Research Reports

SUBSTANCE ABUSE PROGRAMMING
A PROPOSED STRUCTURE

DISCUSSION PAPER

2001 N^o R-120

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TABLE OF CONTENTS

• INTRODUCTION
• BACKGROUND: THE LAST 10 YEARS
  • Research
  • Policy
  • Programming
• PROGRAM REVIEW
  • Expert Panel
  • A Front Line Response
    • Program Direction
    • Supporting Infrastructure
• A CONTEXT FOR PROGRAM DESIGN
  • Community Building - A Systemic Response
  • Programming Sets the Stage
• THEORETICAL INFLUENCES
  • Harm Reduction
  • Cognitive and Therapeutic Interface
  • Relational Theory
  • The Model of Change
• SUBSTANCE ABUSE PROGRAM MODEL
  • Purpose
  • Principles
    1. Program Operating Principles
    2. Program Delivery
    3. Program Management & Support
  • Program Structure
  • Program Components
• NEXT STEPS

INTRODUCTION

Substance abuse is a significant concern for most of the offender population. As many as 70% of men and women offenders are identified as having substance abuse problems.

In 1994 Correctional Service of Canada (CSC) identified substance abuse treatment as a priority for women resulting in the development of a national program a year later. While this program represented an important beginning,there is a clear need to move forward with a new model - one that is genderresponsive in all respects and continues to build on best practices in the treatment of substance abuse. Gender responsive, in this context, refers to an environment created through site, staff and program development that reflects an understanding of the realities of women's lives and is responsive to their issues.Experts have provided advice, women's facilities have been consulted, and a proposed framework now exists. The model presented in this document offers asystemic response to programming that draws from the original vision embodied in Creating Choices, embodied in the 1990 task force report on federally sentenced women. Inherent in this design is the belief that programming is most effective when it is reflected in the surrounding institutional milieu. The creation ofa new substance abuse program provides an opportunity to affect a cultural shift in women's facilities. Program coordination and training will be key to its success.The purpose of this document is to provide an overview of the thinking that went into the proposed design. It begins with a summary of recent history for women offenders and substance abuse programming. It then describes the review process and the importance of looking at the role of integrated programming in supporting a healthy community milieu. Theoretical influences are discussed and,finally, a detailed description of program modules is presented. This document describes a work in progress and changes can be expected as the consultation process continues.

The proposed model is ideal and will take time and resources to achieve. Initially,some components may stand alone, while others will evolve and could potentially be integrated with other similar initiatives, such as the current work in creating an"Effective Corrections Strategy".

BACKGROUND: THE LAST 10 YEARS

Current substance abuse programming for women has been influenced by a number of significant initiatives over the past decade. The following overview of research, policy and programming sets the stage for the work currently underway

Research

Substance abuse is a major area of concern for women offenders. In the last ten years there have been a number of important studies, Light foot and Lambert(1991; 1992), Shaw et al (1991), and Fabiano (1993) that speak to the significant role substance abuse plays in the lives of most women offenders. We also know that substance abuse affects most other areas of their lives, including legal status,family life, work and health. In a more recent study by Dowden and Blanchette(1999), the authors examined the characteristics of substance abusing women and confirmed what others have observed; that substance abusing women had significantly more problems with associates, attitudes, employment and their marital/family situations. They are, for example, twice as likely to have unstable accommodation in the community; have few skills to manage stress, and they are more likely to have been hospitalized for mental health reasons. We also know that these women have a higher recidivism rate, and that recidivism is significantly reduced when they participate in substance abuse treatment.

Policy

Creating Choices, laid the foundation for all future treatment of women offenders.The key principles set out by the task force (empowerment, meaningful and responsible choices, respect and dignity, supportive environment, and shared responsibility) became the driving force in designing programming for women,including substance abuse. Substance abuse programming was one of four"core" programs developed and made available. CSC has designated core programs as those designed to address "… needs which research has demonstrated to be linked to offending and, therefore… must be made available at all FSW facilities" (Correctional Program Strategy for Federally SentencedWomen, 1994).

Programming

The first national substance abuse program was introduced in 1995 and was delivered in all federal facilities for women. A community component followed in1997. Both programs drew heavily on the Model of Change (Prochaska,DiClemente and Nor cross, 1994) and offered an action oriented and gender based response to women and addiction. A later and more intensive version("Solutions") was piloted regionally in 1998. Since 1995, close to 500 women have participated in these programs across the country.

PROGRAM REVIEW

Expert Panel

In late 1999, CSC asked a group of national and international experts to assess the existing women's substance abuse programs. Informed by the principles set out in Creating Choices, the panel conducted an in-depth review of all three programs available (the institutional, community and intensive pilot). While they agreed that earlier efforts represented an important beginning, they identified concerns with both process and content, and recommended the development of a more comprehensive treatment model. They proposed a design that would ensure that programming be:

• In accord with correctional philosophy with a clear understanding of the role of abstinence within a harm reduction framework;
• Firmly rooted in holistic and gender responsive principles, including relational theory;
• Balanced, incorporating both cognitive learning and therapeutic needs.

Effective treatment, experts urged, must be multi-dimensional, addressing both the intervention (cognitive, affective and behavioural) and the environment (safety, connection and empowerment).

Cognizant of these elements, the panel also stressed the need to:

• Identify relationships between substance abuse and pathways to crime, which differ significantly for women from the offender population generally;
• Emphasize the importance of appropriate referrals and corresponding levels of intervention, including pre and post treatment components;
• Create linkages to other areas of need and programming. This was identified as key to fostering an integrated environment where 'connection' and 'community' set the stage for positive change;
• Train and maintain qualified staff. The panel noted that training and upgrading are integral to effective treatment and program integrity.
• Evaluate effectiveness using a combination of behavioural (recidivism, suspensions, infractions) and personal/emotional variables (self-esteem, post traumatic stress symptoms, depression, changes in health, improved functioning, productive use of leisure time).

Overall, the panel members were emphatic that, in order to maximize treatment efficacy, a substance abuse program must create an environment which permits women an opportunity to integrate information and behaviour within their own life experiences.

CSC accepted the panel's findings and made a decision to develop a new program model for substance abuse. Several members of the panel continue to participate in an advisory capacity for this project to ensure that the latest programming techniques and research findings are incorporated into the program.

A Front Line Response

As a first step, management, program staff, and federally sentenced women in each of the regional facilities were consulted. The women interviewed included those in the early stages of treatment, those who had successfully completed treatment and a number who had returned to custody following a lapse or relapse.Both groups (staff and women) shared their experiences with the existing programs and identified areas of consideration in the design of a new model.This consultation clearly illustrated that many women have benefited from existing substance abuse programming. Equally clear, however, were the gaps not addressed by current treatment.

The following are excerpts from interviews with women offenders. They provide a glimpse into the lives of these women offenders and they also speak to the strengths and weaknesses of programming.

My life was very different before…my partner was abusive and I have a history of abuse. The program helped me to come to terms with my reality…They didn't preach quitting, but pointed out my options

The model of change helped me to take responsibility, to separate the person from the action…The drugs were the tip of the iceberg.

There's a limit to how much you can share here with staff…I need to stay in counseling when I leave.

I didn't know what drugs were doing to my body…

The program is very basic…taking a bath instead of putting a needle in my arm is a joke…let's go deeper.

I started using when I was 12…in residential school…I took on everyone's pain…I'm on a healing journey now…I need to practice…It will take time to sink in.

I hate the role-plays but that's when I really experience stuff…I need a place where I can continue to do this work when I get out.

My husband was dead… I was grateful to cocaine… The program helped but it scratches the surface.

I wish someone had shown me a rotten liver or tracks, when I wasn't high.

Staff needs to understand…they don't know about addiction…My father injected me when I was eight.

When I used I lost weight, then I felt pretty…Women get labeled and we believe it.

I did the program and now I'm back…I thought I'd be safe, but I succumbed to peer pressure… after care is really needed…there should be another component for us when we come back…we're in a different frame of mind.

I wanted to tell my parole officer I was taking Tylenol 3's, but I was afraid.

I am not in programming now…there definitely needs to be something that runs all the time, even a peer led group…life stories really motivate me…There's not much on relationships and how my use affects the people around me.

Their comments echo many of the issues noted by the staff and the expert panel and offer compelling support for a program capable of responding to a wide range of complex issues and needs.

Many of the recommendations made by staff and the women were program specific, while others are directed at the supporting infrastructure. Together, their suggestions serve as a strategic guide in the design of a new model for substance abuse treatment.

Program Direction

The following are recommendations for programming:

• A harm reduction framework for programming is supported, with the understanding that abstinence holds a valid position on this continuum.Abstinence is required in a correctional setting and, for many women with severe or chronic histories of drug and alcohol use, it may be the safest option in the long term. Learning about using in the context of responsible choice is also valuable. It empowers women and is more likely to result in sustained change.
• While current programming strives to be women-centered, it doesn't go far enough. Treatment must be gender responsive in every respect. This cannot be achieved through modification or substitution. Program content should be presented through the experiences of women and expanded to incorporate relevant and critical issues facing women such as infectious disease, fetal alcohol syndrome, trauma, etc.
• Programming was described as "tipped" with therapeutic needs receiving minimal attention. An integrated and multi-modal approach is needed to ensure that both cognitive and therapeutic needs of women offenders are addressed. The debate between these two approaches is seen as counter productive. Both are clearly supported and should be incorporated in a complementary and balanced recovery component. The model of change remains a valued framework and many saw merit in a broader application within the prison culture. Education, pre-treatment and ongoing maintenance(for both incarcerated women and women in the community) are also considered essential and should be added to the treatment continuum.
• Programs are generally delivered in isolation from one another.Communication is difficult and content overlap has been discouraged.Isolation was also identified as a contributing factor in the growing concernregarding prison culture. The new model for substance abuse shouldpromote connection and common purpose with other program areas and, inso doing, encourage a return to the holistic 'healthy community' modeloriginally envisaged in Creating Choices. Enhanced opportunities for peersupport are also seen as important in encouraging program integration andcommunity building.

Supporting Infrastructure

Equally significant were the recommendations made for strengthening the infrastructure:

• Most supported the intent and value of using community agencies in programdelivery, although stability and continuity are real concerns. Strengtheningcommunity supports requires dedicated effort within each institution. Thismust be treated as an ongoing responsibility that not only affects institutionalprogramming, but also directly impacts on effective reintegration.
• Program resources must be protected. Competing priorities should not impacton program delivery. Alternative mechanisms for funding and staffing must bedeveloped to address operational emergencies/demands.
• Timely orientation and training at all levels, from primary workers to seniormanagement, is critical in order to preserve direction and program integrity.
• Research and evaluation are essential components. Despite the challengesassociated with population size, disbursement, etc., initiatives to developgender responsive instruments for assessment and measurement of programimpact are needed.

This consultation offered essential input for the next stage of development inWomen's Substance Abuse Programming. Experts, CSC staff and the women inthe prison system agree on the need for change. Their assessments of existingsubstance abuse programming and recommendations for the future are strikinglysimilar. Of critical importance was the overall endorsement for the developmentof a multi-faceted treatment continuum, one that anchors programming in agender responsive framework and incorporates best practices from credibletheoretical models.

A CONTEXT FOR PROGRAM DESIGN

Community Building - A Systemic Response

As previously noted substance abuse programming is one of four core programs offered in women's prisons. These facilities are unique. They were originallydesigned to reflect the vision and principles put forward in Creating Choicesincluding the development of 'healthy communities' as a means to promotephysical, psychological and personal development.

The framework proposed for substance abuse revisits the concept of community in a deliberate way. What is envisaged is a strengthening of culture or community'milieu' through program enhancement and integration.

Programming Sets the Stage

With substance abuse as the impetus, a dynamic and evolving process is possible - one that moves from a separate collection of programs to a system thatis interdependent. This interdependency, when supported, can create momentumand move programming beyond structure and content to living and experiencing change.

Phase 1: Depicts the core programming 'package' currently available to all women offenders (living skills, survivors of abuse, literacy and substance abuse). Theyare common to all institutions and are relatively constant. They are also viewedas separate and isolated and, at times, are seen as being at cross-purpose.

Phase 2: Depicts a relationship between programs. In this design, programs are integrated and interdependent. Content would intentionally overlap and engagement would occur at many levels. It is the creation of connection between programs that sets the stage for community building.

Phase 3: Describes a fully evolved model where the community milieu itself has become the focal point with integrated and interactive programming operating asa supporting system. Program modules, at this point, have common threads andcan easily be shared across programs.

The fostering of 'connection' with other core programming has the potential to create a shift in culture. Women living in this setting would participate inprogramming with common and integrated themes. They begin to apply newinsights and skills on a personal and social basis and hold each otheraccountable for change and growth. Community integration initiatives, such ascommunity meetings, peer facilitation, shared program content and goals areproposed as a means to extend learning to a community level. Reinforcementwould come from the setting and the setting would ultimately function as a primaryintervention as well as a foundation for all program content.

The model proposed for substance abuse programming (Phase 2) is multidimensional. It incorporates formal and informal support, and it is ongoingintegrated and holistic. By design, the program uses the environment to fosterhealthy responsible living. This stage of development has the potential to leadprogramming and the current prison environments to a greater level ofintervention and effectiveness (Phase 3). This process will take time to evolve.

Community cohesion cannot be imposed. What is offered is a structure that cultivates movement toward this goal.The direction that is proposed is both a program and a process that sets a coursewith much broader implications for programming in general. This model may bephased in over a period of time and it is conceivable that some program modulesmay initially stand alone. What is critical at this juncture, however, is the overallsupport and commitment to the direction proposed.

THEORETICAL INFLUENCES

There are many theoretical influences supporting the proposed substance abuse program. No one theory stands alone as the answer to understanding andresponding to substance abuse issues for women offenders. To quote onemanager, "…is the richness of the blend that makes for best practices". Sometheories are specific to substance abuse while others offer a frame of referencefor understanding women and their development. Substance abuse programmingwill continue to draw from current models used in motivating and maintainingchange, whether it's at the very early stages of problem recognition or later onwhen a lapse has occurred. Clearly, one of the most important challenges will beenhancing our current focus on thinking and behaviour to include a therapeuticresponse to issues of emotion and trauma as they relate to women and substanceabuse.

The following offers a brief description of some of the prominent theories and their relevance to this population. It is not an exhaustive list, but may provide a betterunderstanding of the importance of adopting an integrated theoretical framework.

Harm Reduction

Fundamental to this mix is harm reduction. While more of a conceptual framework, harm reduction incorporates many theories. Essentially, harm reduction promotes reducing the adverse consequences of alcohol and drug use.The principle feature of this approach consists of understanding that, for some,life long abstinence is not a reasonable or practical goal. While it may be as instituational requirement for women offenders, learning about strategies to reduce use, or reduce the harm associated with use, is both relevant and empowering.As noted earlier, for some women, abstinence may well be the recommended long- term option (and current legal requirement). For others, the need to eliminate crack cocaine from their lives is critical, but it is possible that they, for example, could drink socially at some later point in their lives. Given its fundamental focus on responsible choice, harm reduction resonates well with core programming principles.

Cognitive and Emotive Interface

An integrated design is essential. Substance abuse programming must strengthen cognitive-based learning and provide an intensive therapeutic forumwhere women can address emotional issues associated with addiction. Ratherthan treating these as independent references, this model proposes acomplementary approach.

Cognitive behavioural programming is well known in correctional programming and has been proven to be very effective in modifying thinking and behaviourpatterns. Offenders acquire critical skills in problem solving, decision making,rational thinking, etc. These programs and techniques are equally valuable forwomen. Many of the offenders interviewed commented on changes in theirthought process and the importance of practicing new skills. They also referred toa different need, "…a need to go deeper". Women talk about using drugs andalcohol in the context of coping with emotional pain, abuse, trauma, relationships,parenting and grief. Responding to these issues requires a more intensiveprocess, and is most effective when offered in a trusted supportive setting withtrained counselors or clinicians. Also significant were the comments from womenreferring to body image, socialization and numerous other gender specific issues.Interventions will need to incorporate elements of both cognitive-behavioural andtherapeutic approaches to effectively respond to these areas.

Relational Theory

In recent years, there has been extensive conceptual work on women'sdevelopment. In fact, some have suggested that new constructs, such as self-inrelation theory (or relational theory) have rewritten the book on humandevelopment (Miller, 1986, and Jordan et al, 1991). Relational theory is a way oflooking at gender differences in the experience and construction of self. Forwomen, the primary experience of self is relational; that is, the self is organizedand developed in the context of relationships. This is very different fromtraditional male models of development, which focus on autonomy, separationand independence. For women, building and maintaining "connection" is asource of strength. Relational theory, experts suggest, must be evident in everyaspect of programming.

The Model of Change

The model of change, developed by Prochaska, DiClemente and Norcross, has had enormous influence in the design of substance abuse treatment. It has alsohad many other successful applications in areas such as smoking, eatingdisorders, treating anxiety and depression, and is now being used more broadly incommunity development and organizational change. Essentially, this modeloffers a framework for working with those who are ready for change and thosewho are not. Using the six "stages" (precontemplation, contemplation,preparation, action, maintenance and termination), facilitators match theirintervention to the appropriate stage. Motivational interviewing is a particularlyimportant tool in working with this model. Women offenders who routinelyreferred to "needing to be ready" or "needing to be motivated" illustrate therelevance of this approach. This model is fundamental to the existing women'ssubstance abuse program and will continue to play a prominent role in thedevelopment of new programming.

Other theoretical references will come into play in relation to specific issues.What is clear is that comprehensive programming must respond to a multiplicity ofneeds in a way that includes cognitive, affective and behavioural interventionswhile creating an environment that is safe and empowering.

SUBSTANCE ABUSE PROGRAM MODEL

The following outline was drafted earlier this year in consultation with the programadvisory committee. It reflects the direction already outlined and attempts tocreate connection between the specifics of program content and the broaderenvironment of the institution.

Purpose

In keeping with the spirit and intent of Creating Choices, the proposed purpose ofthe Women's Substance Abuse Treatment Program is:To empower women to make healthylifestyle choices through the experienceof a comprehensive, integrated,and gender responsive program for recovery

Principles

The following principles were drafted in response to issues and concerns thatcame to the forefront during consultations with institutional management, programstaff and women offenders interviewed. They are divided into three areas: 1)operating, 2) delivery and 3) management and support and are intended to guideprogram efforts at all levels of design, implementation, and evaluation.

1. Program Operating Principles

• Treatment is most effective when offered in a positive community milieu;
• Content, culture, and context must be gender responsive - relating to women's lives in meaningful way;
• Substance Abuse treatment must be responsive to changing needs (detox, education, treatment, transition, continuing care). Some form of treatment needs to be available at all times;
• Access to service & support should be immediate;
• Drug and alcohol education should be offered to the entire population;
• Mutual/peer support plays a critical role in recovery and should be formally incorporated in a treatment continuum
• Linkages to criminal behaviour must be evident in all aspects of programming.

2. Program Delivery

• Reaffirm community role as a valued investment in program delivery, recognizing that there may be justifiable limitations or restrictions;
• Contracting process should be reviewed to promote ease and flexibility of use;
• Gender matching of facilitators is essential in ensuring program integrity;
• Expertise in treating addiction, women's issues, and corrections are essential prerequisites for facilitation (as a minimum, an undergraduate degree or its equivalent is recommended);

3. Program Management and Support

• Program resources must be dedicated to ensure continuous delivery;
• Training needs are ongoing and must include orientation for all staff;
• Program integration/interface is essential to foster a holistic response;
• Program criteria/eligibility must include gender responsive assessment instruments;
• Leadership, coordination, evaluation and feedback are essential to ensure commitment and credibility.

Program Structure

The following diagram outlines the proposed structure for substance abuse programming including the core components available to women throughout their sentences. It also incorporates a relationship or linkage with other activities outside the formal program. This integration represents the proposed direction for fostering community building through programming, or the merging of intervention and environment.

Program Coordination: Most institutions have mechanisms in place to address program coordination. Many have created innovative opportunities to enhance communication and support. It is recommended that these initiatives be formally identified and enhanced wherever possible. The importance of this role cannot be overstated. Community building, as described, hinges on program integration.Strengthening this role will be critical to the success of the broader direction proposed.

Program Components

Initial Engagement: Connections made within the first 48-72 hours are critical in fostering positive change. Contact at this stage will set the tone for future interventions. This is an opportune time to provide support and information. It is also an important strategy for maintaining a positive milieu. Using positive peer support either independently or in partnership with staff is recommended. Women Peer Support Group (Open to all)Transition - 4 SessionsCommunity Meetings - not specific to program who have completed treatment and are deemed appropriate would be selected for this role.

Newly admitted women may have detox needs, but are often reluctant to admit this. This model proposes that opportunities to detox be openly supported and linked with substance abuse programming. It also acknowledges that women may have lapses or relapses during their sentence. It is recommended that these circumstances not automatically result in segregation or dismissal from the program. This, in fact, may be a critical time for insight into the addictive cycle.

Detoxification: Although this is not part of the formal mandate for substance abuse programming, it is proposed that a protocol be established in partnership with health services to address this need in a supportive and consistent manner.

Education and Pre-treatment: This component will be offered to all women entering the institution. Research tells us that the majority of women offenders experience problems related to substance abuse. While they may not all have a severe addiction, they will still benefit from education in this area as well as the broad range of issues associated with drug and alcohol use. For example, women involved in trafficking frequently note their lack of knowledge/awareness regarding the impact of using. Others refer to addiction in their families(parents/spouses/siblings/children) and the influence this has had in their lives.

This component offers many opportunities for motivational interviewing and pre-treatment activity. For some, this may be the extent of their exposure to formal substance abuse programming; these women will have increased their awareness and coping skills generally. The added benefit, however, is their understanding ofthe challenges faced by those requiring intensive treatment. This exposure has the potential to positively affect a supportive peer culture.

With drug and alcohol education as the central thread, important linkages will be made with health services. This inclusion is in response to growing concern regarding infectious disease, pregnancy, FAS/FAE, medication, etc. It is also based on institutional feedback regarding safety and prevention. Here again, efforts will be made to incorporate peer support and self- management tools.

All women would receive information and assessment materials for the intensive recovery program prior to completing the education and pre-treatment component

Assessment and Evaluation: This comprehensive package would be utilized to: a)determine eligibility and b) assess program effectiveness/satisfaction. Selected portions of this package, i.e. severity testing, would be interchangeable between phases while others will be phase specific.

Instruments/tools with gender responsive validation would be utilized wherever possible to determine: motivation, readiness to change, severity, using patterns and problems/consequences associated with use, and responsivity.

Some instruments will be self-administered during the Drug & Alcohol Education component thereby increasing the mutuality of this process. Assuming the timeframe is reasonable, i.e. no more than 60 days, these tests would not need to be repeated.

Structured interviews and pre- and post-testing (at the beginning and ending of each program component) will be designed to ensure that the women are participants in this process and given feedback/rationale for all program decisions.Client satisfaction measures will be included. The assessment process will strive to be concise and avoid duplication and testing that is not directly relevant to the program.

Therapeutic Intensive: This is the core treatment component. Women would be referred to this module following completion of drug & alcohol education and a comprehensive assessment of severity and treatment readiness. Using best practices and a combined theoretical framework, treatment would consist of two related and complementary groups - one process group oriented in relational theory and a second psycho-educational group utilizing a cognitive behavioural approach (See Theoretical Influences).

1. An Emotive group would address underlying clinical issues related to addiction, i.e. self-awareness, relationships, communication, parenting, traumaetc. This group operates on the premise that women drink and/or use to deal with their emotional lives and that recovery must be based in safety, connection and empowerment. Individual counseling would be available on a weekly basis as a supplementary support. While some content may resemble that covered in other programs, it would be addressed in the context of substance abuse.
   
2. A cognitive behavioural group would focus on motivation and change. Using cognitive behavioural techniques, structured focus groups would concentrate on skill building with particular attention to goal setting, problem solving, decision making and relapse prevention. Exercises would ensure a balance between theory and practice. Structured individual sessions would be offered at appropriate intervals for education/assessment purposes.

The two groups would ideally be offered in parallel with related content and goals.This construct offers an ideal opportunity to address related needs on multiple levels.

Continuing Support (Maintenance): The need to provide ongoing support following treatment is well documented in relapse prevention literature. Women who return to drug or alcohol use, with rare exception, reference the slippage that occurs once formal treatment ends. Where maintenance programs have been offered in institutions, they have had defined timeframes and frequently end long before the woman's release, leaving her without formal support at an extremely high-risk period for relapse. Similar problems occur post release when attempting to access community programs. Women are either on long waiting lists or forced to participate in programs that are co-ed and frequently inconsistent with the institutional model.

continuous maintenance program is proposed that would follow the treatment component and continue throughout the woman's sentence (in the institution and in the community). It would be an open group with structured content drawing from both the therapeutic and the cognitive components.

Co-facilitation is proposed with staff working with women who have completed the program and who have been identified as appropriate. Ideally women serving longer sentences may offer greater continuity and leadership. These women would then be considered for facilitation of the peer support group described later.

This program is ideally delivered in a group format, but could also be given on an individual basis. When the woman returns to the community, she would continue in the same program, either in a group or on an individual basis (should there be difficulties in establishing a group). Where it is possible, co-facilitation from the parole population is recommended. The immediacy of support is a key feature of this component.

Establishing community groups has historically been problematic due to the relatively small number of women. It is possible, however, that the ongoing structure of the proposed group would alleviate the group size issue associated with sequential groups.

Transition: In addition to the maintenance group, a series of pre-release sessions is recommended for the four weeks prior to release. These individual sessions will provide a booster at a particularly critical and anxious time. As noted earlier, this period is typically high risk for relapse.

Peer Support: A peer support (substance abuse) group will promote leadership, mutual support and self-management strategies. It will complement the staffed program and promote a support network for the women outside structured program times. In so doing, this group has enormous potential to reinforce a positive community culture.

The peer support group would be available on an ongoing basis for all women with substance abuse issues -- a "drop-in" venue with a defined cycle of materials and resources. Women who have completed the core program and have cofacilitated the maintenance component would be appropriate candidates to consider as facilitators for this group. Training and supervision are essential components for peer support activities. **It may be helpful to provide formal training for a select number of women offenders in the pilot or post pilot phase of this program. Linkages to the broader peer support program will be explored in the ongoing development of this module.

Community Meetings: While this component falls outside the formal structure of the substance abuse program, this concept is being proposed in an effort to promote a positive milieu. It is a critical component in the plan to address context. The concept of 'healthy community ' would be the focus of meetings that should be held no less than monthly. Ideally, a brief weekly forum for staff and women to reinforce community values, recognize and celebrate achievements, engage in mutual help exercises etc. would reinforce common purpose, and enhance communication. These meetings are designed to offer positive support and their use as a forum for complaints should be discouraged. This deviation could undermine their intent and contribute to a conflicted and power-based culture. Community meetings are intended as an extension of the broader interest in integrated programming and community building.

NEXT STEPS

Using this comprehensive framework, the development of detailed content in each of the modules will be contracted out. A regional pilot is planned for early in the new year with a second meeting with the advisory committee is scheduled for the fall to review the full program. A second national pilot scheduled for Fall, 2002.A parallel process will also be necessary to address implications related to the supporting infrastructure, i.e. training, contracting, and program coordination.Discussion and collaboration with both mental health and health services will be important as well. Small task specific working groups will be established over the next few months to develop each of these areas further.As previously noted, there may be other similar initiatives such as the EffectiveCommunity Strategy where goals can be merged or integrated in some way.