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Many schools attempted to forge a systematic response to growing alcohol and drug-related problems in the 1960s and early 1970s. At their best, these responses combined primary prevention and early intervention activities with strong linkages to adolescent treatment resources and the development of school-based recovery supports during and following treatment. In the mid-1970s, these activities were integrated within a growing network of student assistance programs (SAPs) which have:
• evolved into a professional field (via the National Student Assistance Association)
• developed different models for delivering SA services (e.g., core team model, in-house counselor model, external SAP model, eclectic model) (Love, 2005)
• extended their focus from alcohol and drugs to an ever-widening net of student problems
• expanded from high schools to middle and elementary schools
• moved towards a philosophy of evidence-based practice (Ferlman, Tarasevich, & Helper, 2003).
A growing body of research on adolescent substance use underscores the importance of SAPs and their collaboration with community-based treatment agencies. Studies revealing that early age of onset of substance use increases the risks for developing severe substance use disorders dramatize the importance of school-based programs that can prevent or postpone substance exposure (Grant & Dawson, 1997). The finding that an intervention at an early age can shorten an addiction career confirms the importance of early intervention services (Dennis, Scott, & Funk, 2005). Equally important are findings of effective, manual-guided therapies for the treatment of adolescent substance use disorders (Dennis, Godley et al., 2004) and that assertive post-treatment monitoring and support elevate long-term adolescent recovery outcomes (Godley, Godley, Dennis, Funk, & Passetti, 2002).
Rigorous evaluations of the effectiveness of SAP programs have been limited, but more recently NIH funded studies have tested interventions designed for this setting (Wagner, Tubman, & Gil, 2004; Winters & Leitten, in press). One model of delivering SAP services involves a collaborative partnership with a community-based treatment program and local schools that utilize evidenced-based interventions to enhance the continuum of care for adolescents in the school and the community. To illustrate the process and outcomes of this type of collaboration, this article will describe the implementation and evaluation of an external SAP that combines the resources of a community-based prevention and treatment agency with 23 schools and note the implications of these findings for addiction counselors.
Overview of the services
Chestnut Health Systems, a community-based behavioral health care provider in Illinois, has provided student assistance services to schools on a contractual basis since 1985. In the Central Illinois region, this service has grown to 11 SAP staff serving four elementary schools, nine junior high schools, and 10 senior high schools. Traditionally, the types of services provided included crisis intervention, screening and assessment, referral for mental health or alcohol or other drug problems, facilitation of support groups, class presentations, consultations with teachers, staff, and parents, and brief interventions.
However, there was not standardization for the screening and assessment activities or for the brief interventions, nor was there training or supervision in the use of a specific screening instrument or intervention model. A federal grant from the Center for Substance Abuse Treatment provided the impetus to introduce more standardized, evidence-based practices.
Screening. The first activity to be standardized across all junior and senior high schools was the use of the Global Appraisal of Individual Needs-Quick (GAIN-Q; Titus & Dennis, 2005), a screener that takes 20 to 30 minutes. One of the qualities of the GAIN-Q that SAP counselors like is that it not only screens for substance use, but also for other behavioral health problems including depression, ADHD, and sources of stress. Most SAP staff use an electronic version that generates a narrative referral andrecommendation summary from the screening data. Possible screening recommendations include: a longer, more detailed assessment; a brief intervention; or other possible referrals to consider. For adolescents who endorse substance use during the screening, a Reasons for Quitting Scale (RFQ) is also administered so that the answers can be used later in the brief intervention. See http://www.chestnut.org/LI/gain/GAIN_Q/index.html for more information about the GAIN-Q.
One of the first challenges staff raised during implementation of the GAIN-Q was determining which students would be screened. Students served by SAPs run the gamut from those stressed out because they cannot find their locker to those who are suicidal. SAP counselors were concerned about possibly providing more screening services than needed for a student who had a relatively minor crisis or making a student sit through a 20-minute screening when he or she was in a serious crisis situation. The planning team decided a student had to be seen at least two times to warrant use of the screener. This approach allows for a later screening of those students who are in a major crisis during their initial referral. During the most recent school year, 443 GAIN-Qs were completed in the 23 schools served by Chestnut SAP counselors.
Intervention. When a student reveals substance use and associated problems, there are two possible recommendations. Those students with little use or associated problems are asked to participate in a five-session Motivational Enhancement Therapy/Cognitive Behavior Therapy (MET/CBT5) at the school with the SAP counselor. If the reported problems are more severe, the student is referred for an in-depth assessment at the school or at a treatment facility to determine if more intensive treatment is warranted. In most situations, parents are not aware that a student has been referred to or screened by SAP. In the case of a comprehensive assessment, students are told that their parents will be informed and this, along with a reluctance to participate in traditional treatment, leads many students to opt out of the more comprehensive assessment. If students refuse further evaluation, they are then approached about participating in the brief intervention. Support for this approach is based on research suggesting that brief motivational enhancement approaches can in and of themselves be effective treatment or have the potential to move the adolescent along the stages of change continuum, so that he or she may be more open to longer and more intensive treatment at a later time.
MET/CBT5 is a manual-guided approach (Sampl & Kadden, 2001) that was evaluated in the Cannabis Youth Treatment study (Dennis, Godley et al., 2004) and found to be effective at reducing substance use and problems. The manual describes group delivery of the CBT portion of the intervention, but in the SAP application, it is provided in individual sessions. SAP counselors vary time frames for each session as needed to fit with school schedules and add additional sessions if needed to cover the necessary material.
The first session is designed to develop rapport with the student, build motivation, provide educational material, and review the personalized feedback report produced during the screening interview. During the second session, the SAP counselor works with the student to set goals and guides the student through a functional analysis of his or her alcohol or drug use. During the subsequent three sessions, students are taught refusal skills, how to enhance their social support, and coping with high-risk situations. After explaining each skill, the student is asked to practice it in session and to complete some mutually-agreed upon practice in a real life situation before meeting with the SAP counselor. Throughout all five sessions, the SAP counselor is expected to use the five strategies of MET: Expressing empathy, developing discrepancy, avoiding argumentation, rolling with resistance, and supporting self-efficacy.
Check-In Sessions After MET/CBT5. During the first year of implementation, SAP counselors raised a concern about students who completed the five-session intervention and were still unwilling to quit using alcohol or other drugs or attend further treatment at a treatment agency. To address this situation, a post-counseling check-in procedure was developed. There is a greater likelihood of compliance with continuing care in a school setting than in a traditional clinic. When students complete MET/CBT5, SAP counselors schedule check-in appointments at least once per month for three months. More frequent appointments are scheduled if the SAP counselor determines that increased contact is needed. For students who are invited to participate in MET/CBT5 and stop attending sessions before they complete the intervention, SAP counselors schedule at least one check-in appointment during the three months after the student stops attending MET/CBT5. For all students identified with alcohol and drug concerns, the SAP counselor schedules a check-in appointment at the beginning of the next school year and completes a GAIN-Q rescreening annually.
During the check-in session, the SAP counselor administers the Happiness Scale (HS) from the Adolescent Community Reinforcement Approach Cannabis Youth Treatment manual (Godley et al., 2001). The HS is a one-page form that covers 16 life areas (e.g., substance use/non-use, school, relationships with friends) that students rate on a one-to-ten scale indicating their degree of satisfaction with each dimension. The HS helps communicate a holistic interest in the student (not just in substance use) and provides an easy entrée into different areas of his or her life. SAP counselors review the HS with each student and work to develop goals.
Continuing Care for Students in or Discharged from Treatment. Students also need support or continuing care services when they are attending or have been discharged from treatment. One of the advantages of the CSAT-funded grant was that an electronic clinical and case management record was developed, allowing electronic notification to an SAP counselor when a student attending his or her school is discharged from treatment.
This system also allows the SAP counselor to view the student’s progress during treatment. Since the SAP counselor is aware of a student’s participation in or discharge from treatment, he or she can call the student for a check-in session and see him or her as often as needed using the HS and other MET/CBT procedures. These students are also scheduled for annual screenings with the GAIN-Q.
Staff training and monitoring
The transfer of evidence-based practices from controlled studies to implementation in applied settings is challenging and requires investing resources in staff training, certification, and ongoing monitoring. The first and foremost barrier is resistance to change existing SAP service delivery methods. The first step in overcoming this resistance is to provide an explanation outlining the reasoning for proposed changes and data supporting the new approach. There are also advantages to a gradual implementation of new procedures. The three-year implementation process used at Chestnut provided the opportunity for those who were trained first to spread their new knowledge and enthusiasm to those who were trained later.
SAP counselors’ competency in administering the GAIN-Q and delivering MET/CBT5 was achieved through training, certification, and supervision. GAIN-Q training was based on the GAIN Coordinating Center requirements, which involve training, practice with feedback, taped administrations reviewed by quality assurance specialists who give written feedback until certification is attained, followed by periodic taped reviews. A similar process is employed for training and monitoring staff in MET/CBT5. After training by an expert in MET/CBT, SAP counselors are required to tape sessions (with students’ permission) for review by the supervisor. SAP counselors also use session check sheets from the intervention manual as a means of self-feedback to ensure they are following procedures. As with the GAIN-Q, once SAP counselors are certified in the use of MET/CBT5, the frequency of tape review is reduced. Another aspect of weekly supervision is the examination of each SAP counselor’s ‘case review log’, which provides a row for each student and shows starting date, number of sessions, and a column for each MET/CBT procedure. This log allows clinical supervisors to quickly assess the status of every student receiving MET/CBT. Group supervision is also provided twice a month so that counselors can learn through a group tape review process and discuss common issues.
To ensure that SAP program managers know each individual and school’s level of implementation, it is necessary to collect performance indicator data on both the screening and assessment process by the SAP counselor and school. Indicators include: type of SAP referral (new, call back by the counselor, walk-in, from the treatment agency); reasons for referral; placement recommendations; number referred and completed for a more in-depth assessment; average number of days from referral to completed GAIN-Q; and number beginning and completing MET/CBT5. Pre- and post-outcome data are also collected using the GAIN-Q to guide program improvement. For example, in the first year, outcome findings suggested that the percentage of students reporting marijuana use decreased after the intervention, while there was an increase in the percentage of MET/CBT students who reported binge drinking. This finding suggested the need for SAP counselors to focus more of their attention and the educational materials on alcohol and binge drinking.
Working with the schools
School district superintendents and school personnel like the standardized screening and the manual-guided intervention because they are similar to professional tools they use (e.g., standardized tests and curriculum). In the beginning, presentations were made as requested to school boards, superintendents, and school counseling and social work teams to describe the planned changes in the SAP program. Last year, a major emphasis was to ask all the school districts in the county to consider adopting similar policies for alcohol and drug infractions that would encourage student participation in the intervention for those who need it. The proposed policy included a reduction in suspension time if the student participated in the GAIN-Q screening and MET/CBT5, and the parent(s) met with the SAP counselor at the beginning and the end of the process.
Lessons learned
One of the advantages of using the GAIN-Q is that it provides data that can be used for program improvement. As compared to adolescents seen in outpatient treatment (n=75), those seen in the school settings (n=61) were significantly more likely to be female (54 percent vs. 29 percent) and younger (41 percent vs. 15 percent under age 15), while adolescents seen in treatment are more likely to be have been arrested in the past year (62 percent vs. 12 percent) and African American. There were no significant differences with regard to prior treatment for a substance use disorder in the past year.
These data provide support that services in schools offer the possibility for earlier intervention.
Outcomes have been evaluated to the extent possible with pre- post- data analysis (Figure 1). Student’s initial GAIN-Qs are used as pre-tests and their post-tests are a follow-up version of the GAIN-Q (administered by research assistants to reduce respondent bias) 90 days or more after their screening. When combining the data across three years of implementation, there are significant decreases in the percentage of these students reporting any alcohol, marijuana, and other drug use.
SAPs and the addictions professional
This brief summary of the contractual delivery of SAP services by a community-based treatment agency underscores the growing role addiction professionals are playing in the delivery of school-based early intervention and post-treatment support services to substance-involved adolescents. This work is being guided around the country by new models of institutional collaboration, more effective screening instruments, the integration of evidence-based and manual-guided intervention protocol, and a commitment to the continued evaluation and improvement of school-based early intervention and support services. We envision a future in which addictions professionals will play an increasingly important role in the design and delivery of such services and the ongoing refinement of these interventions to create even more potent effects.
Acknowledgements
The authors would like to acknowledge the Student Assistance Program staff of Chestnut Health Systems and the many school districts, superintendents, and school administrators in Central Illinois who have helped make this a successful collaboration. In particular, we would like to acknowledge the contributions of Loree Adams, Bruce Boeck, Rod Funk, Mychele Kenney, Lora Passetti, Rick Risberg, Kimi Schroeder, and Kelli Wright for their leadership during implementation, data collection, and analysis.
Preparation of this manuscript was supported by funding from the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, and the U.S. Department of Health and Human Services through the SCY grant (Grant No. TI13356).
Susan Godley, RhD (
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
) is a Senior Research Scientist at Chestnut Health Systems.
William L. White, MA is a Senior Research Consultant at Chestnut Health Systems and the author of Slaying the Dragon: the History of Addiction Treatment and Recovery in America.
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This article is published in Counselor,The Magazine for Addiction Professionals, April 2006, v.7, n.2, pp.66-70.
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