DOCUMENT RESUME. Schacht, Robert M.; Baldwin, Julie TITLE

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1 DOCUMENT RESUME ED RC AUTHOR Schacht Robet M.; Baldwin Julie TITLE The Vocational Rehabilitation of Ameican Indians Who Have Alcohol o Dug Abuse Disodes. Executive Summay. INSTITUTION Nothen Aizona Univ. Flagstaff. Ameican Indian Rehabilitation Reseach and Taining Cente. SPONS AGENCY National Inst. on Disability and Rehabilitation Reseach (EDOSERS) Washington DC. PUB DATE NOTE 27p.; Fo peliminay epot see ED CONTRACT H133B30068 PUB TYPE Repots Reseach (143) EDRS PRICE MF01PCO2 Plus Postage. DESCRIPTORS Alaska Natives; *Alcoholism; *Ameican Indians; Counselo Attitudes; *Cultual Relevance; *Dug Rehabilitation; *Outcomes of Teatment; *Rehabilitation Centes; Rehabilitation Pogams; Substance Abuse; Vocational Rehabilitation IDENTIFIERS Alcoholics Anonymous; Client Attitudes; Rehabilitation Counselos ABSTRACT Begun in 1993 a 5-yea poject examined teatment modalities and outcomes and counselo and client attitudes elated to Ameican Indian o Alaska Native vocational ehabilitation (VR) clients with alcoholism o substance abuse poblems. Specifically suveys and focus goups examined elements of successful substance abuse teatment and VR pogams aeas of social-cognitive dissonance between VR counselos and thei clients and the use of cultually elevant teatment modalities diffeent fom those used in mainsteam pogams. A 1993 suvey of 31 "exemplay" substance abuse teatment centes ecommended by VR counselos and a 1996 followup suvey of 14 of these centes found that most centes extensively incopoated Ameican Indian pesonnel and cultual pactices into the teatment pocess but success ates ove 50 pecent wee ae. In the followup suvey all pogams based "most" o "some" of thei teatment methodology on Alcoholics Anonymous (AA). Teatment oientations based on Native Ameican taditional healing did not claim bette success ates than othe oientations. Counselo and client focus goups in Texas New Mexico and Aizona discussed eligibility fo VR sevices effects of the substance abuse poblem and state of ecovey on the VR pocess client motivations taining needs and factos contibuting to o impeding ecovey. Aeas of conguence and dispaity in counselo and client attitudes ae discussed. Recommendations ae pesented fo VR counselo taining and pogam impovement and the 12 steps of AA ae listed. (SAS) ******************************************************************************** Repoductions supplied by EDRS ae the best that can be made fom the oiginal document. ********************************************************************************

2 t The Vocational Rehabilitation of Ameican Indians Who Have Alcohol o Dug AbUse Disodes ( 1 EXECUTIVE SUMMARY 1997 Robeit M. Schacht Ph.D. U.S. DEPARTMENT OP EDUCATION Office of Educational Reseach and impovement EDUCATIONAL RESOURCES INFORMATION CENTER (ERIC) cchis document has been epoduced as eceived fom the peson o oganization oiginating l O Mino changes have been made to impove epoduction duality. Julie Baldwin Ph.D. J e Points of view o opinions stated in this document do not necessaily epesent official OERI position o policy. Ameican Indian Rehabilitation Reseach and Taining`Cente ( _ NORTHERN ARIZONA UNIVERSITY h Institute fohumevelopment an D Univesity Affiliated Pogam PO Box 5630 Flagstaff; AZ Funded'by the National Institute on Disability and Rehabilitation Reseach (NIDRR) Office of Special Education and Rehabilitative Sevices U.S. Depatment of Education Washington DC Gant No. H133B30068 The contents of this epot ae the esponsibility of the Ameican Indian Rehabilitation Reseach and Taining Cente and no official endosement by the U.S. Depatment of Education should be infeed. "Nothen Aizona Univesity is an Equal Oppotunity Affimative Action Institution BEST. COPY AVAILABLE

3 N 7 -The Vocational Rehabilitation of Ameican Indians Who Hive Alcohol ) o Dug Abuse Disodes In 1993 the Ameican Indian Rehabilitation Reseach and ( ) _ Taiiing Cente (AIRRTC) conducted a suvey of vocational ehabilitation) (VR) counselos who woked with Ameican Indians and Alaska Natives with alcoholism o dug abuse disabilities (Schacht & Gaseoma ). A 5 -yea eseach and tainingiptojectwas then poposed as pait of the AIRRTC's Competitive Application fo This poject numbeed R-36 was entitled The Vocational Rehabilitatioi of Ameiean Indians Who Have Alcohol o Dug Abuse Disodes. The popose of this poject was to (a) identify and analyze the effective componenis osuccessful substance abuse teatment and'vr pogams (b) identify aeas of social-cognitive dissonance between VR counselos and thei clients that seve as obstacles to -successful ehabilitation and (c) examine the_use of effective. - cultually elevant teatment modalities Affeent fom those used in mainsteam teatment pogams. _ Accodingly; a teatment cente suvey was conducted in 1993 and a shotte follow-up suvey was conducted in Next; infomation ftom VR counselos who -Woked with Ameican Indians with alcohobni o dug poblens Was collected by - witten questionnaies and focus goups. Then infomation was obtained fom Aieican Iidian YR clients again using both questionnaies and-focus goups. The infotnation collected fom VR counselos and clients was matched to compae and contast attitudes of 'counselos and clients on simila issues.- Howeve the clients who esponded wee not necessaily clients of the VR (

4 2 TREATMENT " CENTER SURVEY Methods counselos who esponded so the contast in attitudes could not be; pecisely contolled. The eseach findings ae summaized unde the headings of Teatment Cente Suveys Counselo FOcus Golipsi Counselo.Suvey Client Focus Goups and Client Suvey. The methods_ esults and conclusions of the eseach activity ae descibed in each of these sections. Five types ofteatmentmodels used fo Ameican Indians who have alcohol and othe substance abuse disbdes have been identified: the Medical Model thelisychosocial -Model the Assimilative Model the Cultue-Sensitive Model and the _ Syncetic Model (Weibel-Olando 1989). These ange fom the Anglo oientation exemplified by the Medical Model with an all Anglo staff stong AA' Oientation counselos with univesity degees who teat alcoholism as a medical disease little o no cultual accommodations and no coopeation-with Indian healesto a Mostly Indian oientation (the Syncetic Model). An example of the Syncetic Model might be the -Red Road. APpoach (Abogast 1995) which uses the medicindwheel as a cental concept. Anothe indigenous teatment modality fo alcoholism involves using a sweat lodge (Hall 1986). Leland '(1980) discussedameican Indian objections tathe Alcoholics Anonymo us (AA) fomat obseving that "it appeas that AA has been successful with Native Ameicans when it has been Nativizedi (pobably to a point. Whee it would be unecognizable to othe AAs)" (p. 18): It must also be_noted that since AA Was 'designed as' a suppot goup cetain modifications would be necessay to use it as the basis fo a teatment-pogam. Ou teatment cente suveys wee designed to follow up on some of.these-issues. The 1993 suvey of vocational ehabilitationcounselos (Schacht & Gaseoma 1993) asked if 'they knew of an exemplay teatment cente fo Aineican Indians with alcoholism o dug 'abusedisodes and if so to identify if. Thetaget population fo the 190 teatment cente suvey consisted of 50 teatment centes

5 N 1993 Suvey Results ecommended to- us by these VR counselo (Schacht Gaseoma' 1993; Appendix' C). Whethe o not the teatment centes in this sample wee in fact any bette than othe teatment centes is unknown and unpovable with the data at hand. The 1993 suvey evealed that most of the teatment centes wee appaently based on AA. The 1993 teatment cente suvey included some questions to facilitate compaison with the-types of teatment centes defined by Weibel=Olando (1989). Thity-one of the 50 ecommended teatment centes'esponded (62% esponse ate). In 1996a fou-page follow-up suvey was conducted to exploe how and to what extent the same teatment centes used the philosophy and tenets of.aa. The follow-up questionnaie was designed with.the assistance of Cut Yazza NCADC CADAC a Navajo. The follow-up questionnaike was sent to each of the 31 teatmentcentes that had esponded' to the 1993 suvey; 14 esponded. - Most (18-31) of the teatment centes in the 1993 suveywee located on a esevation. Tweity-nine pecent wee in an uban _ aea and one was in a ual; nonesevation location; The location.of thee of the centes was not specified. Almost half (1431) wee tibally opeated; most of the othes (1231) wee opeated by the Indian Health Sevice (IHS). The top five teatment oientations epoted wee AA Na'cotics Anonymous (NA) geneic outpatient teatment pogams outpatient dugfee pogams 28=day Hazelden o Minnesota model inpatient teatment-pogams and Native Ameican taditional healing. Most (1631).of the centes had beenopeating fo moe-than-12 yeas with a angeo 3 to 30 yeas and offeed-both esidential and outpatient teatment (1731). Fo 27 of the centes teatment of alcoholism and dug abuse was thei main sevice. The of counselos involved in the teatment of Ameican Indians o Alaska Natives (AIAN) vaied fom 2 to 46; with a - - mode of 9. The pecentage of counselos who wee Native Anieican vaied fom 3% to 100%. In most-cases (2531) at least 3 N N

6 -- V. half wee AIAN. The tibal affiliations of the counselos vaied but most of-the time (2031) at least half of the counselos wee fom one tibe. The "most common tibal affiliations when most of the counselos wee fom one tibe wee Sioux (n = 5) _ including Sissetoii-VV ahpeton Dakota and Assiniboine Sioux ChippewaOjibwa' (n = 3) and Nothen Cheyenne (n =_2). - Each teatment cente was 6-Valuated by type and compaed with the fequency of pogam types Weibel-Olando's (1989) study. Togethe the cultue- sensitive and s'yncetic pogam "types (the most "Indian" types) constituted 90% of the 1993 sample of teatment Centes Compaed with 69% of Weibel- -- Olando's (1989) sample. Each teatment cente epoted clients atwidely vaying- stages in thei ecovey pocess fom denial though contemplation'._--- pepaation and ecovey (o action followed by maintenance; a. Pochaska DiClemente & IToco s 1992). Befoe teatment the lagest numbe wee epoted to be in eithe the conteniplatioh o pepaation Stage. Howeve these same pogams-also epoted' some clients who wee still in denial (sometimes these-wee cout-odeed efeals) and othes who wee aleady in ecovey and had been abstinent fo some time Even duing teatment simila anges of (clients Wee-epoted with of couse moe clients who had been in ecovey fo a longe peiod of time. ti 7) Success Rates 1 Each_cente was asked what pecent of thei Ameican Indian Alaska Native clients could be egaded as '''sucstessfiilly _ehabilitated." Re'sponses anged fom 1% to 95% With an aveage-of 45%. The centes Wee also asked which teatment bestchaacteized thei Oveall oientation. We compaed the aveage success ate fo each oientation with the ayeage success ate fo teatment centes that did nothave that oientation. None of the teatment oientations had d statistically significant edge ove the othes. The highest success ate fo an oientation was 76% fo the Native Ameic.an Chuch; howeve only one pogam had this oientation. Employee assistance pogams (n = %) and psychiatic and psychological model pogams -- i

7 199 Suvey Results z. ) (n = %) also had high success ates but few pogams hadthese -oientations eithe. The success ate-fo pogamswith-an AANA (outpatient) oientation which was ttie most.popula (n = 20) aveaged_only 43%. Othe teatment oientations claimed success fates-aveaging fom. 41.3% fo the outpatient dug fee po'g-am (n = 17) to 48.4% fo the flazeldenminnesdta modelln 18). The aveage success ate claimed by Native - Ameican taditional healing pogams (n = 15) was 45%. The 14(teatment centes that esponded to the 1996.follOw:- up< suvey came foin nine states:" The distibution of esponses was 'vey simila to the-1993 suvey except that no espoises wee eceived fom five of the oiginal state.; Half of the teatmentcentes indicated that "most of" thei teatment_ methodology was - based-on AA. The est indicated that "some"-of thei teatment Methodology was.based on AA. Most Of them (71%))equied attendance at AA meetings as pat of thei teatment method and the emainde indicated that attendantewas ecommended. The aveage numbe of meetings was about six pe month.- Attendance at AA Meetingswas "always" (86%) o "usually" (14%) a pat of thei aftecae-ecommendations. 'Most of the teatnient c'entes (64%) e-poted that-thei clients. did' not expeience significanccultual baies to thei paticipation in- AA Of ilie-peviouly identified cultual baies to the use of AA by Native Ameicais (Leland 1980) the most significant Was "public discussion of pesonalpoblems" With. half of the teatment centes indicating that it was an impotant o significant baie and half indicating that it was not:- Six-of the 14 (43%) thought that "effots to influence othe people's behavfo" and "dominant' society eligious ovetones" wee poblems. 'Most of theteatment centes (86%) said that thei clients did not feel that AA meetings wee too feligiotis.- The equiements fo abstinence.and fo the exdusioniof nonakoholics wee not consideed impotant cultual baies. Half of the teatment centes epoted that thei use of AA-has stayed the same ove the yeas_ 29% said they wee integating.

8 p N < - The Twelve Steps Conclusions moe of iin ecent-yeas and the emainde wee moe ( ambiguous in thei esponses. Because Leland (1980) suggested that the most successful pogams fiac"nativized" thei teatments each cente was asked if they did this: Half esponded positively. This Nativization was achieved in a vaiety of ways with the most common method being sweat lodges (fou centes). When used these wee offeed-at Steps 3' 6; o 11 of AA's Twelve Steps (see Appendix A). Meditation was used at thee centes. Step (11 explicitly involves meditation but some centes asedt ealie (e.g. in Steps 6 and 7) and Othes do not1 get-that fa in teatment: 1TWo centes used the medicine wheel: N All 14 teatment centes used the fist fou steps of. AA 13 centes used the fist five steps and 9 used all 12 steps. Howeve two centes did moe picking and choosing: One used steps 1-5 and 12; anothe used Steps 1-5 -then 7 and 8 and then 12. A 'big facto in how many steps wee used was-how long the-client was in teatmeit; That is most wee not in teatment long enough to advance past Step 5. The Twelve Taditions of AA which goven hiow AA meetings should be oganized andjun wee not as well known_and wee not used as much-as`fhe Twelve Steps. ; In summay the exemplay alcoholism teatment centes fo Ameican Indians that we suveyed wee pogiams that - 1- extensively incopoated Ameican Indian pesonnel and I cultual pactices into thei teatment pocess. Ninety pecent of these wee thepogam types deetned most "Ameican Indian" accoding to the.weibel-olando categoies descibed ealie. All of the pogams used-some pat Of the AA philosophy and most could be conside:ed to be based on AA. Howeve even amongst these exemplay pogams success ates ove 50% wee ae. PogamS- with a teatment oientation based on Native Ameican taditional healing 'did not claim success ates -- significantly highe than othe teatment oientations ("success" Was self-defined). BEST COPY AVAILABLE

9 L N N - J COUNSELOR FOCUS 6ROUPS I v The pupose of this activity was to elicit infomation- not likely to' be obtained fom quesfionnaies fom VR counselos ' who had woked with Ameican Indian o Alaska Native clients With alcohol o dug poblems The open-endedness of esponses to fdcus 'goup questions plus the inteaction among' paticipants in stimulating moe fa-anging- infomation about counseloclient inteactions esulted in infomation thatcomplenlents-the esponses to witten questionnaies. The esults of these discussions-wee then compaed with client 'focus goups to identify aeas of disageenient o diffeences in attitudes and beliefs. N Counselo fociis goups of 6=12 paticipants wee conducted in_ thee _states: Texas New Mexico and Aiiona. The. counselos fom Aizona and Texas wee pinaily-anglos; the New Mexico counselos howeve wee pimaily Ameican Indians (mostly Navajo). :The potocol that was deyeloped fo all thee focus_ goups consisted of aset Of pimay questions each accompanied by.follow-up questions used on an acl7hoc basis to stimulate - additional discussion-if needed. Thus all pimay questions wee asked of each focus goup; but use of the follow-up questions vaied fom goup to goup as needed. The meetings wee tape ecoded and tanscibed fo each goup. The tanscipts wee then analyzed using Tally 4.0 (Bowye 1991). Each questioi fom the inteview poto-col Was assigned a mnemonic that was used to code-the-discussion of that paticula question. In addition submnemonics wee ceated to identify specific topics within the focus goup convesations. This facilitated the afialysis of:the discussions by topic. " - Eligibility One common theme concened the application pocess fo Vocational ehabilitation sevices. Vocationalehabilitation counselos 'in Aizona and Texas thought it took too -long; in Texas it might take a month o two just to get an appointment With a VR counselo. Some of the Texas and New Mexico counselos thought that this was not necessaily a bad thing 9

10 because it would show Who was eally seious about applying. On the othe hand some potential clients just give up. _Anothe ecuent theme concened alcohol abuse as a seconday disability Counsel-Os in all thee states epoted that in some cases they wee not awae'that a client had an alcchol abuse poblem until VR was aleady in pocess and then it could ceate poblems(e:gi the client missing an appointment). -The counselos felt a lack of guidelines on how to deal With this poblem: Some agued fo immediate confontation; othes agued fo suspending VR until the alcoholism was in emission. Othes wondeed how to tell when the poblem' was in fact in' emission. ( is` Rehabilitation 5. Abstinence `vs. Abuse Stages of Change VR counselos in.aizona and especially New Mexico thought that dealing with thei alcoholic client's equied moe time and effot than with many othe clients but that this effot was' usually Wothwhile. Howeve they also noted that with big caseloads this_exta effot was often not possible. Counselosin Aizona and Texas also mentioned the 'impotance of faniily suppot 'in ehabilitation while ecognizing that if the family included othe alcoholics it could lead to moe po6lems. They ecognized that this was a Common occuence. One of the biggest diffeences between abstinent and abusing clients was appaent-in thei ability to make goals and plan effectively. This involved stategies othe than alcohol fo dealing- with life's poblems. One consequence of -this 'is that the counselos felt that abstinent clients wee moe dependable All of the paticipants in the focus goup-sessions wee givei a handout descibing five stages of change in the ecovey pocess (Pochaska DiClemente 8' Nocoss 1992). They wee then asked to discuss the ealiest stage at which an applicant would be eady to benefit fom VR sevices. The AizOna VR counselos along with seveal fom New Mexico ageed that Stage 4 was the ealiest (action: actively engaged in changing_behavio successfully_but_fo_less than six months; success citeia may

11 N N ' include abstinence o sobiety) but one New Mexico- VR counselo] and seveal Texas VR counselos felt that Stage 3 (pepaation : eady to take action'in' the.next 30 days; may have - unsuccessfully taken -action in the past yea; may have - achieved. 'some' eductions in poblem behavios) wasthe ealiest they Would accept someone while admitting that Stage 4 was moe ealistic. Many counselos especially those fom New Mexico; i( noted thatsome clients came intpvr while they wee in Stages 1 (pe-coitemplation) o 2 (contemplation') biit) that they did not get beyond applicant VR status until they wee in Stage 3 of highe. MOtivdtions All thee.gpups of counselos ageed that seeing thei clients succeed anchnakepositive changes was one-of the things that motivated 'them the most But One of thei pet peeves was dealing With the denial and the manipulative con games of clients who wee -totabstinent. -( Taining-Modules Conclusions Counselos in Aizona and Texas wanted 'moe taining in cultual sensitivity issues including thpse concening impoveished clients. Counselos in. New MeXico who wee mostly Ameican Indian's wanted moe taining in.technical- 7subjects such as theoies of client change--12-step pogams and alcoholism as a disease. A Counselos ageed that thee Was a need foil. awaeness about how-to deal with alcoholisnwhendt shows up as.a seconday disability duing VR Sevices. They...also ageed that the pocess of application and eligibility detemination-takes too long although in some cases thismay not be a bad thing. Most agieed that although it is best fo a client to be in ecovey befoe eceiving VR sevices counselos_nust be pepaed to deal-with clients in- -evey stage of ecovey. Finally they all ageed that one of the most motivating things-is to see a-client expeience success and positive change: _

12 10 COUNSELOR SURVEY. Methods i. Results Ou inteest Was to suvey counselos who had woked with at least fiye Ameican Indian' o Alaska Native_clients duing the past yea who wee eligible fo VR sevices and fo whom alcohol o substance abuse o dependence was a pimay seconday o t'etia'y disability. The suvey instument `-which was aveelopecl by the poject staff; was pilot- tested face-to-face.with thee VR counselos in Texas. The questionnaie was-then finalized and lettes.of invitation wee mailed to moe than 100 VR counselos acoss the county. Telephone follow-up calls wee made to VR counselos o thei supevasos to detemine whethe o f iot they - met the caseload citeia and wee inteested in-p paticipating in- the poject. If they ageed to complete the questionnaie the suvey_was- mailed to the VR counselo. ' The types of questions in the suvey included sociddemogaphic chaacteistics and backgound of counselos; special issues-aound client eligibility fo VR sevices; caseload chaacteistics counseling activities and'baies to implementation of VR sevices fo Ameican Indian clients; client chaacteistics including intention to change addictive behavio; peceived taining and backgound- ieeds fo self and othe VR counselos; views on what makes an effective alcohol o dug-teatment pogam fo AmeiCan Indian clients; and ' pespectives on aftecae-and maintenance theapy fo clients. All of these aeas ae biefly summaized' it ) A total of 32 VR counselos fom'10 states -completed the follow-up suvey (esponse ate 30%). Of. these 32 individuals - '63%- wee male and 37% wee female; the most common age was between-40 and 49; and- 50% wee Anglo; 40% Wee Ameican Indian and 10% wee Hispanic. Slightly ove half (55%) of the counselos-had maste's degees. Twenty-five counselos epoted woking fo State Rehabilitation Sevices Administation pogams and seven Counselos woked fo tibally opeated Section 130 VR pojects. The counselos L 12 BEST COPY AVAILABLE

13 to. N' I 7" epoted woking an aveage of 8 yeas as VR couiselo. In addition five 'counselos had woked an aveage of 5 yeas as an alcoholism 'counselo. Counselos indicated _thatthey had counseling cetification o taining and expeience in at wide ange of aeas but most notably ehabilitation and alcoholism o dug abuse. Six of the counselos identified_themselves as ecoveing alcoholics. ) ' With egad to special issues fo AI AN clients 63% (15 state VR counselos and5 Section 130 VR counselos) thought that these clients wee as successful in becoming eligible fo VR1 sevices as non-indians> The to five factos listed as Contibuting to eligibility poblems fo these clients included lack of tansidotation lack of follow-thiitigh by client; cultual ' diffeences lack of tust and confusion about eligibility. Counselos wee asked to descibe thei client caseload chaacteistics within the past yea They epoted having an aveage of 8.40 AIAN clients with a pimay seconday o tetiay disability of alcoholism o dug abuse who becane eligible' fo VR teatment. Thee wee no diffeences in caseload chaacteistics by counselo ethnicity counselo educational level o-counselo cetification. Counselos wee also asked to descibe thei counseling activities with thei AI AN clients? duing the last 30 days. The five activities ated as most impotant in _ woking with these clients included showing concen and- ' eempathy encouaging acceptance of esponsibility and self- eliance defining longiange goals specifying shot-tem objectives and inceasing-the level_of appot and tust. Counselos wee asked to indicate whethe special needs fo sevices existed fo AIAN clients with alcohol o dug_disodes and-to descibe the baies that they felt peented implementation of the special sevices. Some of the special needs that aose with egad to maintenance of sevice's included the _ability to obtain diagnostics financial assistance access to a halfway house a centally located' teatment _cente positive ole models and moe education fo families. Baies to the implementation of maintenance- sevices included lidited 13

14 ti 55. ( esouces distust of physicians not being able-to aftod 'specialized followlup teatment igid state and fedeal laws that pevent helping cetain inclividuals papewok tanspotation and lack of Client-follow-up-on teatment plans Othe aeas of special need included on-thejob taining business o vocational taining and college o univesity taining. Each of these had thei OWn baies to ovecome bilt some common" issues aised by all included lack of awaeness of sevices and pogams lack of client follow-though lack of tanspotation client elapses and discimination by non- Indians. In dekibing-how`alcohol o dug ablise was affecting thei-- clients' lives counselos ideitifed five main issues: alcohol o dug use-was causing poblems with family o fieids theywant to get thei lives staightened out alcohol o_ dug abuewas a poblem fothen alcohol o dug abuse Was causing poblems with the lawand they need help in dealing with thei alcohol o ' dug use Counselog also descibed many of thei clients 'as having one o moe alcoholic paents haviig difficulty with elationships and being involved-with both sbcial and binge_: dinking. Counselos-wee;asked to descibe the peceived state ofmiicl of thei clients pio_to eaching VR case management Status 10 (eligibility) vesus afte teaching Status 10. Counselos epoted that pio to eaching Status 10 most of theitclients wee still about the natue-of the addictive behavio. Afte eaching Status 10 counselos felt that Most of thei clients wee awae that atpoblem with alcoholo dug use ;existed and that the client was seiously thinking about dealing with the addiction. Of the 32 "espondents 17 had a univesity 'degee and a taining backgound that was medically oiented. Eleven counselos epoted a-taining backgound as being]niixed'i (any combination of cetification seminas and on-the-job taining). The emaining fou counselos' indicated mostly on-the-job-life expeiences and some Indian healing pactices. Iniaddition-16 counklos.epoted having had taining in alcohol o dug abuse counseling; 10 indicated that they would like moe taining in 12 14

15 1 13 N. I thissaea and 6- epoted that they had neve eceived any taining in alcohol o dug abuse counseling.: Counselos wee also asked to poyideinfomation they felt Would help them to make bette-use of suppotive 'sevices in developingthe Individual Witten Rehabilitation Plan (IWRP) to impove chances fo successful ehadlitation. They identified the following aeas: elapse pevention; Fetal Alcohol Syndome' (FAS) infomationconcening eligibility fo su ppotive sevices infomtion elated to cultual needs to bette 'undestand - cultual diffeences infomation about fina'ncial aid esouces i offeed by specific agencies infomation about Cultue-sensitive evaluation and testing and moe knowledge about client suppot 2-4- systems including family ties beliefs and customs. - Counselos wee asked to ank the teatment pogams 1 available in thei espectiveaeas fo Ameican Indian Clients. They egaded AA NA spiitual o elikious pogams and Atheican Indian healing pogams as the thee most effective appoathes. -When counselos wee asked how' they defined successful ehabilitation most eflected a elationship between a client's sobiety employment; length of sobiety and - employment and othe suppotive factos. Counselos weefalso asked to identify aftecae pogams that wee most impotantin helpifigthese clientsmaintain sobiety o-abstinence. The - Pogams included AA' NA halfway houses teatment centes 'fo. AIAN outpatient sevices fo client theapy goup and individual counseling spiitualleadesin the community the I chuch and efeals'to an alcohbl o dug cente. Counselos wee questioned about client community-and sociocultual baies to aftecae and how counselos Might -ovecome some of these baies to help' clients econnect with family community o othe suppot netwoks. Peceived baies to aftecae paticipation included lack of tust :lack of undestanding esistance o embaassment with seeking help and lack of tanspotation. Community baies that wee mentioned included lack of community education Concening pogams community denial )Community shame and ) 1

16 "S indiffeence to alcoholism. Counselos alsomentioned family and fiendship baiestci aftecae including the influence of family and fiends who wee still dinking: Seveal" counselos indicated that the type of assistance they povided to the client to help them -econnect withsuppot netwoks included giying efeal infomation to clients about suppot systems tying to_ build suppot" netwoks' into" the plan of sevices and_iefeing clients to local Ameican Indianesouce goups'. One. espondent indicated that involveinent of a Native ceemony to 'econnect family-unity and having a medicine man talk to the family could pove jto be impotant aftecae suppot. --- CLIENT FOCUS GROUPS The pupose of-this activity was to elicit infomation not `likely to be obtained fom questionnaies" fom Aieican 'Indian -o Alaska Native VR clients who had alcohol of--dug poblems. Thl open-endediess of esponses to focus goup questions plus the inteaction among_ paticipants in stimulating Moe fa- ' anging "infomation about counselo-client inteactions esulted in infomation)that-tomplements the-esponses to witten questionnaies.. Methods ti Client focus goups of 6-12 paticipants wee conducted in t - - _thee states: TexasNew Mexico and Aizona. The potocol that Was developed fo all thee focus -goups consisted Of a set of pimay -questions each accompanied by follow -up questions used on an ad-h4c basis to stimulate additional discussion if needed. The meetings wee tape ecoded and tanscibed fo each goup. The tanscipts wee then-analyzed using Tally 4.0 (Bowye 1991). Each'question 'fom the_ inteview potocol was assigned a Mnemonic that wasvused to code the discussion of that - paticula question. In addition submnemonics wee ceated to identify specific topics within the focus 'goup convesations. This facilitated the analysis of the discusions by topic. BST COPY AVAILAbLE.

17 15 Results Eligibility The focus goups in Texas and New Mexico thought that one baie to eligibility sometimes was lack Of follow-up by the client. In addition a wide vaiety ofothe possible baies to eligibility wee discussed including the length of time it-takes to `detemine eligibility caneellation of appointm'ents' by the counselo lack of tanspotation and client elapse due to fustations with any of these baies. N Rehtibilitation Abstinence vs. Abuse ) The focus goups in Texas and Aizona had some concens about diffeences between clients -and counselos in undestanding the VR pocess. These two goups also discussed the poblem of elapse and the_ difficulties of maintaining sobiety. FinallyKsome clients feltabandoned by thei counselos afte.they got a job. Topics bought up by paticipants with espect tb this question wee the ability to think ahead and plan the influence of.fiends the impotance` of eligion and employment. Thus an abstinent client was one who thinks ahead aid Makes plans to impove life stays away fom fiends who dink attends AA d NA. Meetings is involved in eligion and is employed. -The client who is still abusing alcohol is potayed as the mio image of-these 'things. _ Stages_of Change I All ofnthe paticipants in the focus goup sessions' wee given a handout that descibed five stages of change in the ecovey pocess (Pochaska piclemente & Nocoss 1992). They wee then asked to dikuss the ealiest stage in which an applicait would 'be eady to benefit fom VR sevices. The 'Texas focus N' goup ageed that a peson should-not begin VR until in the fifth stage (maintenance: continuous successful behavio change lasting fo moe than six months; key featues ae avoiding elapse and stabilizing behavio change while maintaining 'sobiety). Howeve; the othe focus goups could not bone to any ageement about this question. The Aizona clients did agee that as long as someone was still involved in thei addictive behavio.y

18 he oshe could not benefit fom VR sevices. This would appea to eliminatethe fist two stages (pe-contemplation -[denial] and ' 'contemplation) and possibly the thid stage (pepaation which may include seveal unsuccessful attempts-at sobiety). Motivations -Taining Modules_ Although it is not easy to genealize about client esponses on this subject some helpful points included the counselo's faith in the client's ability to- change finding out what thei stengths wee and' -what they could do well having the suppot and encouagement of theft counselo family and fiends in a familia cultual.envionment and maintaining contact with thei counselo Pet peeves included counselos who disespect thein stae at them like they'e hiding something Change appointment dates efe them to anothe counselo without thei knowledge o make them Wait. _ The New Mexico clients had the most to say about this subject Thei concens included deceasing the amount of papewok in the application-pocess; which they associated with the length of time it takes to become eligible making the 'theapeutic elationship moe seious and impoving the woking _ elationship between client and counselo. These last two points may be elated when consideing fo example impesonal _appointments-with the counselo whee the sole pupose is to-2 sign papes. A client chaacteized 'this as "signs and dash' 'theapy. CLIENT SURVEy Methods;- This VR client questionnaie was designed to mio some of the questions addessed with the YR counselos "in ode to identify aeas whee counselos and clieng had significantly diffeent viewpoints on the ehabilitation pocess 'as well as to identify poblem aeas peceived by both coungelos and. clients. The questionnaies -wee ldistibuted to clients in two main ways: At the end of focus goup meetings in Aizona New Mexico and Texas clients could fill out the questionnaie on the spot-and give them to us befoe we left the site o they could take N I

19 17 the questionnaie home with them and etun it late. Also questionnaies with self-addessed stamped envelopes.wee mailed to VR counselos who had coopeated with the counselo suvey. They wee asked to distibute the questionnaies to any clients with disabilities of substance' abuse o alcoholism to allow the clients to complete the foms pivately and(to mail the questionnaies back in the envelopes.povided especting the confidentiality of the esponses. ' ' Results SI Responses wee eceived fom 24 Ameican Indian clients ' - using state and tibal VR sevices. The clients most of whom y wee male (83%) came fom five states wee affiliated with 15 tibes and wee most commonly'between the ages of 30 and 39. They had a mean educational level of 11.5 yeas and most wee (92%) ecoveing alcoholics. Seventy-five pecent_of the VR clients inteviewed wee involved in Alcoholics Anonymous and majoity of these felt that AA was a vey valuable pat of thei ecovey. Seventeen pecent found help in Native Ameican spiituality sweat ceemonies and family suppot. Anothe 17% eceived help foml thei VR pogam o counselo. Whei- asked about dinking habits of thei family membes 80% epoted that thei-fiends abused alcohol o dugs 46% stated that family membes othe than thei paents o gandpaents abused alcohol o dugs and 25% epoted that one o moe of thei-paents o gandpaents abused alcohol o dugs-high stess levels difficult elationships_ and binge dinking wee epoted fequently. I Most clients said that when they fist enteed the VR pogam they wee seiously thinking about dealing with thei addiction and wee eady to take action-in the next month about thei addiction but had thus fa not been-vey actively engaged in behavioal change. When clients wee asked to descibe thei cuent state of mind egading thei alcohol o dug abuse poblem moe wee eady to take action and wee actively involved in changing thei behavid; moe clients also indicated

20 .7 7 _ -. ( that it was easie-to- talk with thei coungelo about thei 'addiction. _ ( As With the counselos clients wee asked' how alcoli61 o dug abuse was affecting thei lives; t-the-tdp five answes included that they wanted-to get thei lives staightened out - alcohol o dug use was causing poblems-with thei family o fiends alcohol was making life wose and wose alcohol was moe touble than it was-woth and they needed help in coping 18 5'. > with alcohol use.. I With egad to clients' pespectives on the _VR system; most clients (42%) said that they pefeed a ehabilitation counselo; 7 ' 38% saidihat they pefeed a counselo' fom thei _gown tibe and 71% pefeed a counselo who was a-ecoveing alcoholic l' Othes also stated that the counselo needs to be a peson who can iget things done who is undestanding and open- minded and whocan help with poviding taining fo jobs with cuently 1 available esouces. Clients epoted that the way. counselos _ helped them the most was by-poviding an atmosphee of Undestanding and compassion. Peceived aeas of inadequacy in VR- counselos included allocation-of funds keeping - appointments inteestin long-tem-pog'ess being available and ) so foth. _ K l Only 29% of clients (as compaed to 63% oeounselos). thought that AI AN clients wee as successful in VR as non- Indian clients. The top five factos listed as leading-to. unsuccessful ehabilitation included lackof tanspotation lack of follow-up by client cultual diffeences lack of follow-up by counselo and counselo's judgment that the client would not 7. i_ -- -benefit fom'sevices. As with the counselos clients wee asked- to what extent.cetain activities wee taking place duing-thei meetings with counselos. The five activities consideed to be most epesentative of issues aised duing counselingsessions included accepting esponsii;ility and self-eliante defining long- ( ange goals specifying shot-tem 'objectives_building)eonfidence and getting specific advice and guidance. BEST COPY AVAILABLE 4.0

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