continued from page 3

substance abuse issues. In addition to supporting the plan to integrate such services within the primary health care clinics, Mr. Curie observes that such a system also provides an opportunity for the Iraqis to build a community-based mental health system of care from the ground up.

The specifics of a possible SAMHSA plan to assist the Iraqis are still to be determined. However, SAMHSA is focusing on expanding the capacity of Iraqi health care service providers to assess mental health and substance abuse and on enhancing training for primary care physicians as well as psychologists, social workers, nurses, and health care aides. SAMHSA is considering the possibility of funding a mental health expert to assist the Iraqi behavioral health care task force.

"It's essential that this individual speak Arabic fluently, and understand Arabic and Moslem culture and concepts of mental

"All people-whether American or Iraqi― seek lives with jobs,

homes, and meaningful

relationships."

-Charles G. Curie, M.A., A.C.S.W. SAMHSA Administrator

health," Mr. Curie says. "We must engage the Iraqis by approaching them in a culturally sensitive way that includes the ability to connect with tribal and faith-based leaders."

As a second phase, Mr. Curie suggests, SAMHSA officials are exploring with mental health authorities in England and New Zealand the possibility of sending a team of staff from all three countries to Iraq to provide hands-on consultation and technical assistance.

"Both England and New Zealand are aligned around the same recovery model of mental health that is growing here in the United States," Mr. Curie says. "The recovery model recognizes that people with mental and substance use disorders can and do recover, and encourages the use of practices that are evidence-based and consumerdriven. Our efforts may be better received by the Iraqis if offered through a team that is international in scope."

Priority populations for treatment include individuals with serious mental illness in particular, women and children--and Iraqi victims of torture.

Efforts will also address the mental health needs of the general population, still profoundly traumatized.

"On my visit, I was reminded of the universality of human needs," Mr. Curie said. "Fundamentally, all people-whether American or Iraqi-seek lives with jobs, homes, and meaningful relationships with family and friends, all of which contribute to a sense of stability and fulfillment. We want to communicate to the Iraqi people that the United States supports them as they strive for a better life."D

-By Deborah Goodman

Photos of Iraqi citizens, on pages 1, 2, and 4, courtesy of U.S. Agency for International Development (USAID) Web site at www.usaid.gov/iraq/photogallery. Thomas Hartwell and Debbi Morello, photographers.

Everyone who's ever bought a new

appliance has used a manual, one of those indispensable guides to finding out, step-bystep, how something should be done. But few people associate a book of detailed instructions with a process as sensitive and complex as substance abuse treatment. Now, however, service providers throughout the Nation are using a set of manuals developed and tested in projects funded by SAMHSA'S Center for Substance Abuse Treatment (CSAT) aimed at developing evidence-based care for adolescents using marijuana.

The five volumes of the Cannabis Youth Treatment (CYT) Series far exceed the ordinary run of instruction booklets. Each is based on a treatment approach specifically designed for use with adolescents.

A 3-year study beginning in 1997 found that the methods described in the manuals produced "statistically significant treatment outcome results" that were "better than many of the treatments being used at that time," says Jean Donaldson, M.A., who served as the CSAT project officer. (See SAMHSA News, Spring 2001.) A just-completed, 30-month followup study has confirmed "significant post-treatment improvement" among adolescents, according to a forthcoming article based on those results in the Journal of Substance Abuse Treatment.

The CYT manuals are part of SAMHSA's Science to Services Initiative, which seeks to foster the adoption of effective, evidencebased interventions gleaned from research into routine clinical practice, and then strengthen feedback from the services community to inform research. In keeping with these goals, the CYT manuals are now being distributed nationally.

The treatment methods in the CYT manuals depart from former practices in two important respects. First, each volume

details a specific multi-part intervention and then guides service providers through its various tasks and sessions (see SAMHSA News, p. 7). Second, the manual-based interventions all build on a foundation of formal approaches including motivational enhancement therapy, cognitive behavioral therapy, and other models. Unlike more eclectic models traditionally used in many agencies, the CYT interventions specifically focused on equipping adolescents and their families with methods for stopping and preventing use and coping with relapse.

In an informal effort to gauge the effects of the manuals on real-life practices, SAMHSA News spoke with front-line treatment providers who use the manuals in a variety

of settings. Their comments cover many aspects of the change to CYT. To begin with, they find CYT-based approaches less confrontational than much of traditional substance abuse treatment.

"I hate confronting these kids," says Tina Long, a case manager at Sojourner Recovery Services in Hamilton, OH. "We don't counsel anybody else that way. There's no reason to counsel a person with substance abuse that way."

This change requires that service providers become "convinced that they don't really have to confront resistance," says psychologist Win Turner, Ph.D., a project director for the New England Institute of Addiction Studies. Dr. Turner has trained and continued on page 6

continued from page 5

helped supervise the implementation of CYT Volume 1 at community treatment agencies across Vermont. "When people first do motivational enhancement therapy, they think that if the client says, 'I'm not ready to give this up,' that you have to convince them to change. But you say, 'I hear you, you're not ready to quit. Perhaps we could talk about what brought you here.' The idea is to roll with resistance and to listen more, so the client feels understood."

Another difference is that cognitive behavioral therapy calls for "practicing what seem to be rote exercises," Dr. Turner continues.

"That can seem trivial... but it becomes very significant" over time. With experience, service providers learn that "teaching a skill [needed to prevent or stop use] is just as important as talking about how I feel," says Julia Hemphill, a counselor at Operation PAR in St. Petersburg, FL.

The detailed structure laid out in the manuals is also new to many service providers. "People think that service providers are going to hate these manuals, but in fact they find that it makes their working environment a learning environment," Dr. Turner says.

Ms. Long finds the structure very helpful. "I don't walk into a session ever feeling unprepared. If any situation arises, I have got a procedure to deal with it. And it's gone through tests to know that it's going to work."

Thanks to the manual, Ms. Hemphill adds, "you don't have to do your own research or put it together yourself."

The detailed progression of topics, however, does more than save time for service providers and build their confidence. It also gives them "a way to bring up a subject without pointing the finger," says Matt Hassler, M.S.W., another Operation PAR counselor. Sessions have "a structure that clients don't have to take personally. That means clients can choose if they want to talk about a topic."

That predetermined structure, however, makes some service providers "feel like occasionally I lose a little on the creativity side," Mr. Hassler says.

At the beginning, "the assumption is that the curriculum is a rigid entity," Dr. Turner notes. "But that's not true. It is always advisable to follow along and learn the manual as it stands. Once you feel you have a sound understanding, you can then apply it in a different way, as long as the

essential components are left intact."

"You learn the principles, but as to how you implement the principles, you have a good bit of flexibility," agrees Reginald Simmons, Ph.D., of the Connecticut Division of Children and Families, who is coordinating the use of four CYT curricula in Hartford. "You're not really in lockstep like a robot. It still takes a skilled clinician who is a good therapist to know how to implement the principles. There's a great deal of creativity that can be exercised."

Mr. Hassler agrees. "Even within the boundaries of the manual, I can be really creative," he says. In fact, he finds creativity essential because "there has to be some adaptation" of the manual to each particular case as well as "little tweaks for personal style."

Service providers agree that the manuals afford plenty of leeway to meet a client's particular needs. "I find it very flexible," says Ms. Long. "It puts you on the right track and shows the frame of mind you need to be in" to deal with particular situations.

For example, in a rural state like Vermont, Dr. Turner says, "we don't have big groups of people coming in at one time." Elements of the program originally designed for groups "can be done for individuals as well.'

Some service providers find the adjustment to this way of working straightforward. "I'm a manual reader," says Ms. Long. "I read those VCR manuals. I went through the CYT manual and read everything. Each of the sections gives you a little synopsis of how to talk." But, she notes, "Somebody who's been in the substance abuse field and is used to a confrontational style, when given this manual, is going to be really challenged to change their approach." For some service providers, learning to do the manual-based treatment involves "cognitive dissonance," Dr. Turner says. "You're used to having very fluid conversations, so when you're first learning

manual-based treatment, it seems awkward.

The more you work with the manual,
though, you can fit it into your own scripts
that you've had with clients anyway. If you're
doing motivational therapy, there are four or
five skills that you need to learn and hone. If
you're doing cognitive-behavioral therapy,
you provide an activity, go over

a skill, and then rehearse it. Those
foundational elements are not awkward
once you integrate them. But it takes
a little while."

Adjusting to doing manual-based
interventions is "really about practice,"
Ms. Long agrees. "I've probably done
50 functional analyses of substance abuse
as outlined in one of the manuals, and
every time I do it, I learn something new
about a client and I learn something new
about the procedure."

The challenge that service providers face in learning a new way to work is "a parallel process" to what clients experience trying to break out of behavior patterns, Dr. Turner continues. For clinical supervision, "that's a beautiful metaphor. Implementing the manuals and practicing new clinical skills puts clinicians in the experience of change. This moves them a little closer to the client" who is attempting a fundamental change that is "much more intense."

Manual-based therapy has benefits for the field as a whole as well as for individual service providers. "It tries to make treatment consistent," says Dr. Turner. The CYT curricula give a common "template" to service providers who have "come into the substance abuse field from all avenues of training."

Historically, the substance abuse field has had "an inadequate amount of quality assurance," adds Dr. Simmons. "What are therapists doing? How do they know it even works? You hear therapists say, 'Oh, this just feels good.' How do you know?" he asks. But "a manual-based intervention that has been shown to be effective... allows you to really assess what a therapist is doing and how that relates to outcome."

Each of the five volumes in the Cannabis Youth Treatment Series highlights a different approach to treating teen users of marijuana:

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy for Adolescent Cannabis Users: 5 Sessions, Volume 1 (158 pages). NCADI number BKD384.

The Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions of Cognitive Behavioral Therapy for Adolescent Cannabis Users, Volume 2 (162 pages). NCADI number BKD385.

Family Support Network for Adolescent Cannabis Users, Volume 3 (148 pages). NCADI number BKD386.

In addition, "a manual-based approach really helps you to think about what you are doing," Dr. Simmons continues. By forcing service providers "to really plan their work, it gives a platform to evaluate your work." The CYT manuals also permit the program in Hartford to use "a treatment-matching process including comprehensive assessment to help determine what treatment each kid should receive." The availability of several "evidence-based interventions that have been shown to work allows us to really match the treatments to the population."

The CYT manuals are not perfect, however. The treatment providers suggest several ways in which future manuals could be improved. These manuals "have to be updated periodically" to match changing times, Mr. Hassler notes. Ms. Long would like to see some advice for young therapists like herself on "building rapport with parents."

Dr. Turner suggests clinicians need "a short introduction to the process of adopting

The Adolescent Community Reinforcement Approach for Adolescent Cannabis Users, Volume 4 (252 pages). NCADI number BKD387.

Multidimensional Family Therapy for Adolescent Cannabis Users, Volume 5 (242 pages). NCADI number BKD388.

To order copies of these manuals, contact SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI) at P.O. Box 2345, Rockville, MD 20847-2345. Telephone: 1 (800) 729-6686 (English and Spanish) or 1 (800) 487-4889 (TDD). Note the NCADI order number. To order online, go to www.ncadi.samhsa.gov.

a new clinical model" and learning what helps clients get ready for this experience of change. "Vermont therapists asked for more examples and strategies for working with difficult clients," he adds.

In addition, he believes, a separate workbook-like "implementation binder" containing all the checklists, handouts, and forms should be provided. Dr. Simmons warns that CYT "may not work everywhere." An "agency's characteristics" will influence "whether this model will work for them."

But the benefits of the CYT manuals outweigh their limitations and the challenge of adjusting to a new method of work, the service providers interviewed for this article agree. Through structure, consistency, and research-based techniques, Dr. Turner says, the manuals have "provided a tighter framework for clinicians to provide effective treatment for adolescents." D

-By Beryl Lieff Benderly

The Bush Administration's 2004 National Drug Control Strategy calls for a new focus on reducing the illegal diversion and nonmedical use of prescription drugs in the United States while continuing the emphasis articulated 2 years ago on using a balanced approach to reducing drug use through treatment, prevention, and enforcement.

Recent data confirm the wisdom of this approach. Results from the most recent survey show an 11-percent drop in the use of drugs among youth between 2001 and 2003-exceeding the President's goal of 10 percent.

The National Drug Control Strategy has three national priorities: stopping use before it starts, healing America's drug users, and disrupting the market. SAMHSA plays a key role in achieving the first two.

SAMHSA will continue to support the National Drug Control Strategy by maintaining state substance abuse treatment systems through its Substance Abuse Block Grant and identifying and responding to new and emerging trends in drug use through the Targeted Capacity Expansion program. SAMHSA also tracks progress on the Strategy's goals through its National Survey on Drug Use and Health, formerly called the National Household Survey on Drug Abuse.

To address the abuse of prescription medications, SAMHSA will continue to work with the Food and Drug Administration on a collaborative public education effort. Products so far have included posters, brochures, and print advertisements related to the dangers of abusing prescription pain relievers.

In addition, SAMHSA is launching two major efforts in support of the National Drug Control Strategy.

Healing America's

Drug Users

Announced by President Bush in his 2003 State of the Union Address, Access to Recovery provides people seeking drug and alcohol treatment with vouchers to pay for a range of effective substance abuse clinical treatment and recovery support services. In obtaining services, people will have access to faith- and community-based programs.

".. There are many

pathways to recovery

from addiction." -Charles G. Curie, M.A., A.C.S.W. SAMHSA Administrator

"Access to Recovery is based on the knowledge that there are many pathways to recovery from addiction," says SAMHSA Administrator Charles G. Curie, M.A., A.C.S.W. "The promise of this initiative-founded on a belief in individual choice-is that it ensures the availability of a full range of treatment options, including the transforming power of faith. Making these choices available to people who want and need them will provide opportunities for meaningful, contributing lives in their communities."

Funded by Congress at $100 million in Fiscal Year 2004, Access to Recovery promotes consumer choice, improved outcomes, and increased treatment capacity. The President's 2005 budget request for SAMHSA proposes to double Access to Recovery's appropriation. (See SAMHSA News, March/April 2004.)

Funds will be awarded to states, territories, the District of Columbia, and tribal organizations through a competitive grant process. Applicants have considerable flexibility in designing their approach and may target efforts to areas of greatest need, to areas with a high degree of readiness, or to specific populations such as adolescents. The funds are required to supplement, not supplant, current funding and build on existing programs, thus expanding both capacity and available services.

Stopping Use Before
It Starts

The President's Fiscal Year 2005 budget proposal includes $196 million to support SAMHSA's new Strategic Prevention Framework. This effort is an approach to prevention and early intervention that is built on accountability, capacity, and effectiveness at the Federal, state, and local levels. The Strategic Prevention Framework uses a stepby-step process known to promote youth development, reduce risk-taking behaviors, build on assets, and prevent problem behaviors in all areas of a person's life—at home, at school, and in the community.

SAMHSA has begun to use the Framework in its everyday activities in programs within the Agency. In Fiscal Year 2005, the Framework will focus on promoting the replication of effective programs at the community level, with an emphasis on preventing underage drinking.

More information about the President's National Drug Control Strategy is available at www.whitehousedrugpolicy.gov.

For more information about SAMHSA's Access to Recovery program and the Strategic Prevention Framework, visit SAMHSA's Web site at www.samhsa.gov.