BackgroundA variety of forces are now shaping a passionate debate regarding the optimal approaches to improving the quality of substance abuse services for American Indian and Alaska Native communities. While there have been some highly successful efforts to meld the traditions of American Indian and Alaska Native tribes with that of 12-step approaches, some American Indian and Alaska Natives remain profoundly uncomfortable with the dominance of this Euro-American approach to substance abuse treatment in their communities. This longstanding tension has now been complicated by the emergence of a number of evidence-based treatments that, while holding promise for improving treatment for American Indian and Alaska Natives with substance use problems, may conflict with both American Indian and Alaska Native and 12-step healing traditions.DiscussionWe convened a panel of experts from American Indian and Alaska Native communities, substance abuse treatment programs serving these communities, and researchers to discuss and analyze these controversies in preparation for a national study of American Indian and Alaska Native substance abuse services. While the panel identified programs that are using evidence-based treatments, members still voiced concerns about the cultural appropriateness of many evidence-based treatments as well as the lack of guidance on how to adapt them for use with American Indians and Alaska Natives. The panel concluded that the efforts of federal and state policymakers to promote the use of evidence-based treatments are further complicating an already-contentious debate within American Indian and Alaska Native communities on how to provide effective substance abuse services. This external pressure to utilize evidence-based treatments is particularly problematic given American Indian and Alaska Native communities' concerns about protecting their sovereign status.SummaryBroadening this conversation beyond its primary focus on the use of evidence-based treatments to other salient issues such as building the necessary research evidence (including incorporating American Indian and Alaska Native cultural values into clinical practice) and developing the human and infrastructural resources to support the use of this evidence may be far more effective for advancing efforts to improve substance abuse services for American Indian and Alaska Native communities.

Authors' Note: The authors are indebted to Jonathan Peck, president, and Michael Cahn, director of operations, of Learning Systems, Inc., as well as to David Vinikoor and Peter Parrado, directors of JSP during the period covered by this evaluation.Four hundred thirty-six participants, ages 12 to 16, in a pretrial intervention project were compared to an equivalent group of 132 cases who were treated by whatever other means were available to the juvenile justice system. The experimental group incurred significantly fewer rearrests over an average exposure period of 311 days. Differential results were obtained for subgroups of the experimentals, and certain factors were also found to be predictive of outcome. arious approaches to the diversion of juveniles from the criminal justice system have been advocated and a variety of these have been implemented. While evaluation of these efforts has also been advocated, the criteria for success and the evaluative designs have differed widely. This paper reports on the effects of a diversion program on rearrest experience of participants and of an equivalent control group.

Pay for performance, the provision of financial incentives for favorable performance, is increasingly under study as an evidence-based practice. This study estimated the improvement in client retention from offering incentives to 11 substance abuse counselors providing outpatient aftercare treatment. During the incentive period, a counselor could earn a bonus of $100, in addition to his regular compensation, for each client who completed at least five aftercare sessions (the "milestone" which we considered the minimum adequate dose of the aftercare curriculum). We evaluated this and a similar, 12-session incentive using a logistic regression in which the retention "milestone" was the dependent variable and the proportion of time in the incentive condition was the independent variable. Among the 123 clients offered this aftercare program, their probability of completing at least 5 sessions was 59% with the incentive compared to 33% beforehand (odds ratio 4.1, P<.01). These findings suggest that counselor incentives are an effective strategy to improve client retention in substance abuse treatment.

The psychometric properties of the Significant-other Behavior Questionnaire (SBQ), an instrument measuring the specific social support in terms of the patient's drinking. Assessments of the significant other's behavior in the presence of the patient drinking is provided by both the patient and significant other. Data from the two SBQ forms were analyzed with a principal axis factor analytic procedure with varimax rotation. The scales were similar for the two forms with four behavioral reactions, withdraw from the patient, support drinking, support sobriety, and punish drinking. Correlations between the two forms on the same four scales were higher than correlations within groups on three of four scales and differed from measures of general social support. Applications of the SBQ are discussed.