After substance abuse treatment, then what?

Few people today can claim they don't know someone who has or is currently misusing a chemical substance, be it in the form of drugs or alcohol. Even those who are "in recovery," particularly Native Americans, daily confront barriers to successful rehabilitation from substance abuse. Trying to address these cultural, social, and personal barriers that exist for Native Americans, particularly in obtaining vocational rehabilitation services (VR), is a real and significant problem, one that is strongly substantiated by Rehabilitation Services Administration (RSA) statistics. For example, in fiscal year 1993-94 the Salem and Portland, Oregon, state vocational rehabilitation (SVR) branch offices reported that only 3 of 12 Native American clients with alcohol abuse listed as a primary disability achieved successful closures ("26's") (Oregon RSA/VR Branch Offices, 1996, personal communication).

The impetus for the NARTC/Oregon Tribal and Vocational Rehabilitation Project ("Oregon Project") was a request from a member of the Native American substance abuse treatment community in Salem, Oregon, whose chief concern was that people recovering from alcohol dependency could not secure adequate employment, a situation that she saw as directly impacting their self-esteem and sobriety. Upon conferring with the state's regional vocational rehabilitation office, NARTC staff found that the Salem RSA/VR staff agreed with her assessment of the situation. The Salem RSA/VR staff acknowledged its difficulty in seeing Indian clients through to successful rehabilitation. Subsequent to these discussions, the Native American Research and Training Center (NARTC) submitted a grant and received funding from the National Institute on Disability and Rehabilitation Research (NIDRR) to develop a multidimensional aftercare program for Native Americans in the Salem and Portland, Oregon, greater metropolitan areas who had recently been through treatment for substance abuse. The purpose of the project was to offer participants an aftercare program critical to the stabilization of their recovery and to their acceptance into successful employment through the VR system.

The multidimensional project that developed as a result of these discussions linked Native American treatment programs with VR branch offices. The key element linking the treatment programs and the VR system was an intensive self-empowerment aftercare program sponsored by NARTC.

Presented as an auxiliary component to aftercare, the self-empowerment program provides the recovering substance abuser with a process for increasing his/her sense of self, sense of community, and employability. This is accomplished by learning how to release a way of thinking that is self-destructive to the person and that leads to negative emotions and feelings (e.g., low selfesteem, hopelessness, helplessness). The program also offers a workshop that helps individuals who may be disenfranchised from their culture to explore the unique strengths of their Native American heritage and by doing so to develop another bridge for succeeding in the dominant society.

As is true for most programs, the coordination of the program turned out to be far easier to put on paper than to put into practice. The NARTC staff found that it was breaking new ground because it was coordinating agencies that not only had never worked together but also in some cases had no idea of one another's existence. The staff also discovered that the commitment of the agencies at each program site was essential to the success of the program.

Issues to be Addressed

1. Well over a quarter of a million Native Americans live in urban areas; another 450,000 reside in suburban areas and outside reservation areas (American Indian Digest 1995). Many social services are tribal-land specific or are for specified tribal groups, a situation that disenfranchises the segment of the Native American population not on tribal lands from needed social services.

2. Alcohol abuse among American Indians and Alaska Natives has produced alcohol related mortality rates far exceeding that of the U.S. general population (10.S times as great for ages 25-34 and 6.5 times as great for ages 35-44) (Indian Health Service 1995). This behavior is part of a pattern of selfdestructive actions (violence, accidents) whose source is low self-esteem, a sense of hopelessness/helplessness, and post traumatic stress syndrome occurring as a result of the 500 years of interaction between Anglos and Native Americans.

3. Rates of recidivism among people treated for substance abuse run as high as 86 percent 2 years post-treatment, with the majority of relapses occurring within the first 6 months (Marlatt and Gordon 1985). For Native Americans, the high rates of recidivism are the outcome of a number of factors, including socio-economic issues, limited aftercare support, and an inability to see an alternative option to a lifestyle that supported their habitual behavior. These factors profoundly affect the person's ability to access and successfully complete the VR process.

4. The VR counselors are not adequately prepared to deal with the consequences of this historical process or with the cultural values of their Indian clients, whose views are often in conflict with those of the dominant society (of which most VR counselors are members). There is also the tendency by some VR counselors to judge people with a substance abuse disability as irresponsible and to view disabilities such as alcoholism as not quite as "real" as physical problems that are overtly evident. To address this problem, VR counselors must receive training about Native American cultural values and how these values impact the client-counselor relationship.

Setting the Pattern of Links

The agencies that collaborated to make this program possible included the North Portland and Salem RSA/VR offices, the Native American Rehabilitation Association (NARA) in Portland, the administrative offices of Red Willow in Salem, Oregon, and NARTC.

Links and ties among these agencies were the key to the continuing participation, good will, and knowledge transfer that took place in the program. Staff from each agency was able to clarify their agency processes and functions and help contribute solutions to difficult problems. In this respect, NARTC benefited along with the participating treatment and VR programs in learning about the capability and flexibility of each of the participating agencies. The function of these ties cannot be minimized because participant success in the program was dependent on agency cooperation and interaction. As one member of the VR team noted, if this project had accomplished nothing else, it was a success because it raised the awareness of the different organizations to each other's presence, needs, and functions, and by so doing provided a conduit for open communication between Native American treatment programs and the State of Oregon VR.

To enable VR counselors to work more effectively with their Native American clients, NARTC provided Portland and Salem counselors training and assistance through the auspices of two of its other NIDRR funded programs. One program provided cultural sensitivity training to the counselors, giving them background essential to understanding and appreciating the behavior and actions of their Native American clients. The second program helped facilitate communication between the counselors and their Native American clients by assisting VR in implementing a Native American Technician (NAT) position in the office. A very able person was hired as a NAT and soon began acting as a liaison between the counselors in the Salem and Portland offices and their Native American clients. The NAT provided additional support to the clients as they progressed through the VR system. These kinds of auxiliary linkages helped develop a healthy and supportive groundwork on which to set the Oregon Project.

First, Some Numbers

According to the 1990 National Census, there are approximately 1.9 million Native Americans in the United States (a number many believe to be underreported). RSA reports that American Indians have a 1.2 times greater incidence of disabilities in their population than those in the general population (RSA 1992). Translated into real numbers, this means that 10 percent, or approximately 190,000 Native Americans, have a major work disability. In Oregon, American Indians comprise 1.4 percent (38,500) of the state population, but only 2.1 percent of the American Indian population between the ages of 16 and 64 has been recorded by the Oregon VR as having a work related disability, a percentage that could be low because of a possible lack of access to VR services by Indian people. A substantial portion of this group has substance abuse as a primary or secondary disability (RSA, 1992).

As of fiscal year 1994-95, American Indians represented 2.1 percent of those currently in Oregon's SVR. Their success rate (successfully employed for 2 months following completion training, a "26" closure) is 42.3 percent, the lowest of all ethnic groups surveyed (white, African American, American Indian, Hispanic, and "other"). American Indians enrolled in VR in Oregon with a substance abuse related disability (primary or secondary) prior to the Oregon Project (fiscal year 1993-94) show a rehabilitation rate of 25 percent (3 of 12 individuals), a rate similar to that for the general population for that year, which was 28 percent, or 70 out of 249 individuals (Oregon SVR, 1996). During fiscal year 1993-94, the Salem branch office had no successful closures for Native Americans served by VR. Because alcoholism was considered a critical barrier to successful closure for Indian clients, the Salem and Portland RSA/ VR branches joined NARTC in this program, providing cooperation and support for this new and innovative multiagency intervention.

The Participants

Participants for the aftercare intervention were chosen by qualified treatment counselors using three major criteria to determine acceptance into the program: counselor assessment; personal internal cultural strength; and a desire for vocational rehabilitation. While a history of attendance in multiple substance abuse programs did not affect whether or not a person was eligible for this program, eligibility was contingent on whether or not the individual met all the qualifications for acceptance into VR. Most of the participants had been treated for their chemical dependency in a Native American substance abuse program. For the intervention program to have its greatest impact, the NARTC staff decided that it should occur no later than 2 years subsequent to completion of primary treatment for substance abuse. The staff felt that having the intervention and particularly the "Self-Empowerment" (S-E) and "Walking in Two Worlds" training as part of an aftercare program would maximize the benefits the participants received from their treatment programs.

Of the original 29 people who began the program, 22 (9 women, 13 men) completed the self-empowerment workshop training, 8 from the Portland area (4 women and 4 men) and 14 (5 women and 9 men) from the Salem area (including Grand Ronde). The average age of the participants was 35, with the Portland group being on average approximately 4 years older than the Salem group. Half of the Portland participants and 29 percent of the Salem participants had not finished high school or received a GED at the time they began the program. Both groups showed a high rate of substance abuse in their immediate families. Most rated themselves as having a low to fair involvement in Indian culture, with the Portland participants rating themselves higher on this scale than the Salem participants. Of the original number, seven did not pursue any involvement with VR; one of the seven already had a full-time job and was pursuing an associate degree to become an alcohol and drug counselor.

Purpose and Goals

Major barriers to American Indians with an alcohol-related disability achieving successful VR closure are: (1) maintenance of sobriety; (2) ability of the VR counselor to work with someone with that disability (which historically has a low VR success rate); and (3) lack of communication between the Native American client and the Anglo counselor because of cultural and social differences. It is widely accepted that substance abuse among Indians is a symptom of underlying problems, including post-traumatic psycho-socio-cultural stress, and learned dependency (May 1977; Mail, 1980; Jones-Saumty et al., 1983). This project had three specific goals: regain stability, change feelings and perceptions of self-worth that inhibit personal growth, and achieve successful outcomes through the VR system. To accomplish these goals, Drs. Paul Skinner and Carol Locust developed a four-step intervention program, with each phase responding to a different aspect of the participant's education and preparation. Each phase of the program focuses on the person's self-regard and life options. To address issues regarding the alcohol work-related disability (which in some cases is part of a dual diagnosis), VR and treatment administrators worked directly with NARTC staff in the planning and execution of the project. To ensure that problems involving communication between program participants and VR counselors were minimized, NARTC staff trained and incorporated the VR counselors into several aspects of the intervention effort.

Incorporating the Intervention into an Aftercare Program

While treatment has been shown to be very beneficial to people in the short run, many begin using alcohol and/or drugs again within 2 years of finishing their programs. Much of this recidivism can be attributed to the unchanged conditions (e.g., unemployment, lack of skills, low self-perception) of the person's daily life following treatment. The following discussion details the multiple, intertwined components of the intervention and the incorporation of basic aftercare methods and goals into this process and how they are a response to some of the causes of recidivism.

Phase I. The first phase of the intervention was an intensive 4-day workshop consisting of two components: (1) "Bridging the Gap," and (2) the "Self-Empowerment Process." Workshops were conducted for groups in both Portland and Salem. As the S-E training is based on a cumulative learning model in which each unit is dependent on the learning and mastering of the previous one, all participants were expected to attend all sessions. If a participant missed a day, the person became ineligible to complete the program. Completion of the program did not affect the individual's VR eligibility.

"Bridging the Gap" was designed to be presented in a 1-day workshop. The workshop, designed by Carol Locust, engages participants in a directed self-discovery of Native American beliefs and practices, health issues, and cultural commonalities and differences, providing them with ancient, historical, contemporary, and future perspectives for understanding themselves as American Indians. This is a very interactive, hands-on workshop that encourages people to explore their respective cultural heritage and strengths. The purpose of the workshop is to show them how those strengths can be used to live not only beneficially within their own Indian cultures but also to function successfully in non-Indian cultures.

"Self-Empowerment (S-E) Training Program" is a 3-day workshop. Developed by Paul Skinner, the S-E training is based on a theory and intervention that recognize cognitive, motivational, and behavioral processes as the underlying causes of both our problems and our solutions. Directed at a self-analysis of the purposes we assign to our actions and our behaviors, S-E addresses psychological, social, and cultural issues and how as humans we view and experience our lives, health, and the choices we make. The program presents an alternative way of thinking and acting that enables participants to release or unlearn the unhealthy ways in which they had been thinking. In so doing, their sense of powerlessness is released as they start to become aware of their past dependency for happiness on all things outside of themselves. In particular, the S-E process looks at conditioned thinking and how it is manifested in a variety of actions that range from violence to a need to please and through a spectrum of feelings that include fear, anger, guilt, and stress.

Nine separate units (three units per day) were presented in these workshops, covering topics such as conflict, guilt, and stress; coping strategies; critical thinking and decision making; compulsive, abusive, and addictive behaviors; and relationships and dependency.

As with the "Bridging the Gap" workshop, the S-E sessions are interactive in nature. Participants are encouraged to explore both with others and within themselves how they experience the multiple aspects of conditioned thinking and behavior and how they could choose an alternative way that relies on peace within themselves rather than conflict.

Phase II. "Mutual Support Groups" were designed to provide continued support for the individuals in the group as they dealt with everyday life issues, their sobriety, and working their way through the VR process. Meetings were 90-minute sessions held once a week for 9 consecutive weeks. Sessions took place at locations accessible to the participants. Each of the nine sessions was developed to reflect the nine separate units of the S-E process. Participants reviewed the principles of the process and discussed how they were able or not able to use them in situations that arose during the previous week. In essence, the support groups familiarized them with the tool (for the process itself really is a tool for thinking about choices) as they supported each other during this critical time in their lives. The sessions were particularly beneficial because people were able to ask questions they had about the material and to re-examine and learn from their experiences of current events and situations. Specifically, participants were able to use the process to help themselves through a variety of challenging life situations, i.e., child custody problems, viable employment, maintaining sobriety, and releasing anger. All meetings were facilitated by a person t rained in the S-E process.

Phase III. "The VR Process" was introduced at different points in the project. The first intervention occurred prior to the Self-Empowerment Workshop. Regrettably, because we did not anticipate the immediate interest in information about VR, the Portland participants did not have a VR counselor present at their first meeting. In lieu of that interaction, participants submitted a list of questions for the Portland VR staff to address. This situation alerted and prepared us for a similar interest among participants of the Salem group. A VR counselor attended the first meeting of the Salem group and answered a wide variety of questions. She was there for approximately 1 hour. At the conclusion of the workshop, all participants in the Salem group met with and were given appointments with VR Counselors.

Having a VR counselor present at each session of the mutual support group meetings to address any VR-related questions was another important intermeshing of VR with the S-E process. Unfortunately, because of personnel changes within the Portland VR office, this component was not implemented there. It did, however, successfully occur with the Salem group. During and subsequent to these interventions, participants continued as regular clients with their respective VR counselors.

Counselors were chosen to participate in this project by expressed interest, experience, and expertise. Ultimate assignment rested with their SVR branch managers. As their involvement required additional work on their part (i.e., progress reports to the project evaluator, meetings, and training), their wholehearted commitment to the program was critical. As with any client-counselor relationship, if the situation did not work out, the project participant could request a different VR counselor. Only one person requested such a change.

Phase IV. The "Teaching of Teachers" component is the final stage of the intervention. Individuals interested in becoming teachers of the Self-Empowerment program were given training on how to teach the "Bridging the Gap" workshop and how to establish a Self-Empowerment program. This was a challenging phase for all involved as it not only required participants to understand the principles on a personal level but also to be able to convey that knowledge on a broader level to others. The "Teaching of Teachers" workshops provided the now seasoned participants with a review of the material plus exercises specifically created to assist them in their own workshops. All participants were given the text, Healing the Self, and an instructor's manual from which to work. Following completion of the training, the new teachers were then certified to conduct and to teach the two programs.

Because the ultimate aim of the project is autonomy and ownership of the program by the participants and by the tribes, the program was also offered to representatives from the participating tribal agencies who wanted to incorporate these processes into their own aftercare programs. The tribes expressed a very strong interest in the project and a willingness to assume responsibility for teaching the entire program.

Taken in a larger perspective, this phase of the program addresses more than the above stated objectives. It also embraces the visionary goal of expanding and broadly applying the S-E program wherever there is an expressed desire to have it. This could be realized through tribal ownership of the "Bridging the Gap" and S-E processes and their incorporation into aftercare substance abuse treatment programs. It could also be seen in the growth and expansion of the program beyond these geographic areas. Furthermore, the S-E program could also be applied in other health, social, and educational areas (e.g., as a training component in a child welfare program).

Although this project and the kinds of communication links that were developed within the individual workshops (among participants) and among the different agencies were noteworthy, there were a number of questions that had to be answered about the results of the program: Was there a noticeable reduction in recidivism? Were the lives of the participants enhanced? Did participants successfully complete the VR process? To find answers to these questions, NARTC staff conducted detailed process and outcome evaluations with the full cooperation and input of the participants, for ultimately those individuals experiencing the program had the insights and understanding so critical to the success and future development of the project.

All participants were paid for their time. While this may be considered irresponsible by some in the treatment field, NARTC staff in fact felt it to be quite necessary. Participants were asked to set aside 4 complete days to learn and use an alternative way of thinking about their lives, problems, and personal situations, and to reflect on their behavior. This is not an easy task. During the program, participants were asked to complete questionnaires and evaluations and to be interviewed. It seemed only appropriate to pay people for each intensive day of learning and work. Ultimately, we felt that it showed respect for the individual.

Evaluation Design

All phases of the program were evaluated by quantitative and qualitative measures. These included attendance and participation in the workshops, participant questionnaires, unit evaluations/ quizzes, field notes, interviews with participants, reports on S-E followup mutual support group meetings, and monthly VR counselor reports. Seven assessment scales were used: The Self-Empowerment Scale (Skinner and Scott, unpublished); The Marlowe-Crowne Social Desirability Scale (Gerstein, Ginter, and Grazian, 1985) to measure the validity of participants' responses to The Self-Empowerment Scale; The Self-Esteem Culture-Free Inventory (Rosenberg, 1965); The Rand Health Survey (Ware and Sherbourne, 1992); The Perceived Stress Scale; The Emotions Scale (Veit and Ware, 1983); and The Leadership Scale (Skinner, Hassin, and McKnight, unpublished). Data collection procedures were identical for both the Portland and Salem groups.

All the qualitative data were coded and analyzed according to a set of defined constructs. These included self-empowerment, self-esteem, health, abstinence from drugs and alcohol, VR compliance (keeping appointments and developing workable plans for education and employment), and successful VR closure ("26" closure).

Results of the Evaluation

Quantitative Analysis: Workshop attendance and participation were high for both groups. To measure the latter, we used a scale of 1-5 (1 = the lowest rate of participation and 5 = the highest rate of participation). The rates for the Portland and Salem groups were 3.65 and 3.68 respectively. The rate for both combined was 3.67.

The assessment scales and the evaluation/ quizzes were administered at three separate intervals: time 1: pre-workshop intervention; time 2: post-workshop intervention; and time 3: 2 months postworkshop intervention. Throughout the project, little if any change occurred in response to the assessment scales. The nonsignificant results can in part be attributed to a sample size that was too small for the number of questions asked. Parametric statistics (e.g., ANOVA), although reasonable to use for large samples, can be troublesome when analyzing a relatively small sample size.

The respective means of the mean score of participant performance for all nine unit quizzes were the following (maximum possible score = 4.889, minimum possible score = 0.0; standard deviation [s.d.] will appear in parentheses): Portland = 3.882 (s.d. = .393); Salem = 3.859 (s.d. = .353); both Oregon groups = 3.867 (s.d. = .362). The nine individuals to whom we were able to readminister the quizzes showed no significant change in their retention of the self-empowerment material.

After 18 months post-workshop intervention, only 4 of the 22 participants (18 percent) who completed these sessions began using any drugs or alcohol again. One of these individuals is back in treatment.

Qualitative Analysis Results: Field notes taken at the beginning of the "Self-Empowerment/Bridging the Gap Workshop" helped provide a different perspective from which to examine the reliability of the quantitative findings. Several constructs were identified and coded in the data. Of particular interest for this discussion were self-empowerment and self-esteem. Using a scale from 0 to 10 (0 = no sense of self-empowerment or self-esteem and 10 = a strong sense of self-empowerment or self-esteem), NARTC staff coded the field notes from the first meeting and compared them with a wide spectrum of data sources (field notes of the last meeting, post-workshop interviews, mutual support group reports, 2 months post-workshop interviews, and VR counselor reports). The results are shown in Table 1.

                               Table 1
               Comparison Pre- and Post-Workshop Means

                Self-Empowerment              Self-Esteem

Group      Pre-Workshop  Post-Workshop  Pre-Workshop  Post-Workshop

Portland   (1) 2.857        6.456           2.429         4.425
Salem          2.429        6.857           2.286         6.214

(1) Based on the scale 0-10, with "0" equaling no sense of self-empowerment or self-esteem and "10" equaling a strong sense of empowerment or self-esteem.

As seen in the above comparison, there is strong evidence of change in both self-empowerment and self-esteem with the former increasing substantially over the time of the workshop. Self-esteem also showed an increase although less dramatically than for self-empowerment.

Two of the most pronounced indicators of empowerment were reduction of anger and an increase in feelings of control rather than helplessness in their daily lives. In concrete terms, this was seen in the substantial changes that occurred throughout the year: five participants regained custody of their children, and many gained full-time employment (see Table 2). One person is also in the process of finishing her GED. Others are currently involved in long-term training (e.g., cosmetology school, nursing program). Project participants, both through interviews and in discussion with their VR counselors, described how they used the empowerment process in their daily lives, choosing this new way of thinking to respond to such difficult and challenging situations as homelessness, illness, violence, and bureaucratic red tape. One participant had to work her way through Child Protective Services (CPS) dealing with a person who was confrontational. She related to her counselor how she applied what she had learned in the empowerment program. Her counselor noted:

"She kept herself from reacting to the situation in a negative manner. Although she was unable to achieve instant gratification by reacting out of anger, she put the situation in its proper perspective and maintained her self-control and dignity."

                              Table 2
Participants VR Involvement, "26" Closures, and Employment Status

             VR Process (Means)(1)

Group        Appointments     Plans      "26" Closures

Portland         4.667        5.833       25   %(n = 2)
Salem            7.462        6.539       57.14%(n = 8)
Combined         6.579        6.211       45.46%(n= 10)

                    Employment Status (%)(2)

Group          Pre-Intervention      Post-Intervention

Portland          0   %                 25   %(n = 2)
Salem            14.29%(n = 1)          64.29%(n = 9)
Combined         4.55 %(n - 1)          54.55%(n = 11)

(1) Based on a 0 to 10 point scale, 0 = no progress; 10 = consistent and continued progress.

(2) Based on a total number of 8 for the Portland group and 14 for the Salem group.

Over the course of several months she worked with CPS to increase her visitation rights, went to parenting classes, and without rancor or losing her temper, worked her way through many frustrating experiences to regain custody of her daughter.

The impact of the S-E process has also been seen in what is known as the "nudge effect" (i.e., although the desired result does not occur, a positive effect does result because of the intervention effort). This kind of effect occurred for a participant who suffered from chronic depression. Although this person was compelled to quit his job because of his mental state, he did not follow his usual pattern of turning to alcohol when this occurred. He attributes his ability to cope with his depression without alcohol to the tools he acquired through the S-E process. After 1 year, he has once again been able to secure full-time employment. Other behavioral changes of this kind were observed among the participants. A woman with a long history of choosing anger and violence in response to problems became, over the course of the workshop, increasingly better able to express and to resolve personal problems without the volatile reaction traditionally part of this person's behavioral repertoire. While she did not make it through the VR process, the changes in her actions and words were of such a noticeable quality that they were frequently noted in reports, comments, and interviews by a variety of individuals, including the instructor of the workshop, the program assistants, the evaluator, and, most importantly, the other participants.

A strong sign that the intervention was achieving its desired objectives was seen in the sizable number of project participants who successfully completed the VR process. To date, results show sustained VR involvement for the majority of the participants. They are keeping their appointments with the counselors, developing employment plans, and successfully completing the process. Once again, a 0 to 10 scale was used to code the results for participation in the VR process (see Table 2). As the table shows, very few participants from the Portland group enrolled in VR. Unforeseen personnel changes in the Portland VR office led to logistical problems that affected the participation of the Portland group in the VR process. This along with the fact that two participants moved out of state and two resumed their substance use (one of whom is currently in treatment) have impacted the number of people who have worked through the process. From the Portland group, two have successfully completed VR and are employed full time, and one is continuing to work through the VR process.

Of the 14 from the Salem group who completed training, 3 are currently receiving VR training and 9 are working full time. Of the nine working full time, one has remained in her present position as she continues her education, and eight have permanent full-time jobs secured as a result of VR. This is an increase of 800 percent for Native Americans successfully completing the VR process out of the Salem office. Information is not available on two participants whose files were unsuccessfully closed.

The third major outcome for the project was the successful training of new teachers of the "Bridging the Gap" and "Self-Empowerment" programs. Three participants chose to do this: two from Portland and one from Salem. They, along with 10 tribal and VR counselors, were trained in February 1996. From that group of new teachers, nine members team-taught three new groups of participants in March 1996. All three original participants were among these teachers.

Discussion

Based on the results of our analysis, there is evidence supporting a strong and positive impact for this intervention. Our findings show that the group of participants that had the strongest developed links between the treatment agency and the VR branch office appeared to have benefited the most from these interagency ties, enabling it to receive important information and support as participants moved back into the workplace. This effort was further supported by the larger positive change in self-esteem among members of this group and their ability to use the VR resources more successfully than the group that had less involvement with VR personnel. These counselors created a bridge of great strength from their personal efforts to participate in the project, their continued attendance at support group meetings throughout its 9-week cycle, their provision of VR services at a tribal facility, and their subsequent involvement in alcohol and drug prevention program events. Making and keeping these connections, while extremely important, were strongly enhanced by the S-E workshop. Comments from the interviews as well as management of personal and job-related problems and issues clearly indicate that most participants were successfully applying the S-E principles they learned to life situations and in so doing improved their own self-sufficiency.

The results of the first phase of this project suggest that the efficacy of the intervention rests on three nesting components: personal empowerment (the function of the individual's perseverance and commitment to the intervention), the VR process, and a new sense of personal self-sufficiency.

Modification of Criteria

Certain changes were made in the project based on the appropriateness and functionality of the measures. While we will continue to use quantitative measures to discern change, we recognize that until the data base is large enough, regular parametric statistics cannot be used with any reliability. As we increase the overall number of people participating in the program, this will become less of a problem. However, the number of actual questionnaires has been reduced from seven to three. Those that are being kept reflect the basic components of self-sufficiency: The Self-Empowerment Scale, The Rand Health Survey, and the self-acceptance scale (Marlowe-Crowne Social Desirability Scale). The demographic data collected has also been reduced to decrease redundancy.

A second modification was made in the criteria for participation. We found that it was necessary for participants to have some assurance of not being homeless after completion of their substance abuse treatment. This level of stability was necessary for them to be able to focus on the S-E process after the workshop and to continue to work with VR. One participant, who had made tremendous progress throughout the workshop and was working with his VR counselor on a regular basis, developed an erratic pattern of contact once he was homeless. Another participant who regained custody of her child and is currently in a training program has had to fight with this problem for most of her training period, moving from the home of one acquaintance to another while attempting to complete her studies.

Conclusion

This intervention project has produced several positive results. First, it provided a conduit for networking and developing links between the Indian community and the regional VR branches and among the different projects run out of the office of NARTC. These links have fostered not only the development of new sources of information but also a greater understanding between the community and Oregon State VR. These links have also enabled the new generation of teachers to accept and use these networks as natural sources of information and conduits for their clients. Second, the project appears to have had a strong impact on the stabilization of sobriety. While it often takes more than a year to determine such an effect, the results after a year have been very encouraging and justify the kinds of thinking tools the S-E intervention offers. Third, as with the stabilization of so-briety, the impact the S-E process has had in relation to the health of the individual can be seen in the "anchoring" of the person, even when his/her ultimate goals are not reached. This effect should not be minimized, as it shows the person choosing to use the empowerment process in situations that he/she would have otherwise found beyond his/her ability to cope with. The fourth, and in many ways the most concrete, result is the number of participants who have worked so successfully in maximizing the potential of VR. Increasing the number of successful closures by 800 percent in one branch office alone is a remarkable result.

Although the actual number of people who have gone through this first phase of the project is not large, the success of the program warrants serious attention as it proceeds through its second phase and the next generation of participants. During the first year of operation, the project involved the cooperation and expertise of five agencies (two Native American treatment programs, two VR branch offices, and NARTC) working together to overcome the logistical difficulties of the project and to make the plan a reality. Today, the program has expanded and incorporates two additional tribal substance abuse treatment programs. In this second phase of the program, the VR counselors are working closely with the treatment counselors to make the S-E aftercare program a successful intervention.

Acknowledgments

This project was supported by funds from the National Institute on Disability and Rehabilitation Research, U.S. Department of Education (Grant #H133B30058). In addition, there have been many people who have aided and supported this project as it has progressed and developed. These people include Ed Heikes, Melanie Smith, Rod McAfee, Kathleen Leatham, Gretchen Ritter, Georgia Isaia, Janie Jenne, Kathy Coley, John Mackey, Alex McCourt, and the incredibly inspiring people who decided to "be the first ones to try the program out." Without their assistance and patience there would have been no "Oregon Project."

Bibliography

1. American Indian Digest: Contemporary Demographics of the American Indian, 1995 Edition. Phoenix, AZ: Thunderbird Enterprises.

2. Gerstein, L.H., Ginter, E.J., & Grazian, W. (1985). Self-monitoring, impression management, and interpersonal evaluations. Journal of Social Psychology, 125 (3): 379-389.

3. Indian Health Service (1995). Trends in Indian Health. Washington, DC: U.S. Department of Health and Human Services.

4. Jones-Saumty, D., Hochhaus, L., Dru, R., & Zeiner, A. (1983). Psychological factors of familiar alcoholism in American Indians and Caucasians. Journal of Clinical Psychology, 39: 783-790.

5. Mail, Patricia D. (1980). American Indian drinking behavior: some possible causes and solutions. Journal of Alcohol and Drug Education, 26: 28-39.

6. Marlatt, G.A., & Gordon, J.R. (1985). Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. NY: Guilford Press.

7. May, P.A. (1977). Explanations of Native American drinking: a literature review. Plains Anthropologist, 22: 223-232.

8. Oregon Research and Evaluation (1996). Annual Report for Fiscal Year 1995. Vocational Rehabilitation Division.

9. Oregon Research and Evaluation (1996). Oregon Cultural Diversity Forum. Vocational Rehabilitation Division.

10. Rehabilitation Services Administration (1992). Amendments to the Rehabilitation Act of 1973. Washington DC: U.S. Department of Education.

11. Rosenberg, M. (1965). Society and the Adolescent Self-Image. Princeton, NJ: Princeton University Press.

12. Veit, C.T., & Ware, J.E., Jr. (1983). The structure of psychological distress and well-being in general populations. Journal of Consulting and Clinical Psychology, 51: 730-742.

13. Ware, J.E., & Sherbourne, C.D. (1992). Conceptual Framework and Item Selection. Medical Care, 30 (6): 476-483.

Dr. Hassin is assistant research scientist at the Native American Research and Training Center, The University of Arizona.