Literature Review

Evaluation Strategies in Aboriginal Substance Abuse Programs: A Discussion

V. Treatment Programs

Characteristics of Substance Abuse Treatment Programs

A treatment program in substance abuse should typically have the following components:

• detoxification: In a detoxification process, all physiological traces of alcohol and other drugs are completely removed from an individual. In the past, this was accomplished by close medical supervision, however, there has been a trend away from hospital-based detoxification to home-based care with out-patient support services. This may not be suitable for many Aboriginal people, as residential detoxification is the preferred method when it is necessary to remove the individual from an abusing environment. The end result of what ever method is chosen should be clients seeking treatment after they have been detoxified.
• system access, assessment and referral: timely access to treatment, comprehensive assessments and referrals which reflect client needs.
• treatment: a range of treatment options which can provide customized care to individual clients. These options can include Alcoholics Anonymous, native cultural treatments, residential treatment and outpatient counseling. Out-patient counseling is an attractive option for substance abuse primarily because of the high cost of residential care. As well, in-patient care does not have a good track record regarding long-term abstinence, as individuals may relapse upon return to their former environment. Outpatient programs are more flexible, offer the individual the opportunity to become sober while living in the community, and has no community re-orientation period. Out-patient care also provides the option for long treatment periods that are normally not available in many residentially-based programs.
• case management: coordination of various aspects of care from different health professionals to ensure continuity of care and clear communication. Optimally the case manager should assist in re-integrating an individual into the community after residential care and in providing access to support services in the community.
• aftercare: a critical element of an effective continuum of care in substance abuse treatment is ensuring that clients receive continuing assistance during the period of recovery. A formal aftercare program is not seen in many established treatment programs and has been identified as a major problem with the National Native Alcohol and Drug Abuse Program (NNADAP) in-patient programs. There are two main types of aftercare which have been favourably reviewed⁷⁹: case management (see above) and relapse prevention. The latter is a relatively recent initiative in substance abuse treatment and is targeted directly to dealing with the difficulties of long-term changes in addictive behavior. Strategies are employed to counteract the factors which can precipitate relapse such as interpersonal conflict, social pressure and depression.
• program documentation: a comprehensive information system is required to facilitate the care process and allow continuing monitoring of the effectiveness of the program.

Treatment Modality Approaches

In a recent extensive review of the literature on substance abuse treatment modalities, 25 treatment approaches were evaluated. Of these, eight were deemed to be effective. The following is an overview of the results of research into these eight modalities which support their effectiveness.⁸⁰

Assertion Training

Assertion training is a standard component of substance abuse programs, providing participants with tools on how to respond to difficult interpersonal situations with assertive rather than drinking/drug using behavior. This type of training has shown behavioral gains in alcoholics, however the effectiveness with drug abusers has not been ascertained. Reports of the positive impacts of such assertiveness are equivocal. Despite this, the benefits of assertion training particularly in a chronic population whose profile can impede recovery, are thought to be critical.

Recognizing High Risk Situations

The concept of high risk situations is based on observations that even persons with severe alcohol problems do not drink incessantly whenever alcohol is available. Identifying high-risk situations and developing interventions is fundamental to behavioral treatment of any problem. Research has shown the most common categories of high risk behavior common with alcohol abusers and heroin addicts to be negative emotional states, interpersonal pressure and social pressure.

Relapse Techniques

In this form of relapse prevention, individual should be able to anticipate and identify high risk situations, possess skills to deal with those situations, and should have the expectations that using these skills will result in a beneficial outcome. One of the main contributions of relapse prevention to the addictions field is that it has brought into open discussion the fact that relapse is a frequent event following treatment. The available evidence largely supports the efficacy of relapse prevention, although improvements attributable to this technique tend to be modest.

Social Skills Training

Social skills training is another common component of substance abuse treatment programs. It assists drug and alcohol users in functioning more effectively in social situations. There are various approaches to this field including teaching more effective communications skills to improve interpersonal relationships and social skills training to improve social functioning. Social skills training in general has been found to be an effective component in treatment programs, and is supported from conclusions of several studies showing positive impacts on substance-abusing behavior after treatment discharge and at longer follow-up intervals. Social skills training can be used as a single component program or as part of more comprehensive treatment approach.

Problem Solving

Problem solving skill training is generally used in as one component of treatment programs that utilize other approaches (e.g. social skills training). In the research literature the evidence supporting problem solving skills training is positive, yet must be considered as indirect as it is difficult to separate the individual benefits of one component of a multi-component strategy. Regardless, the lack of adverse effects and the presence of beneficial outcomes has been used as justification to recommend the incorporation of problem solving in procedures totally lacking in evaluation.

Methadone

Methadone treatment was developed as an alternative to heroin, and was originally intended as a maintenance medication. For physiologic reasons, a person on methadone has little incentive to also use heroin. Methadone treatment is usually accompanied by behavioral counseling. Multiple evaluations have supported the effectiveness of methadone in reducing users' consumption of illicit drugs, reducing criminal activity and allowing users to become socially productive and psychologically stable. In the literature, research results which are not supportive of methadone use are generally explained in terms of an inadequate methadone dosage. One theory on methadone usage supports the continued use of this drug, rather than a gradual withdrawal, an approach that has become part of a moral debate. North American programs generally are reserved for those severely addicted to heroin and have the goal of withdrawal from methadone. In many programs in Great Britain, Europe and Australia methadone is available to less severely addicted cases as well and maintenance is socially accepted.

Employment Training

Generally, persons who present serious drug and alcohol problems also have difficulties finding and retaining employment. Follow-ups of substance using offenders has shown that securing and maintaining employment after incarceration will lower recidivism rates. The purpose of employment training in substance abuse programs is to develop or enhance skills necessary to secure and maintain employment upon completion of treatment. A number of studies have shown improvements in employability of individuals post-treatment.

Provision of Aftercare

Research has shown that about 66% of all relapses following substance abuse treatment will occur within the first 90 days. Aftercare, generally provided in the community, is designed to provide a continuum of care which will allow the maintenance of goals of functioning achieved through treatment. The profile of an aftercare program will reflect the components of the treatment program, whether it be based on the Alcoholics Anonymous 12 steps model or on cognitive-behavioral treatment (problem solving, high risk identification and related skills). Aftercare can be provided through informal discussion or support groups to more formalized interventions that continue the development of specific skills. As the behavioral changes in participants enrolled in aftercare have been quite dramatic in the literature, it is recommended that aftercare should be viewed as an essential treatment modality.

Examples of Treatment Programs

This review was limited to an examination of published and unpublished documentation on substance abuse treatment programs. Few formal evaluations have been done on the various programs now available to Aboriginal people.

1. National Native Alcohol and Drug Abuse Program

Medical/Disease Model

The main vehicle in Canada for substance abuse prevention and treatment program directed to Aboriginal people is NNADAP. The goal of NNADAP is to support First Nations and Inuit people and their communities in establishing and operating programs aimed at arresting and offsetting high levels of alcohol, drug and solvent abuse in these communities. It has four components of prevention, treatment, training, and research and development. In general at the community level, most of the NNADAP funds are allocated to community-based programs and to residential treatment, with lesser funds directed to out-patient treatment and training.

NNADAP community-based programs emphasize prevention as a central component. Despite this, as a 1994 Saskatchewan NNADAP review has indicated, the expectations of what community NNADAP workers should provide in reality extend far past prevention. In addition to alcohol and drug abuse education in the community, these expectations include providing counseling, doing assessment and referrals, and providing aftercare services to Band members. These expectations may have evolved out of practice and the sometimes limited skills of workers.⁸¹ Nationally, the profile of the services provided NNADAP by program varies among the over 400 community programs and the 49 treatment facilities which provide almost 700 residential treatment spaces. The treatment facilities operate primarily on a medical model (with the disease model of causation and an emphasis on the Alcoholics Anonymous approach) and within each the degree of integration of an Aboriginal component to therapy varies. The treatment centres are organized in non-hospital model, however they were originally fashioned after existing programs in non- Aboriginal centres, and therefore a cultural component is often an add-on. In the 1989 review of NNADAP, the four treatment programs which were reviewed illustrated two different approaches to integrating an Aboriginal component to therapy:

• Aboriginal component is an add on to established treatment program: This approach is founded on the belief that some cultural practices and ceremonies will not be accepted by the First Nations community, and that participation should not be mandatory. Other options include orientation to culture, such as learning an Aboriginal language, cross cultural education and cultural awareness.
• Aboriginal culture is integrated into the therapy process: In this model, the treatment process is dominated by a traditional orientation, using ceremonies, spiritual activities, traditional therapeutic techniques and involvement of elders.

The most extensive evaluation conducted to date on the NNADAP program was undertaken in 1989. It evaluated 4 NNADAP treatment centres and 32 community prevention programs. The treatment centres reviewed offered programs which were 4 to 6 weeks long and which were seen to be highly structured and fixed for all clients. The review found many inadequacies in the treatment centres. The method of evaluation use by the reviewers was the Best Advice Model and is detailed in the section on evaluation. The centres were found to have inadequate outpatient treatment (constrained by the funding formula), an unorganized approach to aftercare, a limited spectrum of treatment options, a lack of outcome evaluation and standardized assessment instruments. Many of the recommendations of the reviewers were directed to remedying the lack of continuity of care in the treatment centres, which was due to inadequate attention and resources paid to both the pre-treatment and aftercare systems. In particular, the need for resourcing to encourage the development of non-residential treatment options was highlighted as were suggestions to broaden the scope of treatment alternatives overall.

The absence of a organized approach to prevention was a major review observation, as many of the 32 NNADAP sites which offered prevention services were devoting the majority of their efforts to treatment activities, including assessment, counseling, self-help and aftercare/follow-up services. The review recommended that a prevention model be developed and become part of the requirements of contribution agreements which fund prevention activities. The lack of formalized community involvement was noted as only one of the four programs reviewed had a policy statement from the band council which addressed the issue of substance abuse. With respect to evaluation, the reviewers recommended funding be set aside for outcome based reviews, so that both the on-going treatment programs and innovations to programs can be assessed. The review noted the absence of scientific evidence to judge the success of treatment models, in particular Aboriginal substance abuse treatment.

The reviewers also advised that staff skill levels should be upgraded, but cautioned that without other changes, many of the workers currently in the system were unlikely to benefit from the level of training required to make an impact. This was because the quality and quantity of supervision that was available at prevention and treatment sites was often so low or absent that it could prevent the professional growth and development of persons who had received training programs.

Community-based Evaluation of NNADAP

Treatment for alcohol and drug addiction is a complex area, and it is dangerous to generalize about gaps and inadequacies as what works for one community may be entirely inappropriate for another. The following are observations from the Alexis First Nation who developed a plan to address substance abuse in their community.⁸² The most common deficiencies in the existing NNADAP substance abuse services were cited as:

Inadequate training: In First Nations and Inuit communities, it is not uncommon for NNADAP workers to be untrained in the field of addictions counseling.

Waiting lists: The lack of sufficient beds in residential treatment facilities is a serious problem as most addicted persons seek treatment when they are in crisis. In Alexis two out of three individuals who seek treatment for their addictions experience a relapse before they are admitted to a residential treatment program.

Lack of support programs in community: This is one of the major deficiencies in the treatment system. Community support is needed in relapse prevention, life skills, in-home support, and on-site resource people to continue therapy.

Lack of coordination between addiction and other therapies: Persons with addictions are typically experiencing crises in other areas of their life, such as family violence, criminal behavior or suicide. There often is inadequate or no communication between drug and alcohol counselors and other community service providers.

Role of traditional healing and medicine not acknowledged: Traditional healing has proven effective in drug and alcohol addiction, but there are many barriers and concerns which prevent an acceptance of this approach.

2. Selkirk Healing Centre⁸³

Native cultural model

The Selkirk Healing Centre is described in its promotional literature as a therapeutic community that strives to affect positive changes in the environment, peer groups, family relationships, work habits, attitudes and values of its residents. It focuses on abstinence from substance abuse and use. The centre admits Aboriginal clients only and therefore place importance on individuals gaining an understanding and confidence in their role as Aboriginal people, including an increased responsibility for their actions and behaviors.

The program not based on a medical or disease model and does not subscribe to the Alcoholics Anonymous's 12 step approach. The healing centre's staff includes a contracted physician and a consulting psychologist. Program and community activities are enhanced by pipe ceremonies, healing circles, spring and fall ceremonies, naming ceremonies, round dances, sweat lodges and traditional pow-wows. Elders are employed as cultural and spiritual leaders of the community and also as visiting guests. As well, the Council of Elders is a nationally-represented committee which advises on Aboriginal traditional, cultural and spiritual programming.

There is no formal treatment length of stay as this is based on individual need. There are four criteria to judge completion of the program:

1. Maintenance of a daily routine (e.g. going to work, getting up on time etc.)
2. Substance-free during entire course of treatment
3. Completion of 66% of personal goals. These goals are set in the first 4 -6 weeks of the stay, and can be changed by individuals at any time.
4. A realistic plan for exit. This includes a plan for what people will do, who will be their community contacts etc.

The second criteria above is compulsory. For the rest, the individual must have completed two of the other three criteria in order to have been judged as successfully completing the program. Aftercare is not formalized in an outreach program, however a monthly graduate group exists, and persons are invited to return to Centre events. The person who referred the individual for treatment is also contacted upon program completion, and support is provided through telephone calls as needed.

An evaluation of the first 15 months of operation (January, 1995 to March, 1996) has been completed. A six month follow-up was undertaken for all persons entered into the program, whether or not they were actually judged to have completed the program. Two quantitative evaluations were carried out. The first looked at the reduction or abstinence from substance abuse compared to initial entry into the program (daily use, weekly use, monthly use) and found that 75% of persons had either eliminated use or reduced their use at six months compare to their levels at admission.

The second component of the evaluation used an overall treatment needs assessment. Individuals were rated at entry into the program on a scale of 1 - 6 regarding their emotional and physical needs related to substance abuse. At six months, the assessment was repeated and results showed that 98% of these individuals had achieved a positive change in their levels of treatment need towards being more self-reliant.

The centre is currently facing a fiscal crisis due to lack of federal funding for First Nations clients. The adult and family program is ending at the end of February, 1997 and the youth program has been reduced and limited to solvent abusers only. The future of the youth program is also uncertain.

3. Okunongegayin

Native cultural model

This is a model of treatment for chronic solvent abuse which has been developed in northern Ontario.⁸⁴ It sees solvent abuse as a symptom of a wide range of problems affecting communities where such abuse occurs, and therefore the treatment program involves individuals, families, community organizations and agencies. The strength of this approach is not in building a permanent institution, but rather in drawing resources from all the institutions and agencies around the problem of solvent abuse.

Although this model utilizes a "treatment centre" approach, it is recognized that as a community heals and young people are no longer ill, there may not be a need for this particular structure. The first period of the project (a demonstration period) saw the program operate out of a bush camp. In the life of this program, there will be a declining need for a central camp, and more initiatives at the local level.

Description of program

This model is founded on Anishinaabeg philosophy, beliefs and practices - it is emphasized that it is not based on behavioral change theories seen in psychology, social work and addictions. The program identifies the cause of a client's illness, and tailors actions to improve the condition. In addition to offering healing sessions for youth who abuse solvents, it acts as a resource to help communities develop their own initiatives. As a community-driven program, this model is seen as a expression of self-government.

The program combines therapeutic intervention with a preventative, harm reduction and health promotion framework. The individual is seen not only in terms of their needs, but also in the context of the larger extended family and community. The components of the program are:

• clinical hospital assessment at admission, that verifies the client's fitness for the bush program and screens out violent or medically unstable individuals
• formal opening ceremony and a week of detoxifying sweat lodges
• preliminary assessment by a Anishnaabe therapeutic ceremony called the shaking tent.
• three weeks of intensive therapies, chosen based on individual need.
• follow-up assessment by the shaking tent ceremony.

Operational evaluation

Two evaluations were carried out on the demonstration project: an operationally-focused review of the process and the outcomes of the project and, secondly a formal peer review among the consulting professionals.

The results of the demonstration phase of this project showed that of the 136 candidates admitted to the program, 68% (92 persons) stayed for the duration. Almost all of the persons who completed the program underwent a formal evaluation at the end of the program, and 50% were judged healthy, with a further 41% were in need of further treatment.

Seventy persons were available for follow-up, and at the end of the demonstration period were evaluated. Thirty -five (50%) showed long term significant change, of which 30 persons were judged to be of no concern to social workers or were doing well with regular, supportive visits. Over half of these 35 persons had left the treatment for over a year previously. Almost 40% of the 70 clients who were followed showed no discernable change, with the remainder (11%) unevaluated.

The results of the evaluation program judged the treatment program successful, however the reviewers cautioned that success was dependent on proper referral and admission procedures so that the candidate had a supportive family and environment in which to return. The program was judged least successful with candidates suffering from severe cognitive impairments from solvent abuse.

The evaluation noted that community efforts could also be independently successful in lowering the incidence of solvent abuse, but this was beyond the scope of the evaluation.

The program was evaluated to be cost-effective and innovative. It cost $9,000 per candidate completing the program, or based on the follow up sample success of 50%, $12,000 - $24,000 per long term successful outcome. The length of the program at 4 weeks compared favourably to other solvent abuse programs which were typically 6 - 8 months long. (The Ontario Ministry of Health reimbursement for out-of-country addiction treatment was up to $400 per day.)

The demonstration project conclusions included that this program showed that it is not necessary to follow the dominant institutional models for alcohol abuse interventions, but instead other options such as traditional medical models, harm reduction and brief interventions may be successful. In fact, one of the conclusions of the recommendation is that effective solvent abuse programs cannot follow the usual models common to substance abuse programs. The program successfully integrated institutional resources where necessary, and was not preoccupied with establishing a pure community-based program. Programming must be flexible and integrate an individual's treatment into a larger community framework. As part of the developmental process, the program was extending its expertise and services to other communities.

4. O'Chiese Community Rehabilitation Program

Mobile, community-based treatment

The O'Chiese Program is a mobile treatment for alcohol abuse which was implemented by Poundmaker's Lodge and the Nechi Institute.⁸⁵ The O'Chiese band when it started the program had a rate of alcoholism of well over 90%. The average age of mortality for the community was under 25 years. The program's model is based on community strength from which a team effort arises. This team approach includes a spiritual component, and consists of a circle of interrelationship between the person, family, the community and the band. The program steps include:

• acquiring and cultivating a vision of positive end results: i.e. sobriety
• developing a commitment towards achieving this vision
• establishing a supportive and loving sobriety team
• incorporating into the team, Elders, youth, band workers in all areas, and outside health and social agencies
• a 28 day treatment program which includes education about alcoholism and how it can be treated
• organizing an on-reserve program with alcohol counselors from both the Band and Poundmaker's lodge.
• aftercare - rebuilding or learning how to live with sobriety, enter the work force, find sober entertainment
• beyond sobriety

This program relied on heavy community support. Pre-conditions for establishing the mobile treatment program were sober community leadership and band staff. As well, a substantial number of the band had to voluntarily enter treatment at Poundmaker Lodge. Once the pre-conditions were satisfied, planning for the mobile program began with the establishment of a Community Development Team. This was a working committee comprised of Elders, and representatives from the health and social program areas. The strength of this team was seen to be the organic structure which valued all members contributions and minimized the hierarchial aspect. This team became a focal point of the program's vision and the members were role models in the community.

In an evaluation of the program⁸⁶, it was considered successful for both the individuals who participated as clients and the community as a whole. This was felt to result from strong community leadership, a vision of community development and health, a base of persons who were sober or had at least been treated before for alcoholism, extensive planning and a cultural basis to the treatment program. This assessment was limited to a one-day on-site visit and did not look at quantitative data on outcomes of the program.

5. Beauval, Pinehouse and Cumberland House Community Treatment

Mobile community-based treatment

An evaluation was conducted by the Four Worlds Health Promotion Program in 1992 on three mobile treatment services in Saskatchewan.⁸⁷ These programs were based on the Four Worlds model which is based on community development, not just in substance abuse treatment, but in all facets of learning and development. In the Four Worlds approach:

• the medicine wheel is an effective and powerful analytical tool for looking holistically at human and community development.
• development comes from within the community, which responds to a vision of health.
• individual, family and community level processes must be interconnected. Learning is the key to health promotion.
• community development is seen as a long process, taking from 5 to 20 years before all key issues may be addressed. Community personnel must be trained to think and enhance peoples' involvement in the community health development process.
• strong political will and program leadership is needed to establish a new core programming pattern that integrates all program efforts into a single organic comprehensive approach.
• community development is inside-driven, but outside helpers such as Four Worlds personnel are crucial in the beginning of a program, not to impose outside ideas on the community, but to mirror the development consequences of behavior back to the community so people can see the effect of their words and actions on the process.
• to ensure there is not long term dependency of the community on Four Worlds field officers, a formal mentorship and training approach is used that coaches staff and volunteers in their day-to-day work in community health development.

The evaluation of the mobile treatment programs was conducted through face-to-face (one-on-one) interviews with former clients. The evaluation found:

• there were varying degrees of sobriety achieved among the three communities, varying from 20% "completely sober" to 55% "sober after one year". For all communities, these percentages improved if persons who relapsed but regained their sobriety were included.
• all communities were encouraged by the results, as these rates were seen as much higher than those achieved by residential treatment outside of the community.
• all participants in the three communities reported an improvement in their lives, directed both to community relationships and community interaction.
• the lack of an "organizational or institutional" feel to the program was important. Holding the program in the community was seen to be innovative and successful, however the evaluation noted a lack of aftercare support and community involvement in one community.
• a special mobile program for youth was recommended in one community.
• better communication was needed before the program begins, for both the participants (pre-treatment sessions) and the community (awareness and understanding).

6. Ka-Na-Chi-Hih Solvent Abuse Treatment Centre

Combined medical and cultural model

This solvent abuse centre in Thunder Bay has just recently opened, therefore no evaluation exists on its program.⁸⁸ It does however highlight the direction being taken in solvent abuse treatment for Aboriginal people, towards a merger of traditional and contemporary approaches. In recognition of the extensive neurological damage that can occur with chronic solvent abuse, a multi disciplinary program has been developed including occupational therapy, physiotherapy, counseling, life skills training, education, individual counseling which is melded with traditional teachings from Elders, spiritual healing ceremonies, trapping, recreation and rehabilitation and group work (anger management, self-esteem, abuse, communication).

Assessments are done in the following areas: cognitive/neurological, psychosocial, functional, physical and education. Other services include purification and readiness and consultation with traditional healers. The assessments are monitored for cultural appropriateness and the treatment team uses the information from the assessments in developing a comprehensive treatment team. Table 2 illustrates the contributions of the two approaches used in the treatment centre on the individual, group, family and community.

Table 2 - Program Components - Ka-Na-Chi-Hih Centre

	Traditional Approach	Contemporary Approach
Individual	Individual healing sessions with traditional medicine people	Individual medical treatment with staff
	Individual spiritual counseling with sweat lodges	Individual counseling with psychologist, psychiatrist, or member of clinical team
	Individual counseling with elders	Individual counseling with elders Individual counseling with pastor/minister
Group	Greeting circle/talking circle	Discussion group
	Healing circle/sweat lodge	Group therapy
Family	Family healing circle	Family counseling
Community	Community healing circle	Community development

7. Round Lake Treatment Centre

NNADAP program

The Round Lake Treatment Centre's Client Outcome study which was detailed earlier in this report also conducted a longitudinal study of the centre's program over two time periods. The study evaluated the outcome of the treatment centre during the current period of the outcome study (1991-1995) with a previous study that had been carried out on clients who has been in treatment from 1797-1985.

The centre's goals include high-quality and innovative, in-patient and community-based treatment and treatment services, and a commitment to develop and implement programs that involve the family in prevention, intervention and treatment. Although the structure of the program remained the same over the previous 10 years, several key changes in approach and treatment methods have evolved. These changes related to:

• increased screening of clients prior to intake in order to ensure greater suitability and readiness for an intensive in-patient treatment program.
• increased emphasis in treatment on cultural awareness building and spiritual guidance
• increased emphasis on group support and healing circles as an intervention technique rather than primarily one-on-one counselling.
• decreased use of confrontational authorative AA techniques.

Table 3 compares the follow-up outcome status for those clients who completed the program in 1979-1985 and 1991-1995.

Table 3: Follow Up Outcome Status for Completer Clients, 1979-81 and 1991-95 (Clean and Sober)

	1979-1985		1991-1995
	% clean and sober	# clean and sober	% clean and sober	# clean and sober
3 months post completion	73.3%	148	86.9%	218
1 year post completion	64.9%	131	68.8%	119
2 year post completion	59.1%	114	65.1%	82

Table 4: Follow Up Outcome Status for Completer Clients, 1991-1995 (family relations, quality of life, self image)

	Improved Family Relations	Improved Quality of Life	Improved Self-Image
3 months post completion	69.3%	72.1%	54.2%
I year post completion	53.2%	65.3%	64.2%
2 year post completion	65.9%	73.0%	67.5%

The program showed higher rates of clean and sober clients in 1991-1995 at all periods post completion. The largest difference was at three months (13.6%), which narrowed to 4-5% for the 1 and 2 year follow up periods.

The study also looked at other outcome variables, however this information was available for only 1991-1995. These variables were: improved family relations, improved quality of life, and improved self image (Table 4). The only variable which had consistent increase over the three time periods of 3 months, 1 year and 2 years was improved self image, which increased by 13.3% from 3 months (53.4%) to 2 years (67.5%).

8. Natitch Salallie Youth Residential Treatment Program⁸⁹

Combined medical and cultural model

This adolescent program based in Keizer, Oregon, is based on the principal that recovery will occur by building self-esteem through the social, cultural. physical, and spiritual holistic approach. This is an abstinence based program which uses the 12-step approach in individual counseling. Cultural programming is integrated into all aspects of the overall program, and includes compulsory studies into tribal government, tradition and history.

As an intensive residential treatment, the program varies from 30-90 days depending upon client need. In addition to the individual counseling, other service components include coordination with the client's school to ensure that education needs are met, family counseling, and follow-up and aftercare (begun in the last week of the stay). Upon completion of the residential program, clients at high risk for relapse can participate in the Transitional Living Component (TLC) for a period of 30-90 days. While in the TLC program, a client must be working on education or employment goals. Activities include relapse prevention, establishing support systems, self-esteem building, decision making and life skills.

9. Rediscovery International Foundation⁹⁰

Wilderness cultural model

Rediscovery International Foundation began as a single camp in British Columbia, but in response to requests to help develop programs in other locations, it has expanded to numerous sites in western Canada and the United States. Rediscovery has been described as reversing the process of residential schools. Through the wilderness experience, people are brought back in touch with the land, their cultural roots and themselves. Elders are involved in every aspect of the program, as leaders and counselors. A guiding principle is authenticity as the program must be run by Aboriginal people in Aboriginal communities. Participants are encouraged to take leadership roles, are taught to live from the bounty of the land, and are recognized for personal achievements. This is a two week program, but follow-up is attempted during the winter months, through elders' hospitality and traditional dance groups.

10. Symposium on Monitoring Outcomes for Substance Abuse Treatment Systems

Although the importance of outcome measurement on substance abuse treatment is well understood, it is only recently that an intensive focus on designing and testing outcome measures has occurred in mainstream treatment. The Symposium on Monitoring Outcomes for Substance Abuse Treatment Systems was held in Toronto in February, 1997 and drew together international experts on substance abuse outcome research. This symposium recognized the value of traditional measures of classification, such as demographic information, social support, mental health status of clients and severity of dependence on substances, but went one step further to explore the multi-dimensional measures of outcome, including improvement in personal and social function, reduction in public health and safety risks, and reduction (not necessarily abstinence) in alcohol and drug use. The accuracy and validity of these latter outcome measures are highly dependent on the instruments (assessments, surveys etc.) used. They are also influenced significantly the circumstances surrounding the collection of information, such as the amount of time to be requested of the client and whether face-to-face or telephone interviews are utilized.⁹¹

Outcome measurement tools typically include assessment instruments which are used at admission, discharge, and to gauge progress through treatment. A client-perceived improvement questionnaire should monitor satisfaction and improvement - two important dimensions for the client which may be linked to perseverance and motivation.⁹² The Alberta Alcohol and Drug Abuse Commission (AADAC) has implemented an outcome monitoring system for the continuum of care.⁹³ It has three main subsystems (detoxification, treatment and training) each with their own set of outcome measures and procedures.

Outcomes which are measured in the AADAC system are in the following programs:

• outpatient individual counseling
• day treatment
• short term residential counseling
• long term support services

All the above treatment services have the same outcome measures, clustered in three areas:

• client satisfaction with the treatment services
• post treatment alcohol, drug and gambling use (three months past treatment)
• post treatment life functioning

AADAC staff and managers have identified three main issues when implementing outcome monitoring: time and cost of the process, integration with the work flow, and procedural complexity.

The call for better information on outcomes is now being heard from funding sources. For example, AADAC is now facing pressure from the Alberta government to improve treatment success rates. In the future, there may be a demand for return-on-investment goals (health care and crime offsets), however, the government now is requesting recovery-oriented goals.⁹⁴ The organization is questioning whether or not they know how to change rates, and asserts that the literature has not demonstrated that treatment outcomes have improved over the past thirty years. In addition, AADAC has debated the appropriateness of abstinence as a treatment goal and the levels of post-treatment abstinence currently being achieved. As there is no common accreditation process for measuring and reporting performance such as abstinence, comparisons may be inappropriate among certain centres in AADAC

Outcomes must not only be measured but also managed. Outcome management consists of:

• common patient-understood language of health outcomes
• a national database containing information and analysis on clinical, financial and health outcomes which tries to estimate the relationship between medical interventions and health outcomes, as well as resources and health outcomes
• an opportunity for decision-makers to have access to analyzes that are relevant to the choices they must make.⁹⁵

The Toronto symposium did not include presentations on Aboriginal approaches to outcome measurement. Some non-Aboriginal treatment programs were highlighted which have tracked outcome in their client population. One study looked at the length of time in methadone treatment and its relationship to outcome. The study found:

• improvements in illicit drug abuse, alcohol use, and criminal involvement occurred from before to after treatment, with longer retention in treatment (especially a year or more) being significantly related to better outcomes.
• age over 35 years, lower injection frequency, and higher motivation for treatment were each associated with two fold increases in the likelihood of having favourable outcomes.
• patients staying in treatment a year or longer were nearly 5 times more likely to have better outcomes
• length of stay in treatment was predicted by higher patient motivation at intake and early program involvement.⁹⁶

A long term multicentre outcome study of treated alcohol dependent persons in German speaking Switzerland was also presented.⁹⁷ The study population were inpatients in centres specializing in alcohol addiction. Clients were followed up 7 years after treatment. There was little information supplied in the paper presented to the symposium on the type of treatment that was provided in the eight centres, other than they were aimed at achieving abstinence and were designed to result in the "rehabilitation of the affected individuals." The centres had varying length of stays, ranging from 6 weeks to 12 months, although most patients were admitted for medium-term therapeutic stays (undefined). In the reference treatment of the study, the mean length of stay was 5.5 months, with a range of between 1 and 567 days (s.d. = 90 days). The follow-up investigation used a self-administered questionnaire, or a shortened telephone survey to non-responders of the initial questionnaire. The reference treatment clients comprised 15% of all the clients which were admissible to the study. Results obtained included:

• 63% of former clients reported at least one episode of relapse during the seven years since the index treatment. 15% reported relapses of more than three years.
• the mortality rate of clients followed up was six times higher than the general population. Principle cause was liver damage and internal bleeding of the gastrointestinal tract. The second most frequent causes of death were suicide and cardiovascular disease.
• employment was positively related to abstinence - among the employed, the rate of abstinence was 3 times higher and the relapse rate 20% lower.
• study population suffered from considerably more health problems than the general population (this, however, was not related to age)
• people in a stable relationship were significantly more likely to have an unproblematic relationship with alcohol or drugs (unless the partner also had dependence problems)
• in general abstinence or low consumption of alcohol post-treatment was accompanied with a positive assessment of quality of life.

The authors of the Switzerland research point to the need for adequate evaluation in the alcohol field - evaluation that is able to distinguish minor lapse from heavy relapse, and controlled consumption from uncontrolled consumption. Therefore both patterns of drinking and the related situations are important, and create great challenges to designing complex evaluation tools. They suggest that knowledge of the overall evolution of consumption patterns might be an important tool when evaluating the dynamics of the recovery process.