Literature Review

Evaluation Strategies in Aboriginal Substance Abuse Programs: A Discussion

III. Theoretical Models of Substance Abuse Treatment

Effective treatment of clients suffering from substance addictions is founded on a spectrum or continuum of care which includes early intervention strategies, an access system that ensures clients receive the appropriate intensive care, provision of treatment, and a follow-up supportive system which limits recidivism. The high rate of relapse and recidivism of First Nations clientele in a variety of treatment modalities for substance abuse has been attributed to a lack of follow-up and aftercare. In this context, after-care refers not only to support provided to the treated client, but also to the receptivity of the family and community to a returning community member. In particular, clients who return to a substance abusing environment are often unable to retain their sobriety or drug-free status, particularly without continued support from the treatment program.[Linklater, C. 1991. Follow-up and After-Care Manual. National Native Alcohol and Drug Abuse Program, Health Canada] The discipline of alcohol and drug prevention and treatment has several theories or assumptions from which various approaches to service provision are based. The most common theories/models include:[ibid]

Disease or Medical Model

The disease model of substance abuse was born out of the Alcoholics Anonymous movement in the 1930s. Alcoholism was officially recognized as a disease requiring medical treatment in 1956 by the American Medical Association. As a disease, alcoholism has symptoms and may be acute, chronic or progressive. This model does not include a cure for alcoholism, thus there is an emphasis on abstinence. This model is emphatic that as alcoholism is a disease, a person should not be held responsible for their dependence. Although this has helped remove the stigma of addicted persons having weak characters, the disease model has been criticized by some as not promoting a feeling of personal responsibility in recovering individuals. Therefore in critical periods, such as a relapse, a person may feel powerless as drinking is associated with a symptom of a disease and therefore not controllable.[Marlatt, G.A. and W. H. Gordon (editors). 1985. Relapse Prevention. New York: Guildford Press. pp.7-8]

Genetic Model

The predisposition to addiction is genetically based. This model is similar to the medical model in that abstinence is the only successful treatment.

Psychological or Psychiatric Model

A deep underlying psychological problem is causing the alcoholism. Removal of this problem could cause the alcoholism to diminish or disappear.

Behavioral or Social Learning Model

This model which is based on scientific research holds that alcoholism or other addictions are a learned behavior, as people learn that alcohol has a number of reinforcing effects like reducing anxiety, increasing sociability, reducing shyness and increasing one's own sense of personal power. The treatment component of this model lies in controlling this behavior and moderating substance use.

Moral or Religious Model

This model believes that drug abuse results from a moral weakness or lack of willpower It is based on a punitive religious approach, as the addict has a bad or evil character and only through religious salvation can addictions be treated.

Native Cultural/Spiritual Model

The native cultural model is a form of sociological model, which is founded on the belief that social and cultural factors act as determinants for addictions among the members of a society. his is quite different from the models described above which have focused on morality, psychology and physiology as the primary determinants of addition problems. In an Aboriginal context, this model states that Aboriginal people turn to substance abuse because of the loss of culture and tradition. These must be restored before alcoholism and addictions can be resolved. The following is one adaptation of the sociological model:

Cultural Congruence Model

The theoretical and philosophical basis underpinning the move to culturally integrated and appropriate prevention and treatment activities in substance abuse is beyond the scope of this report. Many of the treatment programs now in practice are integrating culturally-specific components into their service, or delivering the entire program through Aboriginal therapies. The cultural congruence model provides a theoretical framework for mental health care in a variety of cultural contexts.[Swinomish Tribal Mental Health. 1991. A Gathering of Wisdoms, Tribal Mental Health - A Cultural Perspective. Extracted and summarized by the Round Lake Treatment Centre. 1992. Research on Native Adolescents and Substance Abuse. The Next Generation Native Adolescent Substance Abuse Project] It is defined in culture-neutral terms - that is, it can be adapted to any culture or ethnicity. In this model, a culture is envisioned as an organically functioning system into which health care is naturally and harmoniously integrated. Culturally-specific services take priority over mainstream services, and all service elements must be derived from and harmoniously integrated into the overall cultural context.

Cultural identity not only is integrated into treatment activities, the cultural context of the therapist-client relationship should be considered and discussed during treatment if appropriate. Wherever an ambivalence, conflict or devaluation of one self or culture group is seen, a positive cultural identity should be a treatment goal. This model strives for a bi-culturalism, whereby the original culture is positively valued and actively maintained while at the same time comfort, familiarity and competence in mainstream culture is achieved.

Although this model does not devalue the benefits of counseling, medication or other forms of treatment that are not culturally-specific, any culture-specific aspects of a person's problem must be treated in a culturally-specific fashion, so as to ensure success of the other forms of treatment. In Aboriginal culture, the helping role is defined differently from non-Aboriginal culture. Helpers are expected to be of the same cultural system, as they will be accepted by Aboriginal people not based on their training or experience, but because of their personal connections to the community. This has important implications for the role of mental health workers in Aboriginal communities as well as for the credibility of mental health services.

Many treatment approaches currently in use in both Aboriginal and non-Aboriginal programs combine a number of models in their strategy of care. Contemporary theory acknowledges that there is no one single approach to treatment for all individuals, and by matching individuals to treatment options, the effectiveness and efficiency of treatment may increase.

Of the above, the disease model and the behavioral/social learning model are seen most often in treatment programs, often in combination. Table 1 lists their major differences.

Table 1: Comparison of the Social Learning and Disease Models

Topic	Social Learning Model	Disease Model
Focus of Control	Person is capable of self control	Person is a victim of forces beyond one's control
Treatment Goal	Choice of goals: abstinence or moderation	Abstinence is the only goal   Slip is seen as a failure
Treatment Philosophy	Fosters detachment of self from behavior   Educational approach	Equates self with behavior   Medical/disease approach
Treatment Procedures	Teaching behavioral skills   Cognitive restructuring	Confrontation and conversion   Group support   Cognitive dogma
General Approaches to Addiction	Search for commonalities across addictive behaviors   Addiction is based on maladaptive habits	Each addiction is unique   Addiction is based on physiological processes
Example	Cognitive-behavioral therapy (outpatient)   Self-control programs   Controlled drinking	Hospital treatment programs (inpatient)   Aversion treatment   AA and Synanon

From: Correctional Services Canada. 1992. Creating an Informed Eclecticism: Understanding and Implementing Effective Programs: A Focus on Substance Abuse. Ottawa.

Follow-up and Aftercare Model

A recent initiative by the National Native Alcohol and Drug Abuse Program (NNADAP) program has been to develop a model that acknowledges the importance of aftercare and follow up in the continuum of care for substance abuse. This model was developed after consultation with Aboriginal people in communities, and completion of an extensive literature and program review on the subjects of follow up and aftercare. The author of this model has described it a "neutral" in that it is not based on any of the theories/models of alcohol and drug abuse described above. Good assessment, treatment and aftercare are seen as integrally related and dependent upon each other for success.

In this aftercare model, three stages of recovery post-treatment have been identified in the treatment/recovery continuum:

• early stage of sobriety: focus of client on not drinking and learning not to drink. middle stage of sobriety: focus of client on sobriety (to stop drinking and to learn to be sober.
• advanced stage of sobriety: a new phase of growth and development of the client, who is no longer preoccupied with sobriety. In this stage, there is a greater sense and degree of healing and restoration of health and equilibrium to one's life.

The treatment/recovery continuum used in this aftercare model is presented in Appendix 1. The treatment phase is comprised of:

• an assessment of the effects of drinking.
• a pre-treatment phase where the client is prepared for the treatment process and understands what will be needed from them to get maximum benefit from the process.
• treatment, either residential or out-patient where the client is educated about alcoholism, and understands that the only recourse is abstinence. Here the client learns to stop drinking.

The recovery component of the model includes:

• post-treatment stabilization: this is a continuation of the treatment phase where the person, who no longer is drinking, is helped to make the necessary adjustments to his or life.
• follow up: extends throughout the recovery phase and is addressed to obtaining information about the success, progress, and problems that will assist the person and the program to measure the degree and extent of recovery
• aftercare: the process of providing on-going help and assistance in maintaining sobriety.
• transformation: clients go through deep and profound changes in their lives, where they are now comfortable with their sober state.
• growth and development: this is the final phase which may not be achieved by all persons, where interests other than drinking become dominant in their lives. The preoccupation with sobriety no longer exists.

Harm Reduction Model

This is a relatively recent approach to substance abuse treatment. As the name implies, the focus of this intervention is to reduce the harm associated with use of drugs, not to necessarily reduce the levels of use. It can be used in a practical sense to help drug users first use drugs in a safer fashion, before a drug-cessation strategy is attempted.

Key concepts in harm reduction that are relevant to policy development in this area have been described:

• Abstinence is not always the only appropriate objective of policy
• Prohibition and enforcement in and of itself can generate certain types of harms, at both the individual and societal level
• The substance abuser is viewed as a member of society, not as an outsider, and may need treatment and other assistance to re-integrate into the community
• It is most often a community-based strategy, and it places as much or more responsibility for effectiveness on strategic partnerships rather than formal institutional interventions
• There may be a need for some forms of legal controls and their enforcement, but this should be integrated into the overall strategy.[Erickson, P.G. 1992. "Implications of harm reduction for substance abuse problems of Native people." in Aboriginal Substance Use: Research Issues - Proceedings of a Joint Research Advisory Meeting. Canadian Center on Substance Abuse and National Native Alcohol and Drug Abuse Program]

Examples of harm reduction measures directed to drug use are needle exchange programs (to prevent the spread of disease) and methadone maintenance. For alcohol users, a simple harm reduction strategy is to open alcohol retail stores earlier to prevent alcoholics from using alcohol alternatives, such as shoe polish. The benefits of harm reduction strategies can include destigmatization of users, improved outreach, prevention of AIDS and a decline in criminal activity by users.[Single, Eric.1994 Cost Considerations and Intervention Strategies. Presentation at public forum on "Managing the Social and Health Costs of Alcohol and Other Drugs." Foothills Hospital, Calgary, May 10] The major barrier to harm reduction for alcohol is the abstinence orientation of many Aboriginal decision-makers and treatment staff.