Rural Issues in Alcohol and Other Drug Abuse Treatment
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Rachel Cyr Henderson, MRC
Licensed Substance Abuse Counselor
Licensed Professional Clinical Counselor
Rockland, Maine
Susan F. Long
Licensed Substance Abuse Counselor
Rockland, Maine
This paper focuses on a program that was near collapse, the strategies that were employed to build coalitions, and the changes that occurred in the delivery of service. The initial consensus was that this was an impossible task. But, by using the program philosophy, being aware of personal and program boundaries, and engaging both the recovering community and service communities, the agency and services were revamped and revised.
Choice/Skyward is a publicly funded outpatient substance abuse treatment agency located in the small community of Rockland on the coast of Maine. We are the only licensed facility in Knox County, which covers 374 square miles and has a population of 37,000. The population doubles during the summer months. Included in the county are the six island communities of North Haven, Vinalhaven, Criehaven, Matinicus, Monhegan, and Isle Au Haut. These islands lie anywhere from 12 to 20 miles offshore. There is daily ferry service, as weather allows, to North Haven and Vinalhaven. The farther island communities such as Monhegan and Matinicus must be accessed by mail boat, if space and weather allow, or by private plane by those with more resources.
Knox County is one of the poorest counties in New England and maintains an average unemployment rate of 10 percent. In the last 4 years, the State of Maine has suffered particularly hard financial times and social services have been a leading target of budget cuts. Consequently, the needy in Knox County have felt the harsh realities of the scaling down and, sometimes, the loss of badly needed support services.
The closest detoxification and inpatient treatment programs are located 45 and 75 miles away, respectively. Many of the clients seen by Choice/Skyward for treatment have low income. The only inpatient program in the State willing to serve these clients is located 70 miles north of Rockland, and the closest intensive outpatient/day treatment program is located 75 miles west of Rockland. Needless to say, access to these services can pose a formidable problem.
As a result of Maine's stringent drunk driving laws, many of Choice/Skyward's clients are sent for treatment after they are convicted of operating under the influence. Nearly all of these clients have lost their driver's licenses for a period of at least several months. Consequently, in an area where access to services is already limited, and public transportation is nearly nonexistent, compliance with the requirements of the court seems a heroic matter. Three years ago Choice/ Skyward found itself facing the following problems:
It was clear that our strategies for service delivery needed to change and that the community needed to be involved if we were to be successful in building a continuum of care. The staff and the Policy Council met to formulate plans to revitalize and reimagine ourselves and our services. It appeared that, given our circumstances we couldn't get there from here."
Choice/Skyward's problems affected both consumers and the community at large. If Choice/Skyward were to remain a community-based program, it needed to find solutions within the community; professional solutions would only serve to further distance it from the community. The recovering community was our primary focus. Furthermore, both the community at large and the recovering community have the capacity to respond quickly and decisively to problems, since they're not encumbered by institutional interests such as budgets,by-laws,etc. Choice/ Skyward needed to use this responsiveness and energy as a Positive force for change.
At the same time, the hospital community needed to be engaged in the process of finding a solution to the lack of detoxification services and the nonexistent continuum of care. As the only hospital in the county, they could act as a major influence and source of education for physicians and other health care professionals.
Choice/Skyward believes that the services we provide are supported and used by the community and, therefore, the community must take part in defining these services and determining how they will be delivered. We are aware that professionalized service can be disabling to community members. This awareness can help ameliorate the iatrogenic effects of treatment (Illich and McKnight). This philosophical stance has helped us Keep our focus and sustained us in the belief that we could get where we wanted to go, although it appeared there was no road.
The recovering community was approached by every member on staff. People from every Alcoholics Anonymous (AA) group in the area were invited to a meeting to discuss the problems of recovering people in our county and the possibility of using Choice/ Skyward space for a recovery club. Five people attended the meeting. They were acutely aware of the lack of detoxification services and the lack of access to treatment services. They had suspicions regarding the services we provided and felt discouraged that there was no "central place" for members to gather just to socialize or "have a cup of coffee."
AA members also brought to light some of the recovery problems experienced by people working on fishing boats. Many of these individuals are out to sea on small vessels for 2 weeks or more. Any services they receive must have flexible schedules. The island populations also had difficulty accessing services because of transportation problems.
The group members were impassioned in their responses. They very much wanted to help find solutions to problems faced by the agency and by people early in recovery. They felt that this would be more possible if they had space for a recovery club. Space is an asset Choice/Skyward had available.
Choice/Skyward offered the basement floor of our building to the recovering community. It is a 3,000-square-foot finished space with bathrooms, kitchen, and two entrances. We proposed that this space be used in any way the recovering community liked. Choice/Skyward did not want any control over the decisions that would be made. The recovering community would have to comply with city regulations and keep noise down during Choice/ Skyward's hours of business.
This group then began to meet without Choice/Skyward and developed a plan for the space by working through all the AA groups in the county. The plan presented to Choice/Skyward proposed using the space for a club that would be open from around 8 a.m. until midnight. It would be managed by a Board of Directors made up of members from various AA groups. They wanted to have a person in charge present at all times. They wanted to create a safe place where people could drop in for coffee, play a game of cards, read the paper, receive a little reassurance, attend daily noon meetings, wait for or find rides, etc.
Choice/Skyward agreed to their proposal, and the club received 1 year's free rent. At the end of 1 year, a rental agreement would be negotiated.
The club's progress was remarkable. Within 3 months, the space was painted and furnished with donated furniture. They installed a pool table, cable TV, and a coffee service; subscribed to the local papers; and held regular weekend yard sales of donated goods. A volunteer manager staffed the club at all times. They began to plan dances and other recreational events. From the day they received the keys until the present, a daily AA meeting has been held.
The response from the community was overwhelming, and celebration was in the air. After the initial 3 months, the club approached Choice/Skyward to propose that they do more for the treatment program in exchange for the space. They began a fund to provide transportation to detoxification and inpatient treatment centers around the State. They then organized drivers to provide the service.
As the first anniversary of the club approached, we began the process of negotiating a lease. The survival of the club was Choice/ Skyward's agenda. The club had provided our clients with transportation to services, an introduction to AA and recovery that went far beyond what most treatment centers can offer, a fun and energizing place to wait, and the message that recovery is possible.
It also brought to staff meetings and to Policy Council/Board meetings some of the complaints that the community had with the treatment program. The program responded by changing service delivery times, the configuration of the groups, billing procedures, and staff.
The second year lease was negotiated, and the club agreed to pay $50 per month rent, handle trash removal for the entire building, mow the lawn, and provide snow removal. In addition, it volunteered outside of the lease to continue providing transportation services for our clients and to work on improving the AA hotline and institutional committee. Both the lease and the informal agreement continue to this day.
We approached the hospital community in two ways. First, we discussed the problems with our medical director and asked him to speak for us to physicians. Then we approached the manager of the psychiatric unit at the local hospital, who had expressed an interest in our program and in services for recovering persons. We were able, through the psychiatric unit, to renegotiate a contract for consulting services to be made available to all the units at the hospital. We also agreed to work together to find funding to expand services in our community.
The Choice/Skyward staff became a regular presence at the hospital. The different hospital units quickly discovered that the consultations they ordered had an impact on patients and that we were able to connect addicted persons with a variety of recovery programs.
The emergency room hired a new director who had been trained in substance abuse and called us regularly concerning addicts who came to the emergency room. We provided the hospital with the number of persons we saw over a period of time who needed detoxification but who had to be referred outside the county, when they could have been better served here in their home community. The hospital used these figures to support a certificate of need for detoxification beds.
Our hospital meetings moved to a different level when we met with the hospital president, board president, fiscal representative, and psychiatric unit manager. With the hospital's assistance, we were able to submit a proposal to the State for stable funding for our program. This proposal was written collaboratively and funded by the State of Maine.
The hospital received approval for their certificate of need and planned for a building which would include detoxification beds. We dreamed of expanding and collaborating in other ways in order to create a continuum of care.
During this period of time, we worked on a collaborative grant that also included the local mental health center. We proposed to provide education to the community and professionals on dual diagnosis. We also proposed a collaborative board made up of all services and segments in our community to find solutions for our dually-diagnosed citizens. We won the grant.
Our medical director spoke individually with most of the physicians in our community. He created a broad base of support among physicians which resulted in many new referrals to Choice/ Skyward. Many of these referrals were covered by third-party payors and thereby increased our revenues. The director was also willing to staff cases with us when there were questions regarding prescribed medications, and he intervened with physicians when prescriptions seemed inappropriate. Through his efforts, the trust level between Choice/ Skyward and individual physicians grew.
We are well into our third year of building coalitions and creating strategies for improved service delivery. The Choice/Skyward program has changed in many ways. \We listened, although at times it •vas painful, to the complaints and suggestions from the community. It became clear that over a period of time that saw many changes in personnel, the Choice/Skyward program had become self-centered; many times staff members had taken the position that when it came to recovery, we knew best. This conveyed the message that a client could truly benefit only from professionalized help, which counters everything a person learns in AA.
Staff members revised operations with the help of the community. We saw and felt the community's power and sensed respect for the part we played in it. We experienced a sense of relief; we did not have to have the perfect solution to anything. Staff gained visibility, Choice/Skyward's revenues increased, and we grew more willing to try new configurations.
We saw some clients every day for 15 minutes and others for 2 hours. We worked on delivering the service in the most acceptable and appropriate way for each client and changed the way we staffed our program.
The recovering community's support of this program continues to increase, and the club continues to prosper. Over time it has had its ups and downs, but Choice/ Skyward has always kept the boundary firm and reserved comment. Had we interfered, we believe the club would have failed. The recovering community prides itself on its success and its ability to solve problems. They also take pride in having reassumed their responsibility to people trying to recover from addictions.
Our relationship with the hospital continues to grow and now includes the mental health network. Over the past 2 years, the hospital has done some detoxification on an informal basis. They have also been willing to monitor patients medically while we make arrangements for transfer to detoxification and inpatient treatment. This has been a much more formal process than what we experienced with the club. We were much more aware of the chain of command and the many layers of decisionmaking that needed to be included.
At this time in our collaboration, there are plans to open an expanded mental health unit which would include detoxification beds, outpatient detoxification, a special track of services for addicted patients, day treatment services, and an intensive outpatient program.
Although it was said many times "you can't get there from here," we did it. We made it because of a willingness to change, to engage the recovering community and the service system, and to work at keeping clear boundaries between ourselves and others. We saw the possibilities as greater than the problems. We can truly say that we are a community-based program providing services that the community itself has requested and finds valuable. The test over time will be to remain flexible and open to the voices of wisdom in our community.
Illich, I. Disabling Professions. In: Disabling Professions. London, England: Marian Boyer, Inc., 1978.
McKnight, J. Professionalized service and disabling help. In: Disabling Professions. London, England: Marian Boyer, Inc., 1978
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