications of early chronicity among this population of rural inhalant abusers should be identified. Age of first use stands as one pointed indicator. The average age of first use has been 10.2 years of age, and average age at admission has been 13.4 years. Thus, a "typical" patient has used inhalants for an estimated 3.2&nbsp;years before entering treatment. During that 3.2-year time span, the typical patient is likely to have used five different inhalants.

Preferred products have been:

• Gasoline (43 percent)

• Rubber cement (22 percent)

• Spray paint (16 percent)

• Correction fluid (7 percent)

• Other (12 percent)

Frequency of use is as follows:

• Binge use (3.9 percent)

• Daily use (15.8 percent)

• 3 to 6 times weekly (28.7 percent)

• 1 to 2 times weekly (18.8 percent)

• 1 to 3 times monthly (14.8 percent)

• No use in the past month or unknown (17.7 percent)

This final percentage is related to referrals from detention and other holding facilities. Eighty-six percent of the youths treated indicate that they have made unsuccessful efforts to stop inhaling before treatment. Ninety-seven percent of the youths report having experimented with alcohol or other drugs.

Neurocognitive impairment.

Evidence of morbidity in the form of neurocognitive impairment is a critical indication of problem severity. While it is not entirely possible to rule out other causative factors, such as head injuries, fetal alcohol effects, or inadequate diet, the project assumes significant impairment is related to inhalant use. To date, the project has collected neurocognitive assessment and retest data from 50 youths. From this total, 44 percent have tested with measurable impairment. The insidious nature of the problem is evident in the fact that 36.1 percent of the younger group (ages 10 to 14) have fallen within the impaired range, while 64.2 percent of the older youth (ages 15 to 17) have been within the impaired range. Academic findings also reflect the severity of impairment. Based on K-TEA findings, the average admitted patient has a composite deficit of 2.5 years in reading and of 3.1 years in math.

These findings suggest that the project has clearly unlocked the treatment doors for a population of moderate to severe substance abusers.

Section 2

Purpose 2. Constructing a comprehensive model of treatment specifically designed for the inhalant abusing patient.

Project findings focus on project outcomes as measured by neurocognitive test and retest measures, academic test and retest measures, and on the posttreatment followup data collected. The project has conducted complete neurocognitive test/retest procedures on a total patient group of 50 youths. Findings are presented in two subsamples for "children" (table 1) and "older youths" (table 2).

Table 1. Treatment pretest and posttest neurocognitive
performance among children ages 10 to 14
Current sample size = 36

Table 1 details the treatment pretest and posttest of neurocognitive performance among children ages 10 to 14. Findings indicate that a mean average reduction (improvement) of 28 percent in NDS has been measured during the treatment stay.

Table 2 details findings for the older youth group, ages 15 to 17. While the older group has not reached the level of improvement attained by the children's group, a 23 percent improvement in NDS has been noted.

The neurocognitive deficit score is obtained from the entire sample group; therefore, these percentages reflect a total patient population outcome measure. Findings that compare impaired patients to their nonimpaired counterparts have also been considered. These findings indicate that impaired children have been found to show a slightly greater reduction (7 percent) in NDS as compared with those children who are not impaired, as depicted in tables 3 and 4.

Tables 5 and 6 demonstrate that impaired older youth show a 9 percent greater reduction in NDS than do nonimpaired youth. However, in comparing impaired older youth to impaired children, the impaired older youth demonstrate 5 percent less improvement during the course of treatment. During the course of treatment, 30 percent of the patients tested progress enough that they move from an impaired level of functioning to the normal range.

In order to determine if there were statistically significant differences between the impaired and nonimpaired clients' NDS before and after treatment, a multivariate analysis of variance was conducted. As shown in table 7, the pre- and posttreatment NDS was compared for the two age groups and within each age group. The results indicate that for the children ages 10 to 14, there is a significant difference between the impaired and nonimpaired clients (F=59.398, p<.000). The results also indicate a statistically significant difference between the pre- and posttreatment NDS for clients ages 10 to 14 (F=61.029, p=.000).

When the clients ages 15 to 17 were compared, the results indicate that again there is a significant difference between NDS of those clients who are impaired and nonimpaired (F=12.867, p<.003). The results also indicate a significant difference between the pre- and posttreatment NDS for this age group (F=10.790, p<.006). Although there is a significant difference between the impaired and nonimpaired pre- and posttreatment NDS for children ages 10 to 14 (F=11.131, p<.002), no significant difference was found between the impaired and nonimpaired pre- and posttreatment NDS for the 15- to 17-year-old clients. This is likely due to the limited number of clients served so far in the 15- to 17-year-old group (n=14).

Academic outcome findings are presented in Tables 8 and 9. The results indicate that the average composite academic gain of the children's group is 1.01 years during the course of treatment. The older group has gained 1.06 in academic years.

Followup findings (based on 35 youths to date) suggest that 34 percent of the patients have not used inhalants 6 months after discharge. An additional 12 percent report that they "use less often than before attending treatment." Patient tracking has been difficult, and the project has not been able to track 54 percent of the discharged patients. The status of these youths must be viewed as unknown. Followup findings are presented in brief form in table 10.

Tracking problems appear to be related to the frequent moving of project participants. Project intake data suggest 81 percent of the patients have moved one or more times in the 3 years prior to treatment. Twenty-nine percent of the discharges indicate no use of alcohol or other drugs following treatment, and 14 percent indicate that they use other chemicals less often. Such data have helped the project act constructively in that it has secured funding through the Single State Agency to enhance aftercare services in two target communities. This is being accomplished through contracts for service with community providers. The impact of this approach is yet to be determined. Arrest data, school attendance data, and participation in aftercare service data can be made available to the interested reader.

Conclusions

Wide-ranging conclusions can be made from this comprehensive treatment project. The following significant conclusions are based on project experience. Project experience has established that:

1. Inhalant abuse stands as a frequent and severe form of substance abuse within the rural catchment area served. National trends and project experience strongly suggest that similar rural communities are likely to have a comparable or greater problem.
2. The frequency and severity of the inhalant abuse problem merits heightened attention in the rural areas served. In view of the frequency and severity of the problem, a policy of nonintervention is truly unacceptable. The social, emotional, and financial consequences of failing to act on a form of substance abuse so clearly associated with mortality and morbidity need to be addressed.
3. A policy of nonintervention is simply not necessary. These youths can be identified, referred to, and placed in treatment before they shift predominant using patterns to other chemicals or congest correctional facilities. In a similar vein, it seems a logical conclusion that the earlier the intervention the better. The earliest possible intervention is likely to forestall adverse consequences and enhance the likelihood of favorable treatment outcomes, especially in relation to neurocognitive impairment. Given the severity and frequency of physical and sexual abuse among the patient population, treatment and child protection networks must be enhanced to serve these children adequately and to reduce continued risk factors.
4. Inhalant abuse patients can be retained in treatment for lengths of stay that are conducive to patient detoxification and to the demonstrated reduction of impairment in neurocognitive functions, along with improved academic performance and emotional behavioral stabilization.
5. The comprehensive treatment model utilized results in multiple and favorable treatment outcomes. The patient recovery and treatment outcomes with this population go far beyond the basic question of posttreatment substance use. Residential care appears to be central to patient stabilization and early recovery. Aftercare is likely to require extensive enhancement because of current resource limitations and patient demands. The project has also established objective measures that can be utilized to implement and compare other approaches used with similar populations.

Recommendations

While the project has led to certain conclusions, it has also raised broad questions. Seeking answers to such questions might provide further direction on issues such as length of stay, learning and academic approaches to be applied, and patient aftercare planning. Despite a host of unanswered questions, some broad recommendations can be made:

1. Federal, State, and tribal planning jurisdictions must thoroughly assess the inhalant abuse problem in order to:
   • Determine its human and economic impact
   • Plan for sufficient, appropriate, and comprehensive intervention responses, so that a continuum of care extending from prevention through aftercare exists to address the problem.
2. Governmental entities and service providers must cooperate to secure and implement these approaches as they are developed. The general void in services that continues to exist in most areas should be challenged.
3. All approaches should be implemented in conjunction with individual project and systemwide methods of objective measurement, so that approach and impact comparisons may be made.

This problem must not be ignored, given the growing body of evidence about the dangers of inhalant abuse, its impact on youth, and its consequences.

References

Allison, R., and Jerrom, D. Glue sniffing: A pilot study of the cognitive effect of long term use. The International Journal of Addictions 19(4):453-458, July 1984.

Beauvais, F., and Oetting, E. Trends in the usage of inhalants among American Indian adolescents. White Cloud Journal 3(4):3-11, 1985.

Byrd, P.B. The Intermediate Booklet Category Test. Psychological Assessment Resources, Inc. Odessa, FL, 1985.

Cooper, R.; Newton, P.; and Reed, M. Neurophysiological signs of brain damage due to glue sniffing. Electroencephalography Clinical Neurophysiology 60(1):23-26, 1985.

DeFelipis, N., and McCampbell, E. Manual for the Booklet Category Test Research and Clinical Form. Odessa, FL: Psychological Assessment Resources, Inc., 1979.

Dyer, M. "Psychological Aspects of Inhalant Abuse and Its Implications on Treatment." Unpublished, 1991.

Fornazzari, L. Clinical recognition and management of solvent abusers. Internal Medicine for the Specialist 9(6):99-109, 1988.

Jumper-Thurman, P., and Beauvais, F. Treatment of volatile solvent abusers. In: National Institute on Drug Abuse Research Monograph Series, No. 129. Inhalant Abuse: A Volatile Research Agenda. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1992.

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Rural Women's Recovery Program and Women's Outreach . . .Serving Rural Appalachian Women and Families in Ohio

Tanya Tatum
Coordinator of Women's Programs
Health Recovery Systems, Inc.
Athens, Ohio

The Nation's attention on health care problems is at a record high. We have been inundated with numerous versions of plans to improve our health care system. The Clinton plan, the Cooper bill, the Chafee bill, and the Mitchell bill were all submitted to Congress for consideration during the 1994 congressional session. Of the four health care plans mentioned, only the Clinton plan specified provision of substance abuse services. There appears to be a pervasive sense that substance abuse problems are law enforcement problems—not health care problems. Federal drug policy places a priority on law enforcement and interdiction rather than on treatment services. Consequently, Federal funding has followed along those same lines.

Even though we don't like to think about it, substance abuse is our Nation's number one health problem. A recent California cost effectiveness study estimated that victims of crime committed by drug abusers cost $1.3 billion in medical costs, damaged or stolen property, and lost work. The sum of $440 million was spent on health care for these California drug abusers. This study covered a 12-month period and was conducted on a random sample of 145,515 persons enrolled in treatment services. To ignore the role addiction plays within the context of and debate over health care reform is illogical and self-defeating.

In rural areas, many residents are anxiously awaiting the outcome of health care reform. "When are we going to see more doctors and clinics?" "Will there be a doctor in town who takes a Medicaid card?" "Will I still have to wait 3 months for an appointment?" "How far away is that treatment program?" Typically small, remote, and with relatively small populations, rural areas are often neglected in the creating of national political agendas or plans for reform and change. Rural areas are usually handled as the exception to the rule in the development of strategies, regulations, and programs designed to meet the needs of large urban and wealthier suburban populations. The problems of substance abuse affect all segments of society, but prey most heavily on the disadvantaged. These populations—minorities and the poor—have the fewest resources to deal with problems of substance abuse. They have the least access to services, both financial and physical; have the greatest incidence of impairment, disability, and death; and usually end up in our criminal justice and child welfare systems.

Background: Appalachia Today

Appalachia today is a region of contrasts: tradition versus progress, stability versus growth, regional markets versus international markets, agriculture versus industry, and family versus the individual. Appalachia is often synonymous with poverty. The Federal Government identifies the region as a geographic area defined by economic conditions. This definition clearly leaves out the identifiable and distinct cultural aspects that influence to a large degree the success or failure of efforts to improve the region. In truth, much of Appalachia today remains a poverty-stricken, economically depressed, and underserved area. Former president Lyndon B. Johnson's War on Poverty in the 1960s helped, but it merely addressed the symptoms and neglected the source of regional socioeconomic problems.

However, in spite of the extreme regional poverty, there is a wealth of culture, human strength, and a spirit of perseverance. These are the very strengths we relied on to develop programs to address the needs of substance abusing women and their families in Ohio's Appalachia.

While we deal with the same problems faced by many substance abuse providers serving women—extreme poverty, lack of transportation, lack of child care, inability to pay for services, family violence, and low self-esteem—there are additional barriers found in Appalachia. These cultural barriers include a mistrust of outsiders, fear of the "system," the conscious exclusion of specific groups in a bureaucracy, a tradition of self-sufficiency and taking care of one's own, and geographic and social isolation. Additional obstacles to successful programming are providers who fear hostility or rejection from the service population or who have preconceived perceptions of clients, and providers who are reluctant to change service delivery models to be more responsive to the needs of the client population.

We found that the key to delivering effective programs is to gain acceptance from the community and client population. To do this, we had to listen to individuals and then identify and build on the personal and collective strengths of individuals and of the communities to be served. Rural Women's Recovery Program (RWRP) and Women's Outreach are two programs designed to address the gender-specific and cultural needs of substance abusing rural Appalachian women and their families. The work of these programs plays an important role in helping to provide opportunities for health and hope for many in Southeast Ohio.

Methods

Rural Women's Recovery Program

The first consideration in developing this program was to identify community needs. This was begun during the process of creating an application for funding. Upon notification of award of funding from the State of Ohio, we set about formalizing the clinical and program parameters for the residential treatment program, RWRP. (Women's Outreach was not started for another year.) Every effort was made to find out what social and health services were currently available within the community. We contacted the following programs:

• The WIC program for client referrals and nutrition education
• Planned Parenthood for assistance with prenatal care and family planning services
• Local school boards to assist with tutoring and GED programs
• Ohio State Cooperative Extension Service to assist with life skills education for clients
• Department of Human Services for information about public assistance programs available to clients
• The local mental health agency for making referrals and to assist with staff training
• The Area Health Education Center for resource materials
• A domestic violence shelter for making client referrals and staff training
• The homeless shelter for emergency housing
• Many other agencies and organizations

While none of the agencies has large operating budgets or excess staff, all were willing to share information and resources and generally were willing to help out. A cooperative spirit exists in the area. We help our own to provide for our own.

After amassing a wealth of information and offers to assist, we developed the new program. Because the agency had been providing residential treatment services for substance abusing adolescents for 10 years, we were able to work with an experienced administrative and senior clinical staff to develop this program. The new program was designed to have a rural orientation that would acknowledge the multiple and often conflicting roles that women have. The program would also utilize available outside resources. The goal was to interrupt the process of active addiction, to give the clients new coping skills and develop their personal resources, and to reinvest them in their families and communities whenever possible.

Providing Appropriate Staff and Facilities

The first task was to develop staff capable of using a rural approach to deliver services. This does not mean unprofessional or inadequate. It means placing a focus on the individual person, acknowledging and supporting identified personal strengths, and refraining from imposing on clients our own personal and sometimes middle-class or urban-oriented values and measures of success. Many women in the program speak of success as being able to return home to care for their family (aging parents, children, and partners). Success does not always entail completing college and getting a good job. Every effort is made to hire local individuals to staff the facility; such staff help create a sense of safety for clients and provide honest and believable role models.

The program itself is housed in a log home located outside the city limits, but within the county on a high ridge on a gravel road. You have to know where you are going to get there. There were many challenges in turning a four-bedroom home into a treatment facility, but they were worth it in the sense of peace and safety the house created. The building was very reassuring to family members bringing clients into the home. Children of clients were also reassured to see that Mom wasn't going to jail or back to the hospital (psychiatric or medical). As much as clients were ready to come in, yet not wanting to be there, the appearance of the building helped to relieve some of the early distress of being in treatment. RWRP is not a facility with tile floors, stainless steel fixtures, and communal showers. It is a home in a country setting that provides clients with the physical security they need to do the hard work asked of them.

Providing Staff Training

Once the staff were hired and the building secured, staff were required to attend a week-long training program. The training program included the following sessions:

• Delivering treatment services with a feminist perspective
• Respect and knowledge of Appalachian culture, health, and safety issues
• An overview of the program schedule, house rules, and teamwork
• How the clients get here—admissions from initial phone call to intake
• Program collaboration with other community services
• Provider self-care
• Documentation and billing

Ongoing staff training addresses issues of women's treatment and works to develop the cultural competence of the staff, as well as stay abreast of innovative clinical techniques.

Special attention is given to medical and psychological services for the program. We found out very quickly that current literature was right in stating that women, prior to coming into treatment, have typically progressed much farther than men in their addiction. For us this meant many physical and medical complaints. In addition to a full-time nurse, we contracted with a physician to deliver primary care services and to attend weekly treatment team meetings. The agency psychologist provides immeasurable assistance in evaluating clients on admission and in providing needed psychological services.

The physical upkeep, daily housekeeping tasks, and meals are handled by both staff and clients. We created a chore list to eliminate arguments over whose turn it is to take out the trash. Staff are expected to work alongside of clients. This provides clients with specific responsibilities for household operations; staff help clients learn how to complete chores that they are no longer able to perform.

For many clients, helping to make up the grocery list for the house is a terrifying prospect, not to speak of actually doing the shopping. Client chores are seen as a key part of the program. It makes the clients responsible for and respectful of their own living space, renews or teaches homemaking skills, enables clients to establish supportive relationships with other women, and provides them with a sense of accomplishment, no matter how small the task. The physical environment is used to help establish community norms for social interactions and client behaviors.

Women's Outreach

The Women's Outreach program was first funded in 1990. This program began as a client-finding mechanism for the residential program. This was not found to be very effective with the single position we were able to fund. There were also many obstacles presented by the community's lack of awareness about women's need to seek treatment services. During the second year of funding, the program was redesigned to respond to the unmet need for gender- and culture-specific prevention, community education, and intervention services in three rural Appalachian counties. The program focused on reducing the consequences of maternal alcohol and other drug use and on reducing the incidence of fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE). A variety of strategies were developed to accomplish program goals and objectives. These activities include:

• Client education groups for women awaiting admission to treatment services
• Screening, education, and referral for public assistance recipients
• Networking and specific project collaborations with other providers of services to women (such as WIC, Planned Parenthood, and Children's Services)
• One-time educational presentations to community social and civic groups
• Staff training programs and technical assistance for other social service agencies
• Community awareness projects (county fairs, community festivals, parades, and local campaigns, i.e., Red Ribbon campaigns for AIDS awareness)
• Special programs for communities outside county seats (very rural and isolated communities)
• A public information campaign

The basic tenets of program planning are the same as for RWRP.

• Chemical dependency affects women differently from men.
• The program must be responsive and accessible to rural clients.
• The program should view women positively.
• Clients have the right of self-determination.
• The program needs to provide healthy, acceptable, and believable role models.
• The program needs to acknowledge the complexity of clients' lives: children, partners, income level, housing situation, education, employment or lack of it, and values and traditions.

Content Area

Women's Health and Poverty

The health care crisis for women is staggering, and the relationship between poverty and health status is inextricably intertwined. Poverty increases the chance of poorer health status. Lower income leads to increased health risks, and increased health risks lead to lower life expectancy and high rates of chronic disease, including alcoholism and other drug addiction. Preventable hospitalizations (bacterial pneumonia, cellulitis, kidney/urinary infections, dehydration, gastroenteritis, asthma, COPD, congestive heart failure, angina, and diabetes) among poor adults is two to four times as high as for high-income adults (Codman Research Group). Poor women are three times as likely to have problems obtaining prenatal care, and close to 30percent fewer poor women obtain prenatal care during their first trimester as compared to non-poor women (Center for Health Economics Research 1988).

The substance abuse-domestic violence connection and the substance abuse-HIV connection are well documented. In 1984, Wilsnack reported that more than 50percent of all domestic violence and 40 to 74 percent of child abuse cases are related to alcohol and other drug use. She also reported that more than 70 percent of female addicts/alcoholics report a history of sexual abuse. In the State of Ohio, women now make up 8 percent of all reported AIDS cases (Ohio AIDS Surveillance Section 1993).

Alcohol and drug use during pregnancy severely compromises both maternal and fetal health. Robin LaDue, an expert on fetal alcohol syndrome, refers to alcohol as the only known teratogenic agent (cancer-causing agent) in the United States with its own lobby in Washington, D.C. Fetal alcohol syndrome attributed to maternal alcohol use is an entirely preventable condition.

In the four rural counties that served as the initial client referral base, 41 percent of women ages 18 and older are on public assistance, and 27 percent of the total population lives in poverty. Regional poverty, an inadequate number of primary care providers, and poor health-seeking and wellness behaviors among residents (rural adults are less likely to engage in preventive behaviors, according to Bushey) all contribute to the overall poor health status, especially among women. Adverse living conditions, poor education, and poverty are associated with higher rates of alcoholism and other drug addiction (DHHS 1990). Poor health, lack of access to primary care services, and the multiple drug use often seen in women (women have a tendency to use multiple drugs and alcohol, along with use of over-the-counter and prescription drugs) have a cumulative effect on the progression of addiction in women.

Barriers to Treatment for Appalachian Women

Many barriers exist in the region that inhibit and prevent women from obtaining needed services. Women, who constitute a significant portion of the medically indigent, lack the financial resources to pay for care. The lack of child care, lack of available treatment slots, lack of transportation, and discrimination are major hurdles for women anywhere to overcome before they can obtain substance abuse services. Individuals in rural areas must cross additional hurdles that are not typically present in urban and suburban areas, such as not having telephones to ease their access to service. Intrinsic sociocultural obstacles also keep rural women from obtaining care. These obstacles include differences in lifestyle, language, education, values, and beliefs.

Traditional Appalachian values of family solidarity, self-reliance, and pride have held families together in the face of overwhelming problems, yet these same characteristics pose problems for service providers who are promoting healthy lifestyle changes. Cultural beliefs that influence one's view of life, health, illness, and death were very important factors in designing the programs. The "what will be-will be" attitude and a fatalistic perception of how one's life unfolds have a critical impact on a client's health behavior. They also affect our ability to offer acceptable and effective intervention and treatment strategies.

Lastly, there are institutional barriers to be overcome. For residents of Southeastern Ohio, these include a reluctance to go into town (i.e., the county seats) for services, rude and indifferent receptionists, the stigmatization of low-income persons, a general fear of medical and other service providers, long clinic waits, and long waiting lists due to a limited number of providers (all but one of the counties are designated as Health Profession Shortage Areas). Providers must address the need to successfully overcome rural isolationist attitudes, a general lack of trust in institutions, and the need to ensure that agency and program communications overcome barriers of geographic isolation, readability, and cultural differences.

Overview of the Service Area

The target service area for the Rural Women's Recovery Program and Women's Outreach consists of Athens, Hocking, Vinton, and Meigs counties, which make up a portion of the federally recognized region called Appalachia in Ohio. The counties are identified as primarily rural, with a predominantly white population, and with several small Native American communities. The racial minority and ethnic population in the counties can generally be identified as students, faculty, or staff at Ohio University and Hocking College located in Athens County. Minority representation in the area accounts for approximately 3 percent of the total population.

Appalachia is an area plagued with a chronically depressed economy, geographic isolation, and extreme poverty. The heart of regional problems lies in the fact that, historically, businesses were primarily extraction industries (coal, oil, timber) that made little or no significant investment in local communities. When these industries disappeared, small towns and villages were left with no jobs, development, or infrastructure (transportation, water, waste, and sewage). With the global economy of today, there is little call for development in an area that lacks a trained workforce and the political and physical infrastructure to support technology-dependent economic growth.

Limited economic development, high unemployment, and high poverty rates typify the region. The State unemployment rate is 7.7 percent, and unemployment figures in the target counties range from 6.4 to 10.6 percent (Ohio Bureau of Employment Services 1992). Women in this geographic region are not adequately represented in the workforce; many stay at home to raise families or are grossly underemployed. The more traditional the community, the more limited are the employment opportunities for women. The pink collar jobs (service industries that include housekeepers, beauticians, waitresses, and child care providers) and the part-time positions that may be available rarely offer healthcare benefits. For women with children, the choice may be either to accept low wages without adequate healthcare or to remain unemployed and on public assistance with assured medical coverage for themselves and their children. In spite of welfare reform efforts, there remains little incentive to stay employed without adequate healthcare benefits.

The extreme poverty of the region is perhaps the most distressing problem. In the State of Ohio, 15 percent of families live below the Federal poverty level. The poverty rate in Athens County—32 percent—is the highest in the State (Council for Economic Opportunities in Greater Cleveland 1993). Unfortunately, extreme poverty is not the exception in Appalachia, but the rule. The poverty rate is 27 percent in Vinton County, 17 percent in Hocking County, and 28 percent in Meigs County.

In a region that values tradition, the wife in a husband-wife household is especially vulnerable to poverty when the single wage earner loses his job (Tickamyer 1976). Single women holding families together are often the least capable of providing economic security. Across Ohio there are 19.8 percent more female than male heads of households with children. In the target area, the rate of female heads of households with children runs from 23.4 to 36.8 percent, as compared with single men running households with children (1990 U.S. Census data). The most important segments of our population—women with children—are at greatest risk to the dangers of alcohol, nicotine, and other drugs and the related problems of birth defects, mental impairment, incarceration, accidents, violence, physical disability, and death. The daily struggle for survival in Appalachia is clearly visible as alcohol and other drug use become a common way to escape from the harsh realities of living.

Financial and Political Support

Economically speaking, a sparse population limits the number and array of services that can be offered in a given region. The per capita costs of providing special services often make them prohibitive to implement. Yet cost in and of itself does not diminish the need for those kinds of services by the people who live in a rural area.
—Angilene Bushey 1993

Bushey's statement represents the primary problem in providing health care services in most rural areas—money. The State of Ohio, through the Ohio Department of Alcohol and Drug Addiction Services, has made an outstanding effort to address the need for substance abuse services for women and to address the disparity of available services in rural areas of the State. Federal block grant funds designated for women's services have been held separately from the general pool of block grant money.

States have several options for fund distribution. Ohio has chosen to maintain the integrity of the Federal set-aside monies for women's programming and has offered a competitive grant program. This funding mechanism has promoted the development and implementation of specialized programs that specifically address the prevention and treatment needs of women and of women with children.

In addition to State support, the Alcohol, Drug Abuse and Mental Health Service Boards in Athens, Hocking, Vinton, and Gallia, Jackson, and Meigs (agencies legally responsible for oversight of State funding for alcohol and other drug treatment programs) have provided financial, political, and administrative support. Efforts on behalf of these political bodies to recognize the unique needs of rural areas and to secure adequate funding for programs have been invaluable to the success of the Rural Women's Recovery Program and Women's Outreach.

Service Delivery Model

The medical model approaches drug treatment primarily from a physical impairment perspective. While this is important, the model does not recognize the complex and multifaceted lives of women. A sociological model of treatment acknowledges the physical aspect, but also looks at substance abuse from within the context of personal economics and power—or the lack of power. The sociological model demands that one examine and respond to the social and cultural influences and pressures of clients. It was from this model that the treatment and outreach programs were designed. The programs allow women clients to examine how substance abuse is different for them and enable the women to deal with the double standards that exist in many treatment programs, child service agencies, and law enforcement. The program staff and clients need to acknowledge the stigma attached to substance abusing women.

The residential program is committed to assist indigent and low-income women. An 800 number and telephone intakes permit ease of access. Length of stay is typically 90 days, but this is determined by the treatment team for each individual client. Services provided to clients include:

• Individual and group counseling
• Life skills
• Personal health presentations
• Recreation
• Case management
• Parenting
• GED assistance
• Art therapy
• Psychotherapy
• Communication skills
• Conflict resolution
• Special topic presentations and discussion groups (such as incest/rape survivor, eating disorders, pregnancy, HIV, and co-dependency)

The primary counselor helps the client to ferret out her priorities for treatment. Dependency issues are a big item in almost all client treatment plans. Our goal is to help the client believe in her own strengths, in her capacity to care for herself, and to support her taking responsibility for her own recovery and for her life. Group and didactic presentations look at the many competing issues of substance abusing women. We try to help clients recognize that everyone is not a Suzy Homemaker or a June Cleaver, and then help to reestablish a sober mom back into a family unit. Issues around sexuality and intimacy are always addressed. While there are relatively conservative views of sex in the area, sex and relationships are clearly relapse issues for most of our clients. Clients are given the freedom to discuss sex and intimacy openly to get accurate information and honest feedback.

Case managers have the task of helping clients to reconstruct their outside worlds. This includes working on financial counseling, obtaining public assistance, obtaining a primary care physician, securing safe and affordable housing, working with other family members, and child care concerns. All clients being discharged help to create their discharge and aftercare plans. Clients are expected to follow up with outpatient counseling or to comply with other referrals made upon discharge. A monthly alumnae meeting allows former clients to return to the house to share insights with current clients. This meeting also serves to introduce current clients to potential sponsors.

The program has a strong Twelve-Step focus and provides transportation to meetings. Not all women's substance abuse programs and providers feel that traditional Twelve-Step groups are responsive to the needs of women. However, we are committed to help the clients establish as many sober support systems as possible in their home communities. Alcoholics Anonymous is usually the only nonprofessional group available in our rural counties. Cultural strengths and traditional values are also tapped to re-create healthy responses for clients, including:

• Religion—this is a feelings disease with a spiritual base
• Self-reliance—this involves learning how to care for one's self
• Family system—this involves learning how one can create healthy families

In both the residential and outreach programs, activities and plans are examined to ensure that services are acceptable to clients. Maintaining client confidentiality and anonymity in a small town is difficult, but a priority. Women's Outreach operates with a small community, neighborhood, and person-to-person approach. Taking programs to communities instead of expecting people to come to your office goes far in overcoming client reluctance to deal with bureaucracies and "the government." This approach also helps staff learn to relate to residents and clients within the context of their environments, to actually see what their day-to-day realities are. A provider may decide not to see a client because of body odor, but the case quickly takes on another dimension when you understand that person has no running water or electricity.

The reality of living in rural Appalachia is that many people face a day-to-day struggle for basic needs. This reality forms the foundation for our ongoing program development in the Rural Women's Recovery Program and in Women's Outreach.

Findings

A typical client at Rural Women's Recovery Program is 30 years old, divorced or separated, has two minor children, is extremely low-income (50 percent report no source of income—including public assistance—prior to treatment), and has no marketable or vocational skills. Fifty percent of clients have had children removed from the home by child welfare agencies, 99 percent report a history of incest or sexual abuse, 56 percent have an eating disorder, 35 percent have been diagnosed with chronic depression and have been prescribed medication, 50 percent have been prescribed psychotropic medication, 74 percent report alcohol as their drug of choice, and 26 percent report cocaine as their drug of choice.

It is believed that attention to the following areas is what makes these two programs successful:

• The program is psychologically accessible; efforts have been made to eliminate or reduce barriers of perception.
• The program is financially accessible.
• The program is culturally acceptable, with culturally appropriate interventions that address barriers to access.
• The program is based on a holistic approach to health and to self-care directed by client-driven treatment goals.
• Staff exhibit a willingness to learn from clients.
• The program provides both structured and informal programming.
• The community has been incorporated into various aspects of the programs (for example, through a community beautification planting project and recycling efforts).
• Local staff is hired whenever possible.
• Communities are allowed to decide what outreach services they need and what they feel will work for them.
• Community spirit is fostered, as well as a sense of purpose aimed at addressing substance abuse concerns.

Early program outcome evaluations conducted in 1991 document that, at 6 months after treatment, 64 percent of clients were abstinent and 90 percent reported being satisfied with the program. Of clients completing the program, 91 percent reported they were regularly attending counseling sessions or attending self-help groups. After treatment, there was an increase in outpatient health care visits (this was a desirable outcome) and a decrease in emergency hospitalizations. At 6 months after discharge, program completers also reported fewer arrests than did clients not completing the program. Since opening in January 1990, Rural Women's Recovery Program has had 136 client admissions. Women's Outreach has reached more than 9,198 residents, providing education, substance abuse screenings, and referrals.

Conclusions

Rural Women's Recovery Program and Women's Outreach are two programs that address the substance abuse needs of women and families in rural Appalachian communities. Obtaining funding, political, and administrative support from the State and local Alcohol and Drug Abuse and Mental Health Boards allowed us to develop a residential program and a prevention/education outreach program built on the personal and collective strengths of Appalachia. The spirit of the community is evidenced by support from other agencies and programs. Other providers in the State of Ohio who serve women have also shared their trials, tribulations, and successes to help each new program along the way. While Appalachians are not officially recognized as a minority population, our programs are designed to address the specific cultural needs of this population. Substance abuse treatment, prevention, and education really do work.

In 1994, the residential program was expanded to provide space for up to 11 women. The house includes three family units, so mothers of young children may bring their children into treatment with them. We hope to have an even greater impact on entire family systems. Recovery is not a process one does alone. The more positive influence we can have on the family unit, the greater the client's chance of maintaining sobriety.

The outreach program has seven elements for successful programming.

• Lay a foundation for trust; become involved in the community.
• Identify key community leaders; plan activities around community- identified needs.
• Start with what you have; start small.
• Provide programming even when a lot of people don't show up.
• Understand that flexibility and persistence are essential.
• Develop participant and community volunteers.
• Value your key resource—human capital.

"Culture is what a people does, says, lives, dies, and celebrates."
—Deanna Tribe

Recommendations

• There is a need for additional and more secure funding streams for substance abuse programs. In addition, we must be willing to provide sufficient funds to develop new programs and to sustain adequate funding levels.
• Program providers need to find more ways of disseminating information about interventions and programs that are successful. Many of us in rural areas administer, manage, and sometimes see clients in our programs. Finding the time to present or write articles about what we do is often a luxury that we do not have.
• Rural substance abuse providers need to provide assistance to all other programs that are attempting to serve other rural populations.
• The Federal Government should rethink how it defines minority groups. Consideration should be given to raising the status of low-income and rural populations, particularly Appalachians.

References

Bushey, A., ed. Proceedings from the National Rural Health Association Conference. 1993

Center for Health Economics Research. 1988 National Maternal and Infant Health Survey.

Codman Research Group, Ambulatory Care Access Project. New York: United Hospital Fund of New York.

Department of Health and Human Services. Alcohol and Health Seventh Special Report to Congress. 1990.

The Bridges of McKinley County: Building Rural Recovery Coalitions

Raymond Daw, M.A.
Executive Director
Na'Nizhoozhi Center, Inc.
Gallup, New Mexico

Herb Mosher, M.A., M. Ph.
Rehoboth McKinley Christian Hospital
Gallup, New Mexico

The purpose of this paper is briefly to describe the response of a small group of people in rural Northwest New Mexico to an epidemic of alcohol and other drug abuse problems.

A County Under the Influence

McKinley County is located in the northwest region of New Mexico not far from the point where the Four Corners of Arizona, New Mexico, Colorado, and Utah touch each other. With a population of about 61,000, McKinley County covers an area larger than the combined States of Connecticut and Rhode Island. Population density ranges from 4 to 14 persons per square mile. The county contains approximately 43,000 Native Americans who are members of the Navajo Nation or the Pueblos of Zuni, Laguna, or Acoma. Standards of living range from upper middle class households with two incomes and three cars to a large number of dwellings without indoor plumbing, where 50 percent of the families earn less than $10,000 per year.

Gallup is the only incorporated municipality in McKinley County. As a major trading center for Indian jewelry, art, rugs, and other crafts, Gallup attracts more than 100,000 people on weekends. Since alcoholic beverages are illegal in the Navajo Nation and Zuni Pueblo, Gallup has more than 60 restaurants, bars, and retail outlets that dispense wine, beer, and other forms of alcohol. As a result of Gallup's proximity to Interstate 40 and the Santa Fe Railroad, illegal drugs are readily available. McKinley County is especially vulnerable to a high incidence of alcohol-related problems, including driving while intoxicated (DWI), because of the combination of easy access to alcohol and other drugs, long travel distances, poor roads, limited medical services, a young population, and a long history of alcohol abuse.

NIAAA's U.S. Epidemiological County Problem Indicators found McKinley County had the highest composite index (910) of alcohol-related problems of all 3,106 counties surveyed from 1975 to 1985. During this period, death rates from cirrhosis of the liver in McKinley County were 3 times higher than the national average; alcohol-related traffic accidents were 7 times higher; and chronic alcoholism rates were 19 times higher than national averages.

From 1987 to 1993, a total of 255 persons died in McKinley County motor vehicle crashes. Of this total, 188 fatal crashes, or 74 percent of the deaths, were alcohol related. According to the New Mexico Traffic Safety Bureau, McKinley County ranked first among the State's 33 counties for alcohol-related crashes on a per-capita basis. During this same period, McKinley County ranked among the top five counties in America for per-capita DWI fatalities.

From 1973 to 1992, the Gallup Police Department operated a protective custody system that picked up public inebriates and put them in the local jail. Gallup protective custody logs record an average of 32,000 protective custody pickups per year for public intoxication in a city of only 22,000 residents. The magnitude of the problem attracted regional and national media attention. In the fall of 1988, the Albuquerque Tribune conducted a 3-month investigative report. In the following months, the region's problems were the subject of lengthy feature stories produced by ABC's 20/20, NBC's Today show, and PBS' MacNeil/Lehrer Newshour.

March of Hope—Journey for Jovita

In the summer of 1988, the chief executive officer of Rehoboth McKinley Christian Hospital (RMCH), Dave Conejo, invited a small group of health care professionals and concerned citizens to meet informally about the hospital's commitment to the community. From these sessions came a core group of people who were committed to changing the situation in McKinley County. Dr. Tom Carmany, the hospital's Chief of Pathology, urged the group to look at Gallup through the hospital's mission statement, which says that RMCH will provide "a Christian-based health care system which is responsive to all peoples." Dr. Carmany asked core group members, "How long are you willing to step over the bodies?"

With the assistance of Gallup's mayor, Ed Munoz, the core group began meeting with elected officials, tribal leaders, schools, parents, health providers, and even representatives of the liquor industry. Initially, many people discouraged the coalition from trying to change the status quo. The Speaker of the New Mexico House of Representatives said, "You are not going to change things in Gallup, and the legislature has no money for you."

Several members of the community coalition met with Tim Gallagher, editor of the Albuquerque Tribune. Mr. Gallagher was aware of the epidemic in Gallup and wanted to "put a human face on it." The Tribune assigned a team of investigative reporters who produced an exhaustive six-part series, "A Town Under the Influence." The series provoked outrage, statewide attention, and a national award for the paper.

In January of 1989, Robbie Christie drove his pickup truck head-on into a van. He had been drinking all afternoon and had a blood alcohol count (BAC) of .35. The crash killed Mr. Christie and four members of a Navajo family, including a 3-month-old baby. The death of little Jovita Vega electrified the community coalition. Within 4 weeks, the March of Hope: Journey for Jovita left Gallup with several dozen walkers. Ten days later, more than 2,000 marchers converged on the State Capital in Santa Fe to present Governor Gary Carruthers with a reform package.

We Can Make a Difference

The March of Hope enabled the local community coalition to bridge the gap between what was historically perceived by State leaders as a local "Gallup Indian problem" and the more global concerns of regional and State lawmakers regarding the health and safety of all citizens. The coalition convinced many New Mexicans that after a century of suffering and indifference, a core group of leaders surrounded by a large group of supporters were going to stick together to end the epidemic of alcohol and other drug abuse.

The precise moment when both sides crossed the new bridge of understanding was captured in a picture of two women hugging each other be