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Foreword

The Center for Substance Abuse Treatment (CSAT) and the National Rural Institute on Alcohol and Drug Abuse (NRIADA) are pleased to sponsor this publication jointly. For too long, the problems of alcohol and drug abuse in rural areas have received short shrift in the national consciousness. As national studies show, those who live in rural areas are just as likely to have alcohol and other drug problems as those who live in large and small cities. The choice of addictive substances may differ, but the prevalence of abuse is virtually the same for country and city dweller alike. Yet rural areas face special difficulties in providing high-quality treatment and prevention services to their widely dispersed populations—often without the help of public transportation.

To help focus attention on the special service delivery problems of rural areas, CSAT and NRIADA sponsored an "Award for Excellence" competition in the Fall of 1992. Individuals and agencies from rural areas across the country were invited to submit papers describing their efforts in providing services to those with alcohol and other drug problems. The goal of the competition was to elicit—and then publicize—the innovative and unusual strategies, approaches, and research findings from rural programs.

In response to this challenge, CSAT and NRIADA received an excellent collection of papers addressing a wide array of issues and populations, from schoolchildren to alcohol-dependent adults to criminal offenders. The submitted papers are printed here: some describe local programs, while other programs affect entire regions. Readers will find many unusual and innovative strategies. To name just one example—an isolated treatment agency on the coast of Maine solved their patients' transportation problem by offering space for a "club" to the local recovering community; the flourishing club now provides a safe gathering place, recreational events and holiday meals, and a place of comradeship and support to patients.

We are pleased to offer the field this fine group of papers, with their many ideas for meeting the challenge of providing high-quality services to rural areas. Knowing what to do is the critical first step.

But those developing programs must also be prepared to act as advocates with local and State policymakers, who can help provide the understanding, funding, and other resources to make new initiatives possible. The first paper in this collection, originally presented at the NRIADA's annual conference, suggests what local and State programs can do to help overcome the barriers that interfere with gaining support from policymakers. Working together—with collaboration between the public and private sectors—we can make a real and meaningful difference for rural people suffering from alcohol and other drug problems, and bring excellence to rural America.

Bringing Excellence to Rural and
Frontier America: Advocacy for
Substance Abuse Services in the l990s

Susan L. Becker

This paper is adapted from a speech presented by Susan L. Becker, Associate Director for State Programs, Center for Substance Abuse Treatment, at the eighth annual conference of the National Rural Institute on Alcohol and Drug Abuse. The speech was the keynote address for the Harold E. Hughes Awards Luncheon on June 10,1992.

Since President Nixon declared the first modem war on drug abuse in 1974, America has been concerned with substance abuse. While there is acknowledgement that alcohol and other drug use are problems for all of society, media and political attention seem locked on scenarios suggesting that substance abuse is predominantly, if not uniquely, a problem of the inner cities. Participants in this eighth annual conference of the National Rural Institute on Alcohol and Drug Abuse are acutely aware that this is not so. For too long, the national consciousness and the national agenda of the "War on Drugs" have been oblivious to the alcohol and drug problems of rural and frontier America.

Prevalence of Substance Abuse Problems in Rural America

The question is not whether alcohol and other drug use is a problem in rural and frontier areas. Prevalence data provide ample evidence that the problem exists. In 1990, a report on rural drug abuse by the General Accounting Office stated that total substance abuse rates are about as high in rural and frontier States as in nonrural States. What differentiates between rural and nonrural areas is that the prevalence rates for particular drugs may vary. For example, the rate of cocaine use appears to be lower in rural areas than in cities, whereas prevalence rates for other drugs, such as inhalants, may be higher.

Alcohol is the most widely abused substance in rural areas. However, more than 4 of every 10 rural high school seniors have tried marijuana; 1 in 11 rural high school seniors reports having tried cocaine. Among students in rural areas, the lifetime, annual, and 30-day prevalence rates for stimulants, inhalants, sedatives, and tranquilizers are comparable to those of seniors in nonrural areas Johnston et al. 1989, pp. 4246). Most prison inmates in rural States have abused alcohol, other drugs, or both (U.S. General Accounting Office 1990).

Clearly, the problem exists and has been documented. This presents rural and frontier States with a dilemma. When a problem and its constituency are invisible to the majority of the public, how can a rural State develop the necessary support not only to acknowledge the problem and the need, but also to develop excellence in the State's prevention and treatment services? Louis Swanson, in assessing rural development problems, identified six current barriers to action. I believe these barriers apply to the problem of how we can achieve excellence in the delivery of substance abuse services in rural and frontier America. These barriers include:

1. Flawed views of rural America
2. Serious limitations to the social and health data on rural areas
3. Failure to see rural areas as connected to the larger U.S. society
4. A perception that many rural problems do not have a viable political solution
5. Absence of a unified rural constituency, combined with the presence of formidable opposition to rural programs other than farm price supports
6. State and Federal fiscal crises (Swanson 1990, pp. 21-29).

Barrier #1: Flawed Views of Rural America

I believe the most formidable barrier to excellence lies in the flawed views of rural America that are commonly held. This barrier concerns the economics of health care delivery in rural and frontier areas. It is commonly believed that wages, labor costs, and building space are less costly in rural areas and that, as a result, rural health care services are less expensive to deliver compared to their costs in urban areas (Public Law 102-371, Section 1933 and Section 707).

This view is flawed, however, in that it fails to consider the "diseconomies of scale" and the available infrastructure that differentiate urban and rural settings (U.S. General Accounting Office 1990). Thus, while building costs may be lower in rural settings, rural and frontier areas face a unique challenge—that of providing physical access to services for clients who may live significant distances from the treatment or prevention site. Rural States also face the challenge of recruiting and retaining qualified professional staff who live in proximity to the site, but who must be willing to travel almost continuously.

Similarly, the coordination of services may prove more costly and more labor intensive within the rural delivery system because of the difficulties posed by distance, service availability, and accessibility. When calculating per client expenditures, it is imperative to include such critical expense items as travel, availability of specialized personnel, accessibility of other needed health and mental health services, and infrastructure costs. Inclusion of these expenses can drastically affect the accuracy of cost projections on providing substance abuse services to the population in need.

Barrier #2: Serious Limitations to Social and Health Data

The second barrier—the limits imposed by the scarce social and health data concerning rural and frontier areas—exacerbates the first barrier of flawed views. This information gap could be remedied through utilization of existing indicator data or through the planning and health resources of the States and State universities. Unfortunately, most rural and frontier jurisdictions and providers have been slow to utilize these available resources.

Available National Data

The National Household Survey is one example of data available for rural and frontier States to use in documenting their need for services. The 1988 survey, conducted by the National Institute on Drug Abuse, compared the relationship of drug use to demography by analyzing age-controlled data for large metropolitan areas, small metropolitan areas, and nonmetropolitan areas (National Institute on Drug Abuse 1989).

Significantly, the Household Survey showed that large metropolitan areas and rural areas had similar rates for drug use among youth aged 12 to 17 years—approximately 9 percent. Such figures suggest that youth in this age group have a comparable need for prevention and education efforts, whether they live in rural or in large metropolitan areas.

Young adults aged 26 through 34 in both large metropolitan and nonmetropolitan areas also had comparable rates of drug use—15 percent and 13 percent respectively. The rates of drug use among this age group are significant, since they imply that these young adults have a substantial level of chronic drug use and a need for appropriate treatment resources. These findings have significant implications concerning the type of substance abuse services that are needed in rural areas. More importantly, they demonstrate the extent to which drug use in rural areas is similar to use in both large and small metropolitan areas.

Local Data Sources

At a time when State and Federal resources are limited, individuals as well as service providers need to gain maximum benefit from all existing sources of data. While the most ideal data would be a quantified needs assessment for the population served, familiarity with existing local agency statistics can generate a great deal of supporting and helpful information. Local health departments can provide data about the rates of infectious diseases associated with alcohol and other drugs of abuse in their particular areas, as well as data concerning local teenage pregnancy rates. Local justice agencies can provide data concerning the rates of crime and of accidents associated with alcohol and other drug use.

Learning to use and regularly review such data would not only go a long way toward overcoming the flawed views of others, it would also convert some flawed self-views of rural America. Those who live in rural and frontier States are no longer secure from the threat of HIV, tuberculosis, or drug-related crime. Further, the needs of rural people who are being served may be changing. The service system must be sensitive, flexible, and adaptive to meet these evolving needs.

While it may once have been true that rural and frontier areas had a problem only with alcohol, this is certainly not true today. As stated earlier, existing studies demonstrate that alcohol is the most widely and commonly used substance, but that rates of drug use for rural youth and young adults are comparable to prevalence rates in large and small metropolitan areas.

The availability of heroin is limited in rural areas; however, this does not negate the possibility that rural people can be addicted to narcotics acquired through illicit trade in prescription drugs. Intravenous drug use is most commonly associated with heroin and narcotics, but abusers of methamphetamine also commonly administer their drugs intravenously. The prevalence of intravenous drug use, regardless of the agent used, has significant implications. For instance, analysis of Arkansas prison data revealed that, in the State's four rural counties with a high rate of intravenous methamphetamine use, the rate of HIV infection was also elevated.

More accurate and specific data is needed before it will be possible to understand fully the extent of substance abuse problems in rural areas. Nevertheless, there is ample evidence to suggest that the problem is extensive and that aggressive intervention is needed.

Barrier #3: View of Rural Problems as Disconnected From U.S. Society

The third barrier to excellence is the failure to view rural and frontier areas and their problems of alcohol and other drug abuse as connected to the larger U.S. society. The day for insularity has passed. We cannot afford to see substance abuse problems as a separate and distinct issue.

The abuse of alcohol and other drugs must be seen as a public health problem and addressed accordingly. When we view the abuse of alcohol and other drugs in a public health context, we can speak forcefully about the consequences of the use and abuse of these agents in a manner that connects the consequences to the local community and to the State at large. When the connection between rural substance abuse problems and the larger community is successfully made, it will create new stakeholders invested in the successful resolution of rural problems. While some control may be lost, the benefit will be a more effective network of problem solving that will develop through increased resources and the investment of more people in a positive outcome.

Direct and Indirect Costs of Alcohol and Drug Abuse

How do alcohol and other drug use relate to public health services and expenditures by society at large? Drug and alcohol use directly affect the extent of expenditures needed to provide services and also affect the type and extent of health care and support services needed by a community. The process of educating policymakers must emphasize that the direct and indirect costs of alcohol and drug abuse are shared by all of society.

Beyond the costs of treatment and prevention services, there are a wide range of health problems associated with drug and alcohol use; these associated health problems are significant factors in calculating the overall cost of substance abuse to society.

Consider the following estimates for the cost of health and remedial care for health problems related to drug and alcohol use:

• A cost of $785 is estimated for a single case of hepatitis B (CDC 1990; CDC 1992a; Alter et al. 1990)
• A cost of $50,125 is projected for the treatment of one person with the human immunodeficiency virus (HIV) (CDC 1991a; CDC 1992b; Kahn 1992)
• An expenditure of approximately $102,125 is estimated for each case of acquired immunodeficiency syndrome (AIDS) (CDC 1991b; Kahn 1992)
• Current estimates approach $1,400,000 to cover lifetime medical and institutional care for one child with the fetal alcohol syndrome (FAS) (Weeks 1990)

Each of these and many more health problems are significantly associated with the misuse of alcohol and other drugs. The indirect and direct costs of alcohol and other drug use should be presented as justification for both prevention and treatment services. The most significant point about these costs to society is that, through prevention and early intervention services, these costs may be significantly reduced. Every case of alcohol and drug abuse that effective outreach, prevention, and treatment can identify early or prevent entirely will produce cost savings for State and Federal Medicaid expenditures and for society as a whole. Those of us in the substance abuse field must learn to demonstrate not only that treatment works, but also that it is a wise investment in today's economy. Without intervention, our communities will endure the continued costs associated with drugs and alcohol—costs of accidents and injuries as well as additional expenditures for disability, lost productivity, and costs secondary to criminal activity.

Impact of Rural Supply, Production, and Distribution of Drugs

In addition to the health care and crime costs generated by rural drug abuse, policymakers must be made to consider the crucial role that rural and frontier areas play in the overall supply, production, and distribution of drugs. Drug cultivation and drug laboratories are certainly more likely to be found in less populated rural and frontier areas.

Drug smuggling—whether overland or by air in light aircraft—is a phenomenon of extremely rural and frontier areas; this smuggling is supported by our extensive interstate transportation networks. As a result of both availability and organized and active distributors, the drug use problem at production/ importation points in rural and frontier areas may be worse than in most large metropolitan areas.

Barrier #4: Perceived Lack of A Viable Political Solution

There is a perception that many rural problems do not have a viable political solution. This flawed view acts as a barrier to effective program development and therefore must be challenged head-on with quantitative data from national and local studies.

Every rural and frontier advocate needs to educate community decision makers in local businesses and local government on scientific findings, demonstrating that rehabilitation, education, and prevention efforts in substance abuse are effective and work. Such efforts can increase the community's economic opportunities, because potential employers want safe, healthy, and reliable work forces and communities. Every program needs to participate in some formal quantitative evaluation studies. Innovative programs should be fully documented as effective treatment modalities and as cost-effective intervention models.

Overcoming each of these barriers requires that rural and frontier communities be clear in their goals. They need to be effectively organized and to be active in directing all available resources toward their achievement.

Barrier #5: Absence of a Unified Rural Constituency

Unfortunately, a fifth barrier has been the absence of a unified rural constituency able to advance concerns and needs and to propose solutions. Each rural and frontier State would benefit from having an active and organized group of substance abuse providers, a government-sponsored advisory council, and a rural caucus. When political leaders and funding agencies are making decisions, they look to organized groups who can speak with a unified voice for a given population; they look for data that can provide valid and reliable proof of a position. This requires local and State organizational efforts, as well as efforts among those across State lines who have similar interests and causes to advance.

Once organized, efforts must be made at all levels of decision making through active communication and involvement with many individuals and groups. Those who should be approached, involved, and worked with include:

• Local and county governments
• State agencies
• State legislative committees
• Coalitions with other community groups

It is important to hold meetings with State governors, to inform Federal legislators of needs and concerns, and to present the group's agenda to relevant Federal agencies. The National Rural Institute on Alcohol and Drug Abuse itself can serve as a powerful vehicle for organizing and directing the interests of rural and frontier communities. With all of the competing interests for funding and special consideration, those with an organized and active constituency are most likely to receive attention and action.

Barrier #6: State And Federal Fiscal Crises

Finally, consideration must be given to the sixth barrier—current State and Federal fiscal crises. Advocates for rural program excellence need to be aware of and to understand the elements of a particular State budget crisis. It is critical for advocates to educate themselves about how substance abuse problems relate to budgetary problems. Ask yourself these questions. How much do you know about your State budget crisis? Does your State have a problem of income, a problem of outlay, or a combination of the two? Which outlays pose the greatest strain on the budget?

The substantial outlays for prison costs, Medicare, and Medicaid can all be related to the costs associated with chronic alcohol and other drug abuse. In this circumstance, modest investments in substance abuse treatment and prevention can produce large cost offsets and can contribute significantly to the management of these "runaway" outlay problems in State budgets. To a lesser extent, costs such as unemployment compensation and food stamps are also budgetary outlays that can be related to substance abuse.

Advocates for rural programs must have an organized constituency. In addition, the organization must be armed with valid and reliable data that will serve to educate decision makers about the needs of rural and frontier areas and the means for resolving problems in a cost effective manner.

Having presented this overview of flawed views of rural America and the barriers associated with these views, where do we all go from here? As a first step, you need to evaluate yourself and your organization about how prepared you are to overcome these barriers effectively. The scale below has been prepared as a checklist to help you assess both strengths and areas of untapped potential. Using the assessment scale, score yourself and assess where you might strengthen your efforts and expand your activities.

As we all know, there is much to be done. I hope this overview will assist each of you in determining— for your State—where you go from here.

Assessment Scale
1	No effort or knowledge in this area
2	Minimal effort or knowledge in this area
3	Significant effort or knowledge in this area
4	Activity completed or knowledge complete in this area

Rural Drug Abuse Systems Assessment
Points Possible	Activity	Points Scored
4	Calculation of cost (dollar outlay) per client you serve
4	Cost comparison of programs comparable to yours in urban/suburban areas
4	Completion of a formal, quantified needs assessment
4	Knowledge of rates of infectious diseases associated with alcohol and other drug use
4	Knowledge of rates of crime associated with alcohol and other drug use
4	Knowledge of rates of accidents associated with alcohol and other drug use
4	Knowledge of teenage pregnancy rate
4	Demonstration to an employer, insurer, or legislator the cost-offsets for substance abuse treatment
4	Participation in a formal, quantitative evaluation
4	Familiarity with relevant portions of State budget
4	Meeting with gubernatorial/legislative staff on relevant budgetary Problems
44	Total Possible Total Score

References

Adult and Adolescent Community Correctional Services Program

William S. Tanner, B.S., A.S.A.C.
Waterville, Maine

This paper describes the development of the Community Correctional Services Program which seeks to reduce recidivism by establishing user accountability, directly impacting upon the efficacy and efficiency of the seven county jails, the seven county probation and parole offices, the district and superior courts, and the local police departments.

The multijurisdictional effort brought together Federal, State, county, and local resources to meet the needs of the offender population. By combining the Federal Bureau of Justice Assistance (represented by the State JAA) and the Federal Health and Human Services Office of Treatment Improvement (now the Center for Substance Abuse Treatment) (represented by the State Office of Substance Abuse), the seven-county consortium is now able to provide services to both the adult offender and the at-risk adolescent population.

It is the philosophy of the consortium and the Community Correctional Services Program to network with community-based services whenever possible in order to best serve rural Maine.

Purpose

The overall goal of the Community Correctional Services Program is to reduce the recidivism of the substance-abusing offender by

creating an atmosphere of user accountability, providing alternative sentencing, and testing for drug use among offenders. The immediate goals of the program are:

• To identify and meet the treatment needs of adult and juvenile drug-dependent and alcohol-dependent offenders.
• To provide treatment alternatives at the pre-adjudication and pre-trial phases of the criminal justice system for perpetrators posing no danger to the community.
• To provide drug testing for the identification, assessment, referral, case management, and monitoring of drug-dependent offenders. The program collects region-specific data on the type and pattern of substance abuse in order to contribute to long-range law enforcement, corrections, and treatment planning.

Method

It is becoming increasingly apparent that, as State funding and other resources decrease, there must be a concerted effort to maximize Federal, State, county, and local community efforts to provide a coalition approach to services.

Kennebec Valley Regional Health Agency is a rural, community-base,d nonprofit health care provider with a major division of substance abuse and mental health services. Its Community Correctional Services Program recognizes that to ensure services to at-risk youth and adults in the correctional system, it is necessary to form multiple strategic alliances with organizations providing such services to identified populations and their families.

In 1986, Kennebec Valley Regional Health Agency began providing substance abuse services to the Kennebec County Jail. The services were provided in-house with no identified formal, community-based support.

As a result of this lack, the intended impact on recidivism was minimal. It soon became apparent that services needed to extend beyond the jail to the community. These community-based services were necessary to ensure a smooth transition from the institution and continuity of treatment. Our experience indicated that without them, approximately 47 percent of those treated in jail would reoffend by committing new alcohol- or drug-related crimes. If we had continued in our original direction, services in the institution would have had little impact.

Funding for initial substance abuse services was provided by Kennebec and Franklin Counties and the State of Maine. These community-based services included case management by a substance abuse counselor and an alternative to incarceration, the First and Second Offender Operating Under the Influence (OUI) Program.

Sheriffs from five other counties joined the sheriffs from Kennebec and Franklin Counties as well as probation and parole officers to support the development of a consortium.

In Maine, probation officers were significantly hampered by large caseloads (adult: 200 plus per officer; adolescent: 60 plus); responsibility for expansive geographic areas; layoff days that reduced their client time by 2 days per month; and the inability of 85 percent of their clients in need of substance abuse services to pay for these services.

At the time of the development of the multiple strategic alliance, a recidivism study was conducted. The results of the study indicated that 64 percent of the people on probation reoffended.

Kennebec County Sheriff Frank Hackett had just been elected president of the Maine Sheriff's Association when he and the sheriffs of Lincoln, Knox, Penobscot, Sagadahoc, Somerset, and Franklin Counties joined us to develop the consortium. We presented to the sheriffs the idea of a consortium and explained the logic behind its development. The seven counties represented 52 percent of the voting population of the State. The sheriffs were the only officials in the counties elected by a plurality of the vote. We were able to show that the impact on recidivism and the information resulting from a unified treatment, law enforcement, and correctional effort could be profound.

Having obtained the sheriffs' commitment, we identified that, to be successful in our recidivism reduction efforts, it was also necessary to involve the district attorneys of the seven counties. We met with each DA and learned that if the plan could reduce dockets, speed the court process, and garner judges' support, then the DAs would lend their support as well.

Based on our previous work with them, we were able to enlist support of the Superior Court Judges of Kennebec and Franklin Counties. As a result, we also received the support of the other superior and district court judges.

The collaboration between Kennebec and Franklin Counties and Kennebec Valley Regional Health Agency resulted in development of the Community Correctional Services Program, which also provides services to Lincoln, Knox, Sagadahoc, and Penobscot Counties.

The consortium of sheriffs then applied for a Federal Bureau of Justice Assistance Grant. Sheriff Hackett w as named contract administrator, and Community Correctional Services was designated as the sole service provider. The award was made in 1988, w with funds going to the Maine Justice Assistance Council through the grant from the Bureau of Justice Assistance.

The State Department of Corrections, specifically Probation and Parole, offered its cooperation based on its agreement with our philosophy of accountability, responsibility, and consequences.

Our clinicians feel strongly that accountability, responsibility, and consequences are the basis of behavioral changes, and that though we cannot excuse it, we ca provide explications for the behavior. The correctional population must be held to these standards if there is to be any success in the recovery process. Probation's perception of the "do gooder social worker" had to be put to rest in order to gain their support. This was accomplished by close communication and cooperation with the probation officers built on a positive history of work together.

Content Area

From our work with Probation and Parole, the need to provide substance abuse services and mental health assessment to adolescents at risk became apparent. We identified the fact that rural youth experienced distinct difficulties in accessing affordable services. In order to truly have an impact on this population, we had to accomplish rural outreach. In 1990, the consortium of sheriffs and the Community Correctional Services Program— with the additional support of Probation and Parole, local law enforcement, area schools, courts, and district attorneys—developed and presented a comprehensive grant to service at-risk youth aged 14-22. The grant was funded by the Office of Treatment Improvement (now the Center for Substance Abuse Treatment). Services have now been in place for 2 years. To ensure that the Community Correctional Services Program bridged gaps between corrections, law enforcement, and clinical services and maintained credibility with our collaborators, it was necessary to develop a somewhat unique clinical program approach. The Community Correctional Services Program identified seven program areas that needed to be adapted in order to ensure the continuity of services to the correctional population:

1. Services needed to be available to clients at the time of entry to the correctional system. These services were designed to allow for pre-adjudication and presentencing evaluation and screening with recommendations for potential diversion being provided to probation and parole officers as part of the presentencing investigation. To ensure counselors' consistent contact with both the client and probation and parole officers, counselors' offices are located either at Probation and Parole or within a short walking distance. Our experience over a 7-year period indicates that 72 percent of the cases presented to Probation and Parole and the court have been accepted in part or in full into the sentencing process. The Community Correctional Services Program currently provides services from seven Probation and Parole offices and eleven other locations in the seven counties' rural communities.
   
   
2. Loss of client contact with Probation and Parole during the time of incarceration was identified as a major problem. This loss of contact is not unique to rural communities, but is a serious problem in terms of recidivism in rural States. The program reports the client's involvement in counseling while incarcerated and also reports specific release dates to Probation and Parole. The release date information facilitates early probation contact and continuity of services to the community.
   
   
3. Psychosocial educational groups were developed in the seven counties. The structure of the group allows for early access to services. Each jail client is referred directly to the group upon release from jail. The psychosocial modality allows for a larger numbers of clients, including the dually-diagnosed, to be served in each group. As a result, it is possible for each group to serve up to 25 clients. The program currently has 17 active groups in the 7 counties. Each group has a time limit of 16 weeks. Clients needing more extensive services are referred either to outside clinical services or to our own advanced treatment groups. Those clients who successfully complete the Community Correctional Services Program by completing their treatment plan are recommended for probation termination. Approximately half of all clients referred to the program receive early termination from Probation and Parole.
   
   
4. Once the screening and assessment process is completed, clients are referred to psychosocial education groups and to our case management process. Case management permits the counselor and Probation and Parole to maintain contact with the client and at the same time refers the client to appropriate clinical and support services that aid in rehabilitation. Traditionally, rural States have had difficulty accessing services. This case management system allows the program to search out and refer to the variety of services necessary for the clients' successful integration to the community. Clients who leave the program either through early termination or through completion of the psychosocial educational and/or the treatment group, and who are not in need of further clinical support, are provided with case management services that extend to the end of their probation. To ensure user accountability, the clients in case management receive sproradic urine monitoring. If the clients' results are positive, they return to the formal program with a new treatment plan.
   
   
5. The Community Correctional Services Program has assumed the responsibility of drug testing for the clients of Probation and Parole. Testing acts as a strong additional deterrent to client use and allows for user accountability.
   
   
6. The adult and adolescent programs pay particular attention to gaining access to the whole family whenever possible. The consortium has identified the fact that longlasting intervention requires contact with the family.
   
   
7. Probably the single most important part of the program is the willingness of the counselors to regularly communicate the status of the clients to Probation and Parole. We do not report the content of counseling sessions, but we do report attendance and dangerous behavior. The adolescent program draws its treatment modality from the adult program. However, it focuses primarily on working with at-risk youth before they become involved with the criminal justice system. There are modifications that include a wilderness diversion component. The wilderness program allows the adolescents to spend 1 day every 6 weekends in the wilderness. During this day, they explore ways to develop self-esteem and participate in teambuilding exercises. Rural and frontier States, especially in New England, are faced with the real problem of adolescent alcohol abuse. According to our adolescent client contact, 88 percent report that their primary drugs are not a problem, but that alcohol is clearly the gateway drug. Furthermore, because alcohol is so readily available, it is difficult to intervene on its negative impact.
   

Findings

Correctional services in rural and frontier States are faced with many Adult and Adolescent Community Correctional Services Program

difficulties, including the responsibility of covering expansive geographic areas, large numbers of probationers with varied criminal backgrounds, and the sense on the part of many probation officers that they are only bandaging. It has been repeatedly expressed that the officers find themselves setting priorities according to their probationers' level of criminal involvement, because they do not have enough time for their caseloads.

The Community Correctional Services Program has offered Probation and Parole the opportunity to lessen its caseloads. Probation and parole officers are able to rely on the Correctional Services Program Counselors' ability to work with their chemically abusing and addicted adults and adolescents.

Conclusion

Recommendations

My only recommendation is that you be willing to look at the model to see how it applies to your rural or frontier State or county. The program or parts of it could easily be replicated.

(Other materials on our program include First and Multiple Offender Alternative Sentencing Policies and Procedures Manual, Adolescent Thumbs-Up Diversion Program Policies and Procedures Manual, intake and screening instruments (adult and adolescents), "Urine-Monitoring Policies and Procedures," and "Wilderness Experience Development Plan.")

The Upper Peninsula Teen Leadership Program: Marquette-Alger Intermediate School District

Dee Lindenberger
The Upper Peninsula Teen Leadership Program
Marquette-Alger Intermediate School District
Marquette, Michigan

The process of networking to provide quality substance abuse prevention/early intervention services to high school students from across the Upper Peninsula (UP) of Michigan was formally undertaken in 1985. To maximize the limited financial and human resources available, a group of professionals from the major substance abuse service providers across the Peninsula decided to work collaboratively on a project called the Upper Peninsula Teen Leadership Program (UPTLP).

The UPTLP is a comprehensive prevention and early intervention program for high school students. It is a peer leader program that prevents substance abuse by strengthening resiliency factors. It promotes the concept that prevention is not something we can do to our teens, but something we must do with them, as partners. It consists of a variety of innovative student trainings held at different host school sites throughout the year. To meet students' needs for supportive adults and environments upon returning home from the regional trainings, school and agency personnel and community members also participate in workshops that are offered throughout the year to enhance the students' skills in working supportively with student leaders in their schools and communities.

Over the program's 9-year history, a strong network has emerged that includes professionals, community members, and students from all over the UP—a team enriched by the active participation of both Native American and non-Native American persons. The development of a team identity that occurs among the adult and student UPTLP partners is quite similar to the process described by Peter Senge in his book, The Fifth Discipline, regarding the development of aligned "learning teams." It involves (1) the ability to think in terms of "systems theory," (2) the development of a positive vision, (3) ongoing personal learning and growth, (4) the development of a sense of community and team, and (5) the willingness to explore new personal and/or agency paradigms, or "mental models."

These concepts and skills are purposefully incorporated into the UPTLP to provide a conceptual and programmatic framework in which a diverse group of professionals, community members, and high school students can see themselves as part of a larger system. Students and adults have ongoing opportunities for skill development and support that would otherwise not be available within isolated communities. The UP network has continued to work together over the years to meet new challenges and program needs. As a result of this continued collaboration, UP schools wishing to implement Student Assistance Programs have had ready access to necessary training, technical support, and some additional funding sources. Because of its successful history of promoting collaboration, the Marquette-Alger Intermediate School District has gained recognition throughout the State of Michigan and currently provides leadership in the development of a statewide student assistance network. Funded by several State agencies, this network has two tasks: . To develop a guidebook with recommendations for conducting Student Assistance Program trainings. The purpose of the trainings is to help prepare diverse groups of educators and community people to work together as aligned teams in their schools and communities. . To promote greater levels of alignment among State agencies involved with student assistance programs in the State.

Program resources have become increasingly scarce over the past few years. There is no question that the current quality and availability of services could not have been possible without the collaborative teamwork of this network of students, caring adults, and professionals. The UP network is not without gaps; however, it continues to grow in momentum, as well as in numbers.

Purpose and Background

This paper addresses the need for "strategies for coalition building and networking within rural and/or frontier areas." The UPTLP represents a collaborative effort by schools, agencies, and community members from across the entire UP of Michigan to provide a programmatic framework of training, resources, and support that can help to reestablish or enhance positive networks and linkages between individuals, families, schools, and other social systems. Its purpose is prevention: prevention of the onset or escalation of substance abuse and other self-destructive behaviors among UP teens and prevention of relapse for youth returning from substance abuse treatment services.

Although risk factors are identified and addressed at trainings, the major emphasis and strategies are directed toward developing internal and external protective factors that will help develop resiliency among our youth. This includes providing programming and networks designed to enhance a teen's internal assets (such as communication and coping skills and personal convictions) as well as to strengthen a variety of external assets (positive relationships in families, peer groups, schools, and community) (Troubled Journey: A Profile of American Youth, 1992).

The UP is an expansive area bordered by the southern shoreline of Lake Superior and the northern shoreline of Lake Michigan. It is connected to the Lower Peninsula only by the 5-mile-long Mackinac Bridge. The UP is rural, with a population density of 19 people per square mile. Its 16,500 square miles of land consist of wilderness and farmland, interspersed with isolated pockets of population. Although the UP represents just under 30 percent of Michigan's land mass, less than 4 percent of the State's population live there. The economy is dominated by mining, extractive industries, logging, and tourist trade. Layoffs and cutbacks have become a way of life to many residents, and a large segment of the population lives near or below poverty level.

UP communities, like rural communities in other parts of the country, have struggled to find ways to provide quality and cost-effective prevention and early intervention services to their youth. High-risk factors inherent in rural living include limited numbers of trained school and community professionals, scarce financial resources, and large distances between communities, which limit opportunities for supportive networking.

However, agencies and schools are committed to using these limitations as a motivation to share information and pool human and financial resources to make effective substance abuse prevention and intervention programs available to youth all over the area—in short, to network. This process was formally started in 1985. The result is a dynamic and effective UPTLP, a coalition effort making state-of-the-art prevention and early intervention programming available to youth and adults. Over its 8-year history, it has created a strong aligned team that includes professionals, community members, and students working together to promote leadership, resiliency, and positive lifestyle choices.

Methodology

There are two aspects of the UPTLP's methodology to consider: . The UPTLP as a prevention and early intervention program for high school students . The UPTLP as a structural framework for networking and collaboration between school and agency professionals, parents, and community members and groups The methodology and the underlying philosophy that make the UPTLP effective as a youth prevention/intervention and aftercare support program also make it an effective vehicle for networking and coalition building among adults. Five major aspects of the program's methodology play a role in the powerful impact of the program in both arenas. They closely mirror the disciplines identified by Peter Senge in The Fifth Discipline as necessary components for the development of aligned learning teams:

1. Systems awareness and process thinking is incorporated into all levels of programming to provide a sense of the "big picture." In addition to providing a framework for understanding the dynamics and roles of high-risk behaviors in individuals, families, schools, and communities, it also provides a larger structure of available resources and support for positive change. The emphasis on process thinking helps to promote a sense of timing and pacing. Meaningful changes (within both personal and organizational systems) may take time and require ongoing interventions and support.
2. A positive vision propels and guides the shaping of program efforts with students, as well as the working relationships in the adult network. The goal is to find ways to move toward our objectives. The vision includes the wish to help young people achieve their full potential as human beings and as learners. Students and adults alike are motivated and guided by this positive vision to reach their fullest potential and to enjoy the process along the way.
3. Personal learning and growth is encouraged among students as well as adults who participate in the programs. Presentations on topics such as "Understanding Family Systems," "Developing Healthy Relationships," "Enabling," "Feelings and Defenses" are followed by opportunities for discussion and sharing in a small-group format, permitting individuals to integrate information on levels that are meaningful and personally motivating in their lives.
4. A sense of community and team is developed that includes diverse groups of individuals coming from a large geographic area. This feeling can only develop in a safe environment of mutual trust and respect. Honest and respectful communication provides the foundation for a safe learning and working environment.
   Enhancing the communication skills (such as listening, problem-solving, assertiveness, and caring confrontation) of students and adults is an important goal of the trainings. These skills foster positive relationships among youth and adults and promote a sense of belonging in a supportive community and team. These are important aspects of prevention on every level and are vital in building an effective coalition or network.
5. Mental models of "the way things are" or "the way I've always done it" are examined, and perhaps challenged, in the hope of generating new ways of doing or being. A fresh perspective opens doors to powerful new insights and behaviors: it can change the way a popular football player views and relates to a handicapped classmate or draw two turf-squabbling agencies together to accomplish what neither could accomplish alone. The goal is to remain open to discovering and learning new ways of seeing and responding.

The methodologies and contents of the UPTLP's prevention and early intervention program and its structural framework for networking and collaboration will be discussed separately.

Prevention Program: Methodology and Content

It is important for youth to have an understanding of the skills and dynamics that determine whether a system (such as family, peer group, or school) will be "growth encouraging" or"growth discouraging." (These terms are preferred as they sound less accusatory than terms such as "functional" and "dysfunctional.")

Systems and Process Thinking

Virginia Satir identified four aspects that she believed aX family systems share. These aspects can be observed within individuals and other systems as well (schools, peer groups, communities, agency networks, etc.):

1. Self-worth—Core feelings and ideas about oneself. (Are individual's feelings of self-worth positive or negative?)
2. Communication patterns—Verbal and nonverbal methods people use to relate meaning to one another. (Are communication patterns open, honest, and respectful, or indirect, manipulative, and filled with mixed messages?)
3. System rules-Overt and covert expectations for behavior. (Are the rules meant to protect and support individuals or to control and punish them?)
4. Links to society—Ways people relate to other people and institutions outside the family. (Is it an open system or a closed system?)

Understanding that there is a continuum of possible norms within different systems in each of these areas, it helps to lay a working foundation on which youth can build an understanding of how and why some systems are supportive and nurturing (growth encouraging) while others are stressful and emotionally painful (growth discouraging). They practice and learn skills that help them develop mutually supportive and respectful relationships with peers, family members, and other adults.

The UPILP functions throughout the UP and includes youth and adults from diverse backgrounds and communities. Periodic regional trainings provide formal opportunities for youth to get together for ongoing skill building and support.

Perhaps of equal importance, however, is the development of regionalpeergroups. Students forge deep bonds at the trainings; they tend to maintain the relationships as sources of motivation and support that bridge the time between trainings. This support is especially significant for students in rural areas who have limited choices of friends and peer groups.

A student returning home from chemical dependency treatment to a school that has only five to ten other students in the same grade faces difficult challenges when most, and possibly all, of these classmates use drugs. A peer group of close friends who understand and support a chemical-free lifestyle can make the difference in a youth's ability to remain sober, even if the group is spread across a large area.

A Positive Vision

Positive visions of the future, important goals and values, and life's many wonderful possibilities motivate youth to make healthy lifestyle choices far more effectively than do negative, avoidance-based visions of what they should not do (e.g., "Just Say No!"). As Peter Senge points out, these positive visions must be encouraged and supported.

There are two fundamental sources of energy that can motivate. . . fear and aspiration. The power of fear underlies negative visions. The power of aspiration drives positive visions. Fear can produce extraordinary changes in short periods, but aspiration endures as a continuing source of learning and growth.

Instead of conceptualizing prevention as something we do to our youth to prevent certain behaviors, we can think of it as something we do with them. As guides and partners, we can promote and support their development as resilient human beings and positive peer leaders.

In a study of more than 40,000 youth, grades 6 through 12, the Search Institute identified 20 protective factors. Of these, 14 were internal assets: communication skills, friendship-making skills, self-esteem, positive view of personal future, etc. A total of 16 were external assets: communication with parent(s) or another adult, positive school climate, positive peer influence, etc.

The institute's study "Troubled Journey" revealed that the more protective factors a child possessed, the lower the number of risk factors and high-risk behaviors. Other studies indicate similar correlations between strengthened protective factors and reduced levels of substance abuse.

In other words, prevention of drug and alcohol problems happens automatically if we focus our efforts on building resiliency and positive leadership skills in our youth. The primary prevention strategy used in the UPTLP develops teens' resiliency and positive leadership potential by strengthening internal and external protective factors.

Personal Learning and Growth The most significant learning takes place when an individual finds personal meaning or relevance in new information and skills and applies them practically to improve the quality of his or her life. When that happens, it is likely that a self-sustaining cycle will develop as achievements feed the motivation to continue learning and refining new skills.
Positive reinforcement keeps people involved as they grow and gain from their experience. The program's structural design encourages personal learning and growth. Large group presentations are interspersed with small "skill groups" in which students meet with two trained, adult facilitators. These skill groups provide time to process and integrate the information from the presentations. They also offer opportunities to practice both intrapersonal and interpersonal communication skills in a safe environment.

A Sense of Community and Team

Diversity is an important element in the effectiveness of the program. For many years, educational research has consistently demonstrated that the most dramatic learning, for all participants involved, happens in heterogeneous groups. If an environment is supportive, safe, and challenging, participants will most likely benefit from its diversity.

Many kinds of students from many different peer groups come to the UPTLP. Some are outgoing and some shy; some are athletes and some think that walking to the television constitutes exercise; and some have never touched a drop of alcohol or other drugs while some are working on their recovery. Increasing numbers of special need students (for example, physically handicapped or learning disabled) have participated in trainings over the years. The program has also included a large number of Native American students. Recognizing the special needs of the Native American students in the program has made increasing understanding of and respect for Native American culture, and multi-culturalism in general, important objectives of the program. The adults in the program also come from a variety of cultural and ethnic backgrounds. They include school and agency professionals, parents, and community members. The teens learn from their wisdom and experience. They discover that adults can be fun, caring, and helpful. In exchange, the adults learn from the teens' insights and energy; they discover that teens can be fun, caring, and capable of dynamic leadership. Imaginary lines that typically separate the adults from the youth and the "jocks" from the "geeks" and the "brains" seem to disappear as the participants learn more about each other as individuals. A sense of being valued as part of a diverse, yet cohesive, community and team develops over a weekend- or week-long UPTLP training. This development involves the following:

• Getting to know other teens and adults as human beings and understanding that everyone has "gifts and missing pieces"—that everyone has something to contribute, but no one is perfect.
• Being confronted with the need to take responsibility for one's own behavior in a way that is respectful and caring.
• Taking risks to learn new skills, share feelings and ideas, and play together.
• Learning about one's strengths and identity.
• Developing a positive vision of a meaningful, personal future.
• Learning to trust oneself as well as others.

Mental Models

Youth are given opportunities to explore a variety of situations by applying new mental models. For example, by viewing how families function from a systems perspective, a youth can better comprehend interrelationships and dynamics of the "big picture." This leads to a fuller understanding of how certain behaviors might exacerbate problem situations at home or in school and, in the long run, be counterproductive. To maintain resilience throughout life, youth also need positive mental models for envisioning their personal futures and for dealing effectively with stress and conflict. The trainings and support network of the UPTLP allow youth to learn and practice these new models of perception and behavior.

UP Teen Leadership Trainings

More than 1,000 high school students and 500 adults participate in regional trainings at different sites over the course of the year. Each school or community has a contact person who provides followup and support to students after the trainings. Contact persons are also encouraged to work with students as advocates and advisors in the execution of action plans developed at the summer training and at other activities throughout the school year.

UP Teen Leadership Summer Training, the core training of the UPTLP, is a week-long program held on the campus of Northern Michigan University. A student assistance program training for school and agency professionals and community members is offered concurrently. It provides opportunities for adults and students to talk, work, and play together. Major presentation topics for students include "Understanding Family Systems," "Adolescence and Chemical Problems and Enabling," "Loss and Grief," "Intensity or Intimacy (Healthy Relationships)," "Yourselves," "Natural Highs," and "What It Means To Be a Leader."

Social competency and communication skills are taught through role play and rehearsal. Students practice these skills in realistic situations during skill groups. Students are taught reflective listening, assertiveness, decisionmaking, problem-solving, dealing with anger, and caring confrontation. A healthy environment is structured to model and encourage the development of responsibility, trust, respect for self and others, sensitivity to and celebration of individual differences, and ways to have chemical-free fun (see figures 1 and 2).

Teen Leadership PlP-Fest Weekends are booster programs offered several times each school year. PlP-Fests (Partners in Prevention Festivals) provide ongoing support and skillbuilding. Approximately 200 students and staff live in a high school for the weekend. They participate in presentations, skill groups, and recreational activities from Friday evening to Sunday afternoon. These weekends are very similar to the summer training in content and focus.

Athletic Chemical Awareness Programs are offered one to three times each year. They address some of the special needs, concerns, and opportunities that athletes have as leaders and powerful role models in their schools. Again, the underlying philosophy and training strategies remain consistent with the summer training. Role plays are used to explore concepts and practice new skills.

Mini-Training and Program Sharing Conferences are one-day programs at which 100 to 200 students and advisors share action plans and successful program activities.

Structural Framework for Networking and Collaboration: Methodology and Content

As previously noted, the methodology and the underlying philosophy that make the UPTLP effective as a youth prevention program also make it an effective vehicle for networking and coalition building among individual adults and agencies.

Systems and Process Thinking

UPTLP provides a structural framework for a systems perspective that encompasses the entire UP. The ability to view the UP as a suprasystem encourages agencies and community members to collaborate and network more closely in a common effort to make human and financial resources stretch further. The network includes professionals from all areas of substance abuse prevention, intervention and treatment services, education, mental and public health, social services, and the judicial system; parents; and community members.

Positive Visions

The UPTLP provides a foundational philosophy that helps keep the focus on one positive, shared vision: what we want for our youth. This positive vision of common goals and teamwork is nurtured and reinforced at all trainings.

Personal Learning and Growth

The structure and content of the trainings foster meaningful personal and professional growth for the participating adults. Beginning and advanced adult trainings include "Comprehensive K-12 Student Assistance Training," "Crisis Response Debriefing," "Facilitator Training," "School-Based Intervention," "Personal Wellness Weekend," and "Program Sharing Workshop."

Many of the adults who attend trainings or work as facilitators at the UPTLP also hold positions in schools and agencies, such as treatment centers and mental or public health clinics. As a result of the personal and professional growth they experience at the trainings, they bring increased levels of personal commitment and strengthened abilities in communication, trust, problem-solving, and negotiation back to their roles in the interagency network. The student and adult trainings provide a common educational and philosophical basis that helps encourage and equip diverse groups of people to cooperate as an aligned team working toward a shared vision.

Sense of Community and Team

In much the same way that a regional peer group develops among the teen leaders, a sense of community and team develop among the adults who participate in and staff UPTLP trainings. Professionals and community members who may have formerly found themselves at odds, perhaps in competition for funding, are much more likely and able to collaborate on win/win solutions when they see themselves as members of the same larger community and team. As with the youth, authentic communication and the development of personal relationships constitute determining factors in the creation of a sense of community. Again, the relationships depend on knowing and caring about others both as individuals and as colleagues.

Mental Models

It demands great trust to set aside a mental model of "how things are" or "how things are done" and to really examine a situation through the eyes of another person or agency. When individuals identify themselves with a team of people they trust, respect, and share a vision with, their ability to suspend preconceived ideas and mental models is much greater. A team or network must achieve a level of trust before it can successfully use its resources to transcend individual and group mental models and seek new and creative solutions.

Prevention Program: Findings And Conclusions

According to process evaluations of trainings and the subjective feedback of parents and school and agency professionals, the UPTLP appears to have had a strong impact on students. Staff feedback indicates that adults have also benefited greatly from the program. As a result of the trainings, both teens and adults have made major changes in their lives, such as quitting smoking or seeking treatment for chemical dependency.

On average, between 3 and 15 referrals are made at each weekend- or week-long training. Referrals to Protective Services are among the most common. Students are also referred regarding chemical use, suicide risk, and eating disorders. UPTLP staff provide followup to students, parents, and agencies, as necessary.

A followup evaluation of a PIP-Fest Weekend, conducted by the Substance Abuse Coordinating Agency in Ypsilanti, indicates that after a 6-month period, the majority (79 percent) of the students who participated in the PIP-Fest "believed they experienced a turning point during the weekend" that resulted "in a behavior change."

A formal evaluation of the UPTLP is currently under development. It will be conducted at four pilot sites and w ill measure the behavioral impact of the Teen Leadership Program as well as possible changes within the school climate.

Program strengths consistently mentioned in evaluations include a strong staff of skilled and caring adults; the creation of a safe environment where people can be "real;" and opportunites to learn about oneself and others, make new friends, and have fun! Students and adults also consistently identify the small skill groups as a critical component of the training experience.

A committee composed of adults and students from across the UP is currently evaluating ways to improve and expand the program. Possibilities include the provision of more extensive followup and support for students in every school and community. The level of involvement and support provided by the identified school contact person varies from district to district. Although staff and network members of the UPTLP are available to all districts and communities for support, presentations, and inservice trainings, not all districts have availed themselves of the services. In addition to some new types of weekend trainings, possibilities for new parent and community service components that enhance teen linkages to families and communities are currently being explored.

Structural Framework for Networking and Collaboration: Findings and Conclusions

The UPTLP currently has seven financial cosponsoring agencies: the Substance Abuse Prevention Program (SAPE-UP) at the Marquette-Alger Intermediate School District, which coordinates the program; both UP substance abuse prevention coordinating agencies, all three Michigan Model Comprehensive School Health Programs of the UP; and Northern Michigan university. Numerous other agencies (such as Community Mental Health and Department of Social Services) and local school districts provide staff for trainings and scholarship money for students.

Recognition is also due the Partners Institute and PIP-Fest, Inc., both of Minnesota. Much of the training methodology and philosophy used by the UPTLP originated with these programs. The UP coalition network continues to include a number of these program professionals from Minnesota and has even added a few members from Wisconsin and Canada. eir involvement as added a healthy outside perspective and fresh energy.

Approximately 6 years ago, student assistance programs began to pick up momentum as a viable means of providing comprehensive prevention, intervention and referral, and aftercare support services to students and families. An aligned network, with a history of successful interagency collaboration to draw upon, was already in place. It helped to provide trainings, technical support, and funding to school districts throughout the UP. This contributed greatly to the professional community's ability to respond quickly to districts' needs to develop and implement student assistance programs.

The UPTLP has proven extremely effective as an organizational structure that provides an avenue of involvement, shared leadership, and recognition to a diverse and geographically dispersed group of individuals and agencies. The network is not perfect. There are still gaps, challenges, and occasional areas of resistance. However, the members of this network provide a great deal of support to each other. They remain extremely committed to addressing the problems and improving the availability and quality of substance abuse services in the UP. They also recognize their place in a much larger system and realize that their ability to fill in the gaps and meet the challenges is part of an ongoing process.

Recommendations

The UPTLP provided an initial structure to organize a diverse group of stakeholders into a functional network. The nature of its programmatic philosophy and training strategies encouraged the development of systems thinking, provided positive vision and personal learning, suggested alternatives of new mental models for seeing and doing things, and promoted a sense of community identity among participants. The work of Peter Senge has been very helpful in understanding reasons why a strong, collaborative network of professionals and community members seemed to simply emerge as a natural result of cooperating on the program. The answer lies partly in the fact that the five disciplines identified by Senge as essential for the establishment of an aligned learning team are also at the foundation of effective prevention programming. The UPTLP incorporated all five disciplines without having any conscious awareness of their potential power to foster the development of such a strong and expansive network.

Because these five disciplines have been shown to be effective in building collaborative networks and teams, they are being used as the methodology for working with a committee of 50 stakeholders involved with student assistance across the State of Michigan. This committee includes representatives from such diverse groups as the Office of Drug Control Policy, the Department of Education, the Department of Social Services, Community Mental Health, the Center for Substance Abuse Services at the Department of Public Health, Michigan DARE, Michigan PTA, school administrators and teachers, counselors, and student assistance trainers. It has undertaken two tasks:

1. To produce a guidebook of recommendations and guidelines for conducting Comprehensive K-12 Student Assistance Trainings (i.e., how do you bring together diverse groups of people from schools and communities, each having their own perspectives and concerns, and help them become aligned teams that can develop and implement effective student assistance programs?).
   
   
2. To facilitate a closer alignment of agencies at the State level. The underlying belief holds that for student assistance programs to really make a difference, they must represent a collaborative effort that incorporates all relevant agencies and networks, educators, parents, and community members into an aligned team. This process of alignment has a strong chance of successful replication within each community only if it is first modeled and strongly supported by agencies at the State level. This project has become known as "Crossing the Bridge" and is still in its early stages. However, it holds great promise and has generated a lot of energy and hope within the committee.

Since its beginnings 9 years ago, the UPTLP has provided many valuable lessons on effective prevention and early intervention and networking. Perhaps the most significant lesson teaches that good design and content are not enough. Ultimately, it takes good people and relationships to make good programs. This also holds true for developing an interagency coalition or network. In the building of truly functional, collaborative networks in rural and frontier areas, the primary investment of time and energy must go into developing human resources and relationships; problem-solving and the creative identification of financial resources will follow. Specific recommendations arising from the experience of UPTLP include the following:

• Identify a shared area of concern and a programmatic concept that can serve as a structural framework around which to organize. A variety of programmatic concepts could function as the UPTLP did to provide a structural framework and focal point around which to rally.
  
  
• Create opportunities for stakeholders and potential network members to participate in shared learning and training experiences that incorporate the five identified disciplines. It is important that these opportunities be part of an ongoing process of professional and personal development. It can be very helpful to enlist the objectivity and neutrality of an "out-of-system" trainer who has strong process and facilitation skills. Small group process time, which allows participants to integrate information, share relevant personal and professional concerns and ideas, and get to know each other, serves as a key component.

In addition to helping build a common philosophical and informational base from which to work, the trainings also provide an opportunity to gain necessary skills and learn how to use the five identified disciplines. When used together as conscious methodology, these disciplines seem to have a synergistic effect: systems and process thinking plus personal learning plus mental models plus sense of community equals aligned teams and reduced levels of fragmentation. Reduced levels of fragmentation equal more effective use of human and financial resources; more support; and effective prevention, intervention, treatment, and aftercare support programs. Collaborative networks help reestablish and strengthen linkages between individuals and organizations. They are effective because they capitalize on the fact that all of us, together, know more and can do more as cohesive members of an aligned team than any of us can do alone, providing fragmented services as individuals or agencies. Furthermore, networks empower individuals and agencies; they offer opportunities for shared input, shared decisionmaking, shared responsibility, and shared recognition. Everyone wins—especially our youth!

You Can't Get There From Here: The Choice/Skyward Experience

Rachel Cyr Henderson, MRC
Licensed Substance Abuse Counselor
Licensed Professional Clinical Counselor
Rockland, Maine

Susan F. Long
Licensed Substance Abuse Counselor
Rockland, Maine

This paper focuses on a program that was near collapse, the strategies that were employed to build coalitions, and the changes that occurred in the delivery of service. The initial consensus was that this was an impossible task. But, by using the program philosophy, being aware of personal and program boundaries, and engaging both the recovering community and service communities, the agency and services were revamped and revised.

Introduction

Choice/Skyward is a publicly funded outpatient substance abuse treatment agency located in the small community of Rockland on the coast of Maine. We are the only licensed facility in Knox County, which covers 374 square miles and has a population of 37,000. The population doubles during the summer months. Included in the county are the six island communities of North Haven, Vinalhaven, Criehaven, Matinicus, Monhegan, and Isle Au Haut. These islands lie anywhere from 12 to 20 miles offshore. There is daily ferry service, as weather allows, to North Haven and Vinalhaven. The farther island communities such as Monhegan and Matinicus must be accessed by mail boat, if space and weather allow, or by private plane by those with more resources.

Knox County is one of the poorest counties in New England and maintains an average unemployment rate of 10 percent. In the last 4 years, the State of Maine has suffered particularly hard financial times and social services have been a leading target of budget cuts. Consequently, the needy in Knox County have felt the harsh realities of the scaling down and, sometimes, the loss of badly needed support services.

The closest detoxification and inpatient treatment programs are located 45 and 75 miles away, respectively. Many of the clients seen by Choice/Skyward for treatment have low income. The only inpatient program in the State willing to serve these clients is located 70 miles north of Rockland, and the closest intensive outpatient/day treatment program is located 75 miles west of Rockland. Needless to say, access to these services can pose a formidable problem.

As a result of Maine's stringent drunk driving laws, many of Choice/Skyward's clients are sent for treatment after they are convicted of operating under the influence. Nearly all of these clients have lost their driver's licenses for a period of at least several months. Consequently, in an area where access to services is already limited, and public transportation is nearly nonexistent, compliance with the requirements of the court seems a heroic matter. Three years ago Choice/ Skyward found itself facing the following problems:

• A very fragmented support system for recovering persons
• Very limited public transportation
• Clients who traveled long distances who might have to wait hours for a ride or a ferry home
• No detoxification services available in the county
• An agency budget about to be cut by at least one third. (This budget was in fact cut by two thirds.)

It was clear that our strategies for service delivery needed to change and that the community needed to be involved if we were to be successful in building a continuum of care. The staff and the Policy Council met to formulate plans to revitalize and reimagine ourselves and our services. It appeared that, given our circumstances we couldn't get there from here."

Choice/Skyward's problems affected both consumers and the community at large. If Choice/Skyward were to remain a community-based program, it needed to find solutions within the community; professional solutions would only serve to further distance it from the community. The recovering community was our primary focus. Furthermore, both the community at large and the recovering community have the capacity to respond quickly and decisively to problems, since they're not encumbered by institutional interests such as budgets,by-laws,etc. Choice/ Skyward needed to use this responsiveness and energy as a Positive force for change.

At the same time, the hospital community needed to be engaged in the process of finding a solution to the lack of detoxification services and the nonexistent continuum of care. As the only hospital in the county, they could act as a major influence and source of education for physicians and other health care professionals.

Choice/Skyward believes that the services we provide are supported and used by the community and, therefore, the community must take part in defining these services and determining how they will be delivered. We are aware that professionalized service can be disabling to community members. This awareness can help ameliorate the iatrogenic effects of treatment (Illich and McKnight). This philosophical stance has helped us Keep our focus and sustained us in the belief that we could get where we wanted to go, although it appeared there was no road.

The Recovering Community

The recovering community was approached by every member on staff. People from every Alcoholics Anonymous (AA) group in the area were invited to a meeting to discuss the problems of recovering people in our county and the possibility of using Choice/ Skyward space for a recovery club. Five people attended the meeting. They were acutely aware of the lack of detoxification services and the lack of access to treatment services. They had suspicions regarding the services we provided and felt discouraged that there was no "central place" for members to gather just to socialize or "have a cup of coffee."

AA members also brought to light some of the recovery problems experienced by people working on fishing boats. Many of these individuals are out to sea on small vessels for 2 weeks or more. Any services they receive must have flexible schedules. The island populations also had difficulty accessing services because of transportation problems.

The group members were impassioned in their responses. They very much wanted to help find solutions to problems faced by the agency and by people early in recovery. They felt that this would be more possible if they had space for a recovery club. Space is an asset Choice/Skyward had available.

Choice/Skyward offered the basement floor of our building to the recovering community. It is a 3,000-square-foot finished space with bathrooms, kitchen, and two entrances. We proposed that this space be used in any way the recovering community liked. Choice/Skyward did not want any control over the decisions that would be made. The recovering community would have to comply with city regulations and keep noise down during Choice/ Skyward's hours of business.

This group then began to meet without Choice/Skyward and developed a plan for the space by working through all the AA groups in the county. The plan presented to Choice/Skyward proposed using the space for a club that would be open from around 8 a.m. until midnight. It would be managed by a Board of Directors made up of members from various AA groups. They wanted to have a person in charge present at all times. They wanted to create a safe place where people could drop in for coffee, play a game of cards, read the paper, receive a little reassurance, attend daily noon meetings, wait for or find rides, etc.

Choice/Skyward agreed to their proposal, and the club received 1 year's free rent. At the end of 1 year, a rental agreement would be negotiated.

The club's progress was remarkable. Within 3 months, the space was painted and furnished with donated furniture. They installed a pool table, cable TV, and a coffee service; subscribed to the local papers; and held regular weekend yard sales of donated goods. A volunteer manager staffed the club at all times. They began to plan dances and other recreational events. From the day they received the keys until the present, a daily AA meeting has been held.

The response from the community was overwhelming, and celebration was in the air. After the initial 3 months, the club approached Choice/Skyward to propose that they do more for the treatment program in exchange for the space. They began a fund to provide transportation to detoxification and inpatient treatment centers around the State. They then organized drivers to provide the service.

As the first anniversary of the club approached, we began the process of negotiating a lease. The survival of the club was Choice/ Skyward's agenda. The club had provided our clients with transportation to services, an introduction to AA and recovery that went far beyond what most treatment centers can offer, a fun and energizing place to wait, and the message that recovery is possible.

It also brought to staff meetings and to Policy Council/Board meetings some of the complaints that the community had with the treatment program. The program responded by changing service delivery times, the configuration of the groups, billing procedures, and staff.

The second year lease was negotiated, and the club agreed to pay $50 per month rent, handle trash removal for the entire building, mow the lawn, and provide snow removal. In addition, it volunteered outside of the lease to continue providing transportation services for our clients and to work on improving the AA hotline and institutional committee. Both the lease and the informal agreement continue to this day.

The Hospital

We approached the hospital community in two ways. First, we discussed the problems with our medical director and asked him to speak for us to physicians. Then we approached the manager of the psychiatric unit at the local hospital, who had expressed an interest in our program and in services for recovering persons. We were able, through the psychiatric unit, to renegotiate a contract for consulting services to be made available to all the units at the hospital. We also agreed to work together to find funding to expand services in our community.

The Choice/Skyward staff became a regular presence at the hospital. The different hospital units quickly discovered that the consultations they ordered had an impact on patients and that we were able to connect addicted persons with a variety of recovery programs.

The emergency room hired a new director who had been trained in substance abuse and called us regularly concerning addicts who came to the emergency room. We provided the hospital with the number of persons we saw over a period of time who needed detoxification but who had to be referred outside the county, when they could have been better served here in their home community. The hospital used these figures to support a certificate of need for detoxification beds.

Our hospital meetings moved to a different level when we met with the hospital president, board president, fiscal representative, and psychiatric unit manager. With the hospital's assistance, we were able to submit a proposal to the State for stable funding for our program. This proposal was written collaboratively and funded by the State of Maine.

The hospital received approval for their certificate of need and planned for a building which would include detoxification beds. We dreamed of expanding and collaborating in other ways in order to create a continuum of care.

During this period of time, we worked on a collaborative grant that also included the local mental health center. We proposed to provide education to the community and professionals on dual diagnosis. We also proposed a collaborative board made up of all services and segments in our community to find solutions for our dually-diagnosed citizens. We won the grant.

Our medical director spoke individually with most of the physicians in our community. He created a broad base of support among physicians which resulted in many new referrals to Choice/ Skyward. Many of these referrals were covered by third-party payors and thereby increased our revenues. The director was also willing to staff cases with us when there were questions regarding prescribed medications, and he intervened with physicians when prescriptions seemed inappropriate. Through his efforts, the trust level between Choice/ Skyward and individual physicians grew.

The Results

We are well into our third year of building coalitions and creating strategies for improved service delivery. The Choice/Skyward program has changed in many ways. \We listened, although at times it •vas painful, to the complaints and suggestions from the community. It became clear that over a period of time that saw many changes in personnel, the Choice/Skyward program had become self-centered; many times staff members had taken the position that when it came to recovery, we knew best. This conveyed the message that a client could truly benefit only from professionalized help, which counters everything a person learns in AA.

Staff members revised operations with the help of the community. We saw and felt the community's power and sensed respect for the part we played in it. We experienced a sense of relief; we did not have to have the perfect solution to anything. Staff gained visibility, Choice/Skyward's revenues increased, and we grew more willing to try new configurations.

We saw some clients every day for 15 minutes and others for 2 hours. We worked on delivering the service in the most acceptable and appropriate way for each client and changed the way we staffed our program.

The recovering community's support of this program continues to increase, and the club continues to prosper. Over time it has had its ups and downs, but Choice/ Skyward has always kept the boundary firm and reserved comment. Had we interfered, we believe the club would have failed. The recovering community prides itself on its success and its ability to solve problems. They also take pride in having reassumed their responsibility to people trying to recover from addictions.

Our relationship with the hospital continues to grow and now includes the mental health network. Over the past 2 years, the hospital has done some detoxification on an informal basis. They have also been willing to monitor patients medically while we make arrangements for transfer to detoxification and inpatient treatment. This has been a much more formal process than what we experienced with the club. We were much more aware of the chain of command and the many layers of decisionmaking that needed to be included.

At this time in our collaboration, there are plans to open an expanded mental health unit which would include detoxification beds, outpatient detoxification, a special track of services for addicted patients, day treatment services, and an intensive outpatient program.

Although it was said many times "you can't get there from here," we did it. We made it because of a willingness to change, to engage the recovering community and the service system, and to work at keeping clear boundaries between ourselves and others. We saw the possibilities as greater than the problems. We can truly say that we are a community-based program providing services that the community itself has requested and finds valuable. The test over time will be to remain flexible and open to the voices of wisdom in our community.

References

Illich, I. Disabling Professions. In: Disabling Professions. London, England: Marian Boyer, Inc., 1978.

McKnight, J. Professionalized service and disabling help. In: Disabling Professions. London, England: Marian Boyer, Inc., 1978.

School Teacher's Role in a School-Community Alcohol Intervention Program

Ian M. Newman, Ph.D.
Mary Lee Fitzsimmons, Ph.D.
University of Nebraska-Lincoln
Lincoln, Nebraska

Kim M. Maschmann, B.S.
J.W. Upright, Ed.D., President
Lincoln Medical Education Foundation
Lincoln, Nebraska

The work on which this paper is based was supported in part by the Center for Substance Abuse Prevention through a grant to the Nebraska Department of Public Institutions, Division on Alcoholism and Drug Abuse, North East Nebraska Intervention/Prevention Project.

Because the majority of rural and/or frontier children attend school for at least some time in their lives, implementing a low-cost, school-based alcohol and other drug prevention and intervention program is an effective way to reach a majority of children with alcohol and other drug abuse prevention, education, and early intervention services. This paper describes a model program, the School-Community Intervention Program (SCIP), and describes the results of a 2-year evaluation of 35 schools.

Purpose

Adolescent alcohol use continues to be a primary concern for both school personnel and community members. The Monitoring the Future Survey estimates that 90 percent of high school seniors have used alcohol at least once in their lifetimes, and 32 percent report consuming five or more drinks in a row in the 2 weeks before the survey (Johnston et al. 1991).

The rural and/or frontier areas of the United States are not exempt from adolescent alcohol and other drug use. Newman and Anderson (1989) studied adolescent alcohol use in the midwestern State of Nebraska and found that 45 percent of 18-year-old male high school students and 30 percent of 18-year-old female high school students reported consuming five or more drinks in a row at least once in the previous 2 weeks.

In response to concerns expressed by school administrators, parents, and community members about adolescent alcohol use, a medical service organization (the Lincoln Medical Education Foundation) developed a program to help schools deal with student use of alcohol and other drugs. The program is based on the assumption that failure to perform adequately in school is a possible indicator of (1) present use of alcohol and other drugs, or (2) an increased risk of future alcohol and other drug-related problems. This program is called the School Community Intervention Program (SCIP).

Method: SCIP

The SCIP has five stages, including: (1) identification and training of a SCIP team; (2) identification of students with academic and/or behavioral problems; (3) intervention on behalf of selected students; (4) education/prevention; and (5) community liaison.

A typical SCIP team in a participating school consists of school representatives (teachers, counselors, and administrators), trained to identify students who are experiencing difficulty at school, who intervene and provide support for the student and his or her family. Students exhibiting difficulties in school are referred to the SCIP agencies. are given the opportunity to obtain services from the school or frPamiliesom community agencies to resolve problems.

SCIP team members receive 4 days of intensive training to prepare them to assist referred students and their families. This training provides information on values, attitudes, and beliefs about alcohol and other drug use; pharmacology; family dynamics; enabling; identification of at-risk students; intervention techniques; implications of various school policies for chemical use; and techniques for building effective community-school liaison.

The number of people on a SCIP team may vary according to the size and needs of the schools, as may the number of SCIP teams in a school. Most teams have an administrator, a counselor, a school nurse, and one or more teachers. Currently, SCIP teams reflect the following distribution of personnel: teachers, 60.1 percent; counselors, 15.9 percent; administrators, 15.9 percent; nurses, 8.2 percent.

After a student is referred to a SCIP team, all faculty who have contact with that student are asked to review the student's behaviors. This review focuses on the following areas:

• Classroom conduct

  - Disruptiveness in class
  - Inattentiveness
  - Lack of concentration
  - Lack of motivation
  - Sleeping in class
  - Extreme negativism
  - In-school absenteeism
  - Tardiness
  - Defiance
  - Cheating
  - Fighting in class
  - Verbal abuse

• Family concerns

  - Mentions alcohol or drug abuse
  - Speaks angrily of parents
  - Suffered recent loss (such as move, divorce, or death)
  - Other siblings' problems

• Academic performance observed

  - Declining quality of work
  - Incomplete work
  - Declining grades earned
  - Academic failure

• Appearance and health

  - Neglected personal appearance
  - Bruises
  - Bloodshot eyes
  - Continual undiagnosed malady
  - Coloration (pale and flushed)

• Other school conduct

  - Unexcused absences
  - Frequent absenteeism (even if excused)