The Journal of Primary Prevention, Vos 16, No. 2, 1995

Mounting a Community-Based Alcohol and Drug Abuse Prevention Effort in a Multicultural Urban Setting: Challenges and Lessons Learned Maryann Amodeo, M.S.W., Ph.D., l Susan Wilson, M.Ed., and Deborah Cox, L.P.N., B.A.

This article is designed to help planners and community groups anticipate challenges in implementing community based prevention programs in multicultural urban environments. Empowerment and public health goals are described as essential elements. Methods are recommended for capacitybuilding with inexperienced participants and balancing long and short term goals in embattled communities. KEY WORDS: substance abuse; prevention; community-based,

INTRODUCTION With the proliferation of community-based prevention programs, many associated challenges have emerged that could not have been anticipated when the prevention movement was in its infancy. This article is designed to help planners and community groups (a) anticipate the dynamics and barriers involved in implementing prevention programs in a multicultural urban environment and (b) minimize the disruption those factors can exert. Although recommendations are made for ways these challenges can be addressed, it is likely that resolutions will need to vary with the unique characteristics of the communities involved. Failure to address these challenges directly in the planning process may result in any one of a number of negative outcomes, for example, loss of valuable time trying to resolve them IAddress correspondence and reprint requests to Maryann Amodeo, M.S.W., Ph.D., School of Social Work, Boston University, 264 Bay State Road, Boston, MA 02215. 165 O 1995HumanSciencesPros.s,Inc.

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once the implementation phase is under way, unsatisfactory decisions made under the pressure of deadlines, and/or resolutions by default resulting from the failure to acknowledge the challenges, consider alternatives, and make purposeful decisions. These challenges will require discussion and debate within the prevention team because the solutions chosen will reflect personal and professional values, as well as philosophical and political orientations. It is likely that, among staff and community participants, there will be divergent views about the meaning and resolution of the challenges. Through involvement in the Dorchester Alcohol and Drug Abuse Prevention Project, a community-based prevention and education initiative in a multicultural urban neighborhood in Boston, Massachusetts, the authors faced a number of difficult challenges common to many community prevention projects. They describe below their methods for resolution and their recommendations for others engaged in similar work. The challenges were related to choosing a central organizing framework for the project, engaging residents of an embattled community in working on long-term rather than short-term goals, keeping members of the team focused on their own action agenda in a community with many action agendas, and responding to the diverse needs of a multicultural community.

BACKGROUND Prevention efforts directed at a number of health problems have increasingly been focused on the community, which has come to be viewed as an active agent of change rather than simply a passive recipient of it. This shift in perception can be seen most clearly in the development, within the health-promotion movement, of the concept of community empowerment (Goodstadt, 1990). In urban areas, community prevention programs are proliferating, especially those focused on alcohol and other drug problems, and a national alcohol and drug prevention movement has gained momentum (Prevention Plus III, 1991). Despite the many potential benefits of community prevention initiatives-including raising awareness about alcohol and other drug use, exposing deficiencies in services and facilities, and empowering participants to serve as advocates for an often neglected client population--implementing effective programs is not easily accomplished. In the late 1970s and through the 1980s, often with funding from federal agencies, a number of community-based prevention efforts were launched with varying levels of success (Room, 1990). Commenting on such prevention efforts, Holder and Giesbrecht (1990) propose that "community prevention requires adapting to the social context and environment in which alcohol and drug

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problems occur and facilitating modifications in that larger context and environment" (p. 28). They discuss communities as dynamic, advising that rigid intervention protocols can easily become out of line with changing community issues, agendas, or power arrangements. They see communities as complex, counterintuitive, differing on key features, and involving feedback loops rather than simple linear intervention protocols. They focus on the need for conceptual models that will assist with identifying and describing important features of a community, making predictions about future community interventions, and undertaking experiments to aid in program and policy planning. They conclude by saying that "the complexity and dynamics of a community make it difficult to design and implement "quick fix" prevention interventions. Effective changes in community systems take time to produce long-term reductions in alcohol and other drug problems. Community members and political leaders often expect shortterm effects and therefore lose interest in prevention efforts that take time to implement and even longer to reduce problems or high-risk behavior" (p. 36). The authors' experience taught these and other lessons vividly, driving home the need to fashion prevention strategies in response to the felt needs of community members rather than through a preexisting framework, the need for a longer time frame than was originally planned, the benefits of a needs assessment that attempts to hear and respond to the needs in a fresh way, and the difficulties associated with team formation and team building in an ever-changing community environment.

THE DORCHESTER ALCOHOL AND DRUG ABUSE PREVENTION PROJECT In late 1987, the Boston University Alcohol and Drug Institute for Policy, Training, and Research evaluated "The Maine Approach," a school/ community team prevention model that had been designed and implemented by the state of Maine's Department of Educational and Cultural Services, Division of Alcohol and Drug Education Services, in more than eighty communities across the state. The model shares many features with the Community Partnerships which were designed and funded by CSAP (Center for Substance Abuse Prevention). Maine's Department of Education provided specialized training in prevention and team-building, and provided onsite technical assistance and resources to towns who participated. Members of the evaluation team conducted surveys and interviews over an eighteen-month period in four Maine communities where the prevention effort was under way. Evaluators were impressed by the model and

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believed it could be adapted to an urban setting (Amodeo et al., 1989). Staff of the Alcohol and Drug Institute decided to test the model in Dorchester, a densely populated Boston neighborhood characterized by marked racial and ethnic diversity, including African American, white, Hispanic, Haitian, West Indian, and Southeast Asian residents. After a broadly publicized, communitywide open meeting in which residents and agency representatives were asked to vote on whether the project should be started in their community, the Dorchester Alcohol and Drug Abuse Prevention Project began in March 1989. The project had two main objectives: (a) to create community leadership teams composed of neighborhood residents who undertook alcohol and drug abuse prevention activities for their locality and, (b) to provide community agencies and neighborhood groups with the prevention and intervention skills that would enable them to work successfully with adolescents and adults from both affected families and families not yet touched by substance abuse. Central elements of the project's philosophy included a belief that alcohol was as dangerous a drug as many of the more highly publicized ones; that intensive prevention training was necessary for both caregivers and community residents in order to bring about the desired attitudinal and behavioral change; and that a community prevention team would have a stronger sense of ownership and direction if its membership was weighted toward "grassroots" neighborhood residents rather than "high-profile" community leaders. After four years, the project has one active community leadership team whose approximately fifteen members are predominantly African American but include white, Haitian, and Caribbean members as well. Two additional teams, one predominantly white and Hispanic and the other predominantly African American, were in existence for about six months; however, their members decided to join the first and most cohesive team to benefit from its momentum. Urgency among team members about the alcohol and drug issue was born primarily of a family or personal experience with addiction, and a concern for the next generation. Other motivations included a wish to highlight positive community accomplishments and a desire to acquire training that would help in job-related endeavors. Some 250 agency and community-based caregivers who completed the formal prevention sessions reported an improved ability not only to intervene with clients and families affected by alcohol and drug abuse but also to emphasize a prevention message with all families they encountered in their work.

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LESSONS LEARNED

Guiding Frameworks 1. While both public health and community empowerment frameworks were essential in guiding the work of the program, they at times led in divergent directions and required that staff make choices between them. The public health and community organization perspectives are often discussed in the prevention literature as if they are inherently compatible and reinforce each other. The authors, however, found that the two perspectives periodically led planning activities in divergent directions. Only through dialogue and debate among staff was the project able to reach a consensus on the program's direction. In terms of similarities, both models emphasize the individual's and group's ability to make socially responsible choices when the facts are known; the importance of partnerships, cooperation, and collaboration in accomplishing the work; and the community's right to participate in decisions affecting its future. The public health perspective, with expertise acquired from the prevention of a range of contagious diseases and related social problems, emphasizes primary, secondary and tertiary prevention, with a focus on behavior change that will benefit succeeding generations. In the Dorchester Alcohol and Drug Abuse Prevention Project, the public health perspective was central to the substance abuse curriculum taught to community agencies and civic groups. This training focused on primary and secondary prevention, providing the skills for early identification and intervention with clients, families, and loved ones. It also emphasized the long-term task of changing community norms that influence the first and continued use of alcohol and other drugs by children and youth. This perspective has been emphasized by CSAP in its many community partnership grants. The community organization perspective leading to empowerment includes methods for mobilizing constituencies, forging alliances between disparate groups, and dealing effectively with power structures to gain access to decision making. Inherent in this perspective is a commitment to building leadership and resources in the local area. This also is a perspective endorsed by CSAP in its work with community partnerships. The Dorchester Alcohol and Drug Abuse Prevention Project reflected the community organization and empowerment perspective in its community team structure, recruitment methods, and ultimate goal of resident leadership of the project. Team training retreats, which served as major vehicles for team build-

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ing and promotion of team ownership of the project, were focused in this direction. The public health perspective led us to emphasize the need for longterm changes in community norms related to drinking and drug use, changes that could best be brought about through activities focused on primary prevention. The community organization perspective led us to emphasize that success would occur when the community leadership teams became the decision makers for their own neighborhoods. Yet not far into the project, the first community leadership team departed from the primary prevention (public health) focus in favor of shortterm goals and activities addressing immediate community problems. When staff members tried to redirect the group and met with resistance, they felt an impulse to impose on the team those activities which "prevention purists" and public health experts would regard as more effective. Confronted by other staff members, they realized with some dismay that the perspectives and goals of community organizing and public health were not automatically compatible and that the scientific expertise from public health would need to be subordinated, at least temporarily, to the process and wisdom of community control. Since the teams were the vehicle through which community change would ultimately occur, and since team members were chosen because of their unique understanding of neighborhood needs, the community organizing framework predominated. Given that the intention was to leave behind a community infrastructure capable of carrying on prevention work after the period of university sponsorship, it seemed imperative that support be provided for those with the vision, commitment and energy to sustain that infrastructure. Had project staff enforced the primary prevention emphasis as an equal or principal focus, they would have risked snatching control from the team and sabotaging the overriding goal of empowering the community. Unlike some professionals in the field, who may come armed with scientific methodologies and research emphasizing the need for long-term interventions, our community members came with an urgency for immediate solutions born of living in a violence-wracked area. Neighborhood people working as citizen volunteers in inner-city prevention programs are repeatedly exposed to families desperately in need of services for problems related to drug dependency, AIDS, and related conditions. In our project, residents traumatized by gang violence, confrontations with police, and the murder of loved ones came to the prevention office seeking mental health assistance and support for themselves and family members. One community training effort for an African American church group found that virtually every participant of the twenty-five attending an eight-week Saturday morn-

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ing substance abuse program was living with an active addict, had a parent or close relative who had died from alcoholism or drug abuse, or had personally struggled with an alcohol or drug abuse problem. We learned that prevention activities in such a community must be broadly defined and flexible enough to allow residents to respond to those issues which they find preoccupying and in which they have much at stake. For our project, broadly defined prevention activities included joining prayer vigils focused on "taking back the night" from violent elements in the community; undertaking a voter registration drive; supporting the development of more meetings of Alcoholics Anonymous, Narcotics Anonymous and Al-Anon in neighborhoods of color; arranging appearances on cable TV by recovering members of our teams to educate the public about treatment, relapse, and recovery; participating in a "treatment on demand" coalition; and training selected team members in the production of cable TV shows so the project would be less dependent on outside technicians to design and film programs. While the community empowerment goal took precedence and was the dominant dynamic throughout the life of the project, the public health framework was kept in view to guide the teams toward longer-term goals. We felt that project efforts should not only empower the community but also ensure that people had "expert knowledge" about the nature of prevention and how to implement prevention activities. It seemed that emphasizing expert knowledge without community empowerment or emphasizing community empowerment without expert knowledge would be dangerous and self-defeating for any project undertaking prevention work. Our educational activities continued to focus on the importance of primary prevention but highlighted the treatment-oriented activities of the community leadership team. The challenge for prevention programs lies in maintaining a balance between activities that respond to immediate needs--activities some prevention purists would call tangential to the prevention task- and activities that focus the community on the generations to come, wherein true systems change is possible. In inner-city prevention programs, the former may be an essential developmental step serving to acknowledge the day-to-day turmoil of people's lives and to "start where the client is." Nevertheless, projects risk subverting their prevention goals if they fail to maintain this balance by giving in to pressures to become a crisis-oriented or direct service program. Projects with a duration of five or more years may be able to maintain this balance more easily, either by moving through three developmental stages wherein they focus on tertiary, secondary, and then primary prevention, or they integrate all three loci at all three stages. The decision to emphasize the community empowerment framework, while re-

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mining the public health viewpoint, allowed the project to avoid giving conflicting or negative messages about empowerment. Had both frameworks been promoted with equal emphasis, conflicting messages would have been conveyed. Had the public health philosophy predominated, the disempowering message that "the technical experts have the last word" would have been given. And had all focus on the public health model been relinquished, the result might have been ultimately disempowering: a preoccupation with short-term goals to the exclusion of making the community a better place for the next generation. Time Frame for Grassroots Efforts

2. The three-year life span planned for the project was too short for a multilevel community intervention focusing on building leadership on a grassroots level in a multicultural inner-city neighborhood. While the project was designed as a three-year undertaking, in our second year we discovered that this time frame was unrealistic. The ambitious scope of the work (including the goals of forming three community leadership teams and training 400 caregivers, neither of which were fully realized by the end of three years), the embattled nature of the community (involving drug-related violence, widespread unemployment, lack of affordable housing, and a host of other social ills), and the commitment to recruit and build skills among grassroots community members should have persuaded us that successful implementation would require five years or more. (Ultimately, the project continued for a fourth year, at which time the community team took over the sponsorship and raised money for its continuation.) We decided not to build a team around agency directors and highvisibility people already identified as community leaders (although we did ask some of these individuals to serve on our advisory board). Agency representatives tend to be overcommitted in terms of time available for community projects, and often they drop out of such efforts if their job description or job status changes. We were also concerned that teams too weighted toward this type of membership would risk being split apart by agency loyalties and interagency rivalries. So in the interests of community ownership, we gave preference to longtime residents who were strongly committed to the neighborhood and belonged to the civic and church groups that were part of our target audience for prevention activities. Yet in choosing these individuals rather than those with proven skills and leadership ability, we recognized that much time would have to be dedicated to developing skills and building confidence. These members re-

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quired extra staff support on several levels--coaching on meeting management skills, guidance with group decision making, feedback on interpersonal style, and assistance with correspondence, meeting minutes, and program publicity. Some team members were reluctant to chair meetings and needed extensive instruction when they did agree to take on the role. Others, having little or no experience as decision makers on any but the most personal level, found it difficult to be decisive when voting on program options. Still others were not self-starters and required considerable help in initiating their part of a project. Moreover, given the predictable turnover of some team members, project staff found it necessary to repeat the process of personal coaching and individual skill building. In the book Tactics and Techniques of Community Practice, Erlich (1984) raises the question of whether practitioners should focus on "task" or "process" goals. Task refers mainly to specific and tangible results, such as a policy shift or an increase in the number of people receiving services. Process refers to building and strengthening the relationships between and among people involved together in community work. The author emphasizes that undoubtedly both task and process goals must be attended to, but the dilemma may lie in how much time and how many resources are allocated to each goal. Although ideally both could be integrated, the reality for many community programs is that more process work is required than was anticipated. In the case of our project, much more time was needed for building cohesion and strengthening consensus, arguing for a longer project time frame that would have taken this factor into consideration. It would have been wise to plan for a discrete stage of project development where "capacity building" was the sole focus and team development and consolidation of team members' skills could have occurred in a planned fashion. Instead, we tried simultaneously to do team building, to educate team members about alcohol and drug abuse prevention, and to have the teams initiate prevention activities. As a result, some team members felt overwhelmed and inadequate to the task at hand, hence reluctant to assume responsibility for even those tasks which they were equipped to execute. In retrospect, one alternative might have been to aim for a careful balance in team membership between (a) agency representatives and highvisibility community leaders and (b) grassroots participants. Role modeling by the more experienced members and coaching provided by one team member to another rather than by staff might have been a more desirable arrangement. Another alternative might have been for us to give a more central role to the advisory board- for example, asking them to rotate in attending team meetings and to provide feedback to team members on

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strengths and areas for improvement. This approach too would have provided team members with community role models to emulate. At the end of three years, we had made considerable progress on the goal of training community caregivers--more than 250 had been trained, and it was dear that our goal of 400 had been unrealistic. The three teams had merged and were still in the process of developing cohesion and working together as a single group. A dedicated core of team members representing the ethnic and racial diversity of the community planned and completed programs on a sporadic basis; they also worked toward acquiring the skills to take over the project, including completing "training of trainers" preparation sessions to enable them to teach the prevention curriculum, which previously had been taught by substance abuse professionals. Although a substantial number of initial goals had been accomplished, it was clear that the three-year time frame still left the ultimate objective unattained: the existence of a strong, independent, prevention-oriented community infrastructure. Initial and Ongoing Needs Assessments

3. The needs assessments taught staff about the community's perception of the alcohol and drug problem, helped staff promote realistic expectations and allay fears about the project, and helped the teams design workshops that responded to the community's pain. One of the first steps in the project was a needs assessment, involving semi-structured interviews with some ninety neighborhood residents, agency administrators, and community leaders. Interviews focused on assessing the respondent's view of the alcohol and drug problem and his or her exposure to prevention issues, explaining the project, and exploring roles the respondent might be willing to play in the project, including joining a community leadership team, serving on the advisory committee, or receiving agency training. The university sponsorship of the project raised suspicions about whether community residents would serve the university's purposes without an equivalent benefit to the community. In the early days of the project, the project coordinator, who was from the community, was repeatedly questioned about the university's commitment; she found the task of responding to the issue both delicate and time-consuming. Conducting a systematic needs assessment provided her with a structured forum for discussing this issue and clarifying misconceptions. Her personal credibility helped to convince people of the project's intent and helped the project to move beyond this stage. In the authors' view, projects that attempt to shortcut the needs

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assessment or that give only token attention to it make a serious error, one that can undermine the project throughout its operation. Implementation of our project occurred during a time of increasing economic hardship in the state and city, and loss had touched the neighborhoods in myriad ways. Many community people were dealing with the deaths of loved ones from gang-related violence, drug dependence, and AIDS. And as the state's economy worsened, it became commonplace for team members and neighborhood participants to experience personal job loss, the loss of community services, and the closing of neighborhood businesses and social service agencies that were part of the fabric of the community. The rapid accumulation of these losses seemed to increase their potency. Team members encouraged staff to provide workshops to help people grieve these losses and learn ways of coping with long-standing grief and chronic loss; however, the original project plan held no provisions for such workshops. It was only as a result of the needs assessment, coupled with an ongoing dialogue with team members, that staff were struck by the magnitude of losses suffered by community residents and the need for a protective, healing response to those losses. Had such workshops been suggested earlier in the project, before staff were forced to think about whether public health goals or community empowerment goals would predominate, the workshops might well have been seen as tangential to the goals and therefore inappropriate. When offered to team members and community residents, these workshops served as catalysts for group cohesion and resulted in renewed energy and commitment to the project. The workshops brought participants closer together and seemed to free up energy that heretofore had been difficult to tap. Along with team members, project staff and administrators attended these sessions, shared information about their personal losses, and worked through painful feelings of grief. Role of Recovering Members

4. Project participants who were in recovery from chemical dependency brought unusual commitment, served as symbols of hope to families in the community, and hastened other team members' learning about the nature and treatment of alcohol and other drug problems. With just a small amount of training, those members who were in recovery were able to provide helpful advice to others on a range of issues, including community resources, the need to set limits with loved ones who were drug-dependent, and the role of twelve-step programs as a support for recovery. Because their personal experiences had acquainted them prin-

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eipally with the casualties of addiction, they required considerable reorientation regarding the goals and methods of prevention; that they already possessed a framework for understanding alcohol and drug issues, however, greatly facilitated their learning. Once project staff realized the energy, commitment, and personal insights contributed by these individuals, recruitment of new members began to focus on adding more of them to the teams. Care was taken to ensure that such persons met a requirement of abstinence, as well as other criteria which were applied to new members. Some of these members provided training for the community on behalf of the project, and while they followed a standard curriculum developed by the project, they also made a point of letting audiences know about their own addiction history and recovery process. Here again, our public health and community empowerment orientations led in somewhat different directions and created a challenge for us. For a number of reasons, recent prevention literature from sources such as CSAP Prevention Plus 1I. (1989) and the U.S. Department of Education discourages training that highlights the presenter's own addiction and recovery history. For example, some audiences, especially youth, seeing a successful, physically and emotionally intact person before them may decide that addiction is not so dangerous after all. Other audiences may see only the unique aspects of the presenter's experience and feel that it has little relevance for them. And if subjected to scare tactics (e.g., "If you don't change your behavior, you'll turn out like me--addicted"), audiences may leave totally unmoved to change their behavior, a common result of such approaches to prevention (Schinke and Gilchrist, 1985). Yet after much discussion and debate, staff and team members felt strongly that audiences of color would benefit greatly from knowing the presenter as a recovering person. This factor, they felt, would provide the audience with the opportunity to see an articulate, knowledgeable person of similar background who had struggled and overcome a destructive force; moreover, it would serve as an important counterbalance to the widespread image of people of color as drug addicts uninterested in treatment and recovery. The feeling was that, since the issue of chemical dependency generated such a profound sense of hopelessness and helplessness in the community, any method that could convey hope about the treatability and preventability of the problem had to be considered seriously. Agency Resistance to Intensive "l~'aining 5. Administrators and carcgivers from human service agencies, while eager for exposure to substance abuse prevention issues, sought quick-fix

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workshops and one-time educational programs rather than involvement in intensive prevention and intervention training. Audiences bring a number of "f'dters" through which they view these issues (Amodeo and Drouilhet, 1992; Googins. 1984; Levinson and Ashenberg-Straussner, 1978). Such filters--related to experiences with family alcoholism, one's own personal drinking and drug use, and societal views and stigmas regarding alcoholism and drug dependence--may distort the individual's ability to view the issue objectively. These filters require that, as part of any prevention effort, participants examine their own use of alcohol and other drugs and explore enabling and codependency behaviors. For human service caregivers, a number of additional issues must be addressed, including fear of confrontation in discussing alcohol and drug issues with clients, guilt and helplessness resulting from professional ineffectiveness with this client population in the past, and skill building related to assessment, diagnosis, and intervention (Googins, 1984; Levinson and Ashenberg-Straussner, 1978). It was our belief that a grounding in substance abuse prevention issues required fourteen to eighteen hours, and we offered such a training program free of charge. This training was led by experienced substance abuse prevention professionals, was scheduled at a time and place of the agency's convenience, and offered continuing education credits for those who desired them. Yet we repeatedly encountered resistance from agencies in committing to more than four to eight hours of training. A number of factors contributed to this resistance, among them a common perception among health care and social service providers prior to training that they already knew what they needed to know about alcohol and other drug problems by virtue of exposure to problems in their families and neighborhoods: agency budget cuts resulting in increased caseloads that made it difficult for workers to find time to attend extended training programs; and, for agencies like health and mental health centers that bill health insurers or other funding sources on the basis of number of client contacts, an economic disincentive in that revenue was lost when staff members were occupied in training sessions. We eventually developed a more flexible curriculum that allowed organizations to choose individual two-hour modules from among the topics in the comprehensive eighteen-hour curriculum. And for agency administrators who were especially difficult to engage in training, we designed a four-hour introductory session as a method of publicizing the more extensive but flexible curriculum. Still, we continued to try to convince organizations of the need for intensive courses that would achieve attitude change and skill development. Once caregivers finally participated in the training, they often realized how

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little they knew and requested an increase in the number of training sessions planned. However, initial negotiations were tedious and discouraging. Alcohol as a Serious Drug

6. Convincing agency caregivers that alcohol was a serious drug deserving of community prevention efforts, when their anxiety was centered on cocaine and other "dangerous" drugs, was a challenge. The educational sessions for neighborhood health centers and human service agency staff that often sparked the most excitement were those focused on cocaine, crack, inhalants, opiates, and the paraphernalia and lifestyle that accompany use of these drugs. In some of our audiences, we encountered curiosity bordering on voyeurism. While we tried not to downplay the significance of cocaine, crack, heroin, marijuana, and other drugs, we struggled to raise the visibility of alcohol as the local community's major drug of abuse. In our inner-city neighborhoods, excessive drinking, public drunkenness, chronic alcoholism, and death from cirrhosis of the liver were part of a widespread and urgent intergenerational epidemic. Although the national media have played some role in the emphasis on the so-called dangerous drugs, most likely other factors were at work as well. Perhaps the repeated focus on the more dramatic drugs was a way for members of our audiences to distance themselves from feeling vulnerable to addiction-perhaps they needed reinforcement for the belief that only deviant individuals get caught up in the use of these drugs and that they themselves would never use such substances, or at least never use them to the point of developing a dependence. Alcohol may be a drug that is "too close to home." Although audience members may have been using alcohol excessively or been surrounded by alcoholic family members, friends, and co-workers, refocusing training sessions on these so-called dangerous drugs may have reassured them that they were in no imminent danger of developing a "drug problem." The challenge for prevention programs is to find ways to respond to audience pressure to focus on the so-called dangerous drugs so that alcohol can be elevated to its rightful place as the major drug ravaging and decimating communities across the country. We continue to ponder about ways to achieve this goal. Culturally-Sensitive Training

7. Providing culturally-sensitive prevention training on a broad scale was difficult because educational materials were sparse, skilled trainers were in great demand, and deadlines were near.

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Our program was conceived in 1987 and 1988, a time when the staff and society in general had a much more limited understanding of the concept of "multieultural" than exists today. Although we sensed that modifications would be needed in teaching materials and approach in order to respond to the needs of our audiences, we were naive about the revisions in our thinking that would be necessitated by a commitment to provide training which was culturally-responsive. A culturally-responsive perspective advocates that those involved in prevention activities have an appreciation for the specific culture's definition of use, abuse and dependence, as well as an understanding of the family structure and how it might influence help-seeking behavior when drinking or drugs are involved. A culturally-responsive perspective recommends that education and prevention efforts respond to the racial and ethnic composition of the target group, and that prevention activities be led by those who represent these cultural groups and can serve as role models. This perspective also acknowledges the extent to which information about various cultures may have been distorted by the cultural and gender orientation of those who originally gathered and recorded the facts, statistics, or historical material (Orlandi, 1992). In our initial searches for multicultural materials (films, videos, books, pamphlets, reference materials) related to the prevention of alcohol and drug problems, we found very little. Organizations producing films and videos in this area informed us that the market for materials featuring other than white families was quite small and that production of such teaching materials was thus not a priority for them. Because we were pressured by deadlines, we were tempted at times to ignore the audience's need for a trainer who had cross-cultural experience, but some members of the staff persisted in emphasizing how important this additional experience was. We ultimately resolved this problem by developing an arrangement with a neighboring substance abuse treatment agency whose staff included African American trainers with multicultural expertise. Since these trainers lacked extensive prevention experience, we devoted several sessions to meeting with them, as well as with Latino trainers from other organizations, to orient them to the curriculum and recommend teaching methods and tools. These trainers then modified the alcohol and drug prevention content to fit the varying needs of the community audiences assigned to them. Here again, in the early days of planning we had overlooked the need for a preliminary capacity-building step in program development. We had operated on the assumption that without a process of recruitment, orientation, and preparation, we would be able to hire people equipped to do this work, that is, to provide to individuals and families educational sessions

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on substance abuse prevention and to do so in a way that was responsive to multicultural issues. How mistaken we were! The capacity-building process is labor-intensive and time-consuming. It required that we subordinate our "task" goals (delivering training) to our "process" goals (developing trainers with dual skills in multicultural work and substance abuse prevention). This intermediate capacity-building step increased demands on staff time and, indirectly, increased costs. The benefit of this capacity-building process, however, was that skills and experience were built in both systems: our organization developed greater sensitivity to and knowledge about the cultural and political aspects of the issue, and the cross-cultural trainers increased their skills in substance abuse prevention. The process of developing trainers of color was important in terms of what would be left behind in the multicultural community setting. In the classroom, the goal of presenting trainers as role models was accomplished. And project staff came to regard it as an integral part of not only the material being taught, but the empowerment process as well. This cross-cultural work done by "outside" trainers equipped the rest of the staff not only to address the needs of the human service workers who were in our audiences, but also to support the work of our community team members who came from such diverse cultures and backgrounds. Although team members as a group represented a number of different cultural groups, they had never been in a forum where such issues were dealt with explicitly. They had not examined ways they as individuals might have participated in institutional racism aimed at other groups, nor explored their own feelings about being victims of racism, nor spent time in a group setting exploring the possibility of internalized self-hatred. The weekend training retreats in the second, third, and fourth years gave high visibility to the issues of cultural-sensitivity and culturally appropriate approaches to prevention. It was apparent from participant responses that this was a necessary and much-appreciated segment of training. We recommend that all such prevention programs set aside time for this issue, in terms of process and content, and see it as a central issue that deserves repeated focus and elevation as an underlying theme. Were we to design the project now, we would develop a timeline and budget that specifically took into account the months needed for capacity building for multicultural training. Rather than focusing on delivering training and prevention activities as the important outcomes, we would view the development of a cadre of workers versed in multicultural issues as an end in itself. We would also ensure that this expertise did not simply reside in the people of color who staffed the program-it needs to be developed

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by all substance abuse prevention specialists in the 1990s, as our entire society moves in an increasingly multicultural direction. In addition, we would designate a "resource collection period" for books, films, and curricula as a necessary step in capacity building.

Collaboration with Neighboring Programs 8. Selectivity in collaborating with neighboring prevention projects is essential to avoid dilution of effort, reduction in group cohesion, and erosion of program identity. The benefits of cooperation and collaboration between community programs are recognized by all, yet there is a price to pay for being a "good neighbor" in this way. Each time a neighboring prevention program started up, our program and others were invited to attend meetings to discuss our plans, our activities, and ways our programs could interface. We routinely responded with contributions of time and resources, believing there was much to be gained. Our motivations included the desire to 9 build positive relationships with other programs in order to avoid competition or "turf battles"; 9 learn about other programs' services in order to inform our target population in the event they could utilize these services; 9 present a unified message to the community concerning approaches to alcohol/drug prevention; 9 cosponsor events targeting audiences of mutual concern to us and the other prevention programs; and 9 identify additional funds, free services, or groups of volunteers that could be used to supplement limited resources. In our inner-city neighborhood, however, alcohol and drug prevention programs were springing up at a surprising rate and invitations were received almost weekly by our program to attend yet another prevention group's orientation meeting. (At year four, there were more than two dozen communitywide prevention programs serving our small geographic area, and the number was still climbing rapidly.) The challenge we faced was to guard against fragmentation of effort, loss of program momentum, and erosion of team cohesion. While several benefits accrued from the collaborations (e.g., our project became well known in the community; our image was one of cooperation and accessibility; and, probably as a direct result of our cooperative stance, we were hired to do training and curriculum development for other

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prevention programs), we also paid a high price. Many of our team members had limited time to spend in volunteer activities-some held second and third jobs to pay their bills, and some were still in school to complete their educations--but were committed to the team. When we encouraged them to commit time to other projects as part of our collaborative efforts, such commitments often reduced the time they spent on our project. Two years into our program, we decided that our own action agenda was the priority and that all collaborative activities would be of secondary concern. Rather than being selective in our collaborations, we cut back on them drastically. In retrospect, it seems that some middle ground might have been more constructive. One solution would be for projects either to be selective in choosing only two or three collaborative efforts or to decide what percentage of time they will dedicate to this activity. The percentage can increase over time as the group develops a more solid identity, as leadership within the group is firmly established, and as the program generates its own momentum. Neighboring programs can be told this rationale and encouraged to check back in the coming months when the program is further along in development. Whether this solution would have been satisfactory to team members in the early days of our project, when they were eager to explore and affiliate with any program related to substance abuse, we cannot say. But the sense of team cohesion and momentum might have been better protected using this method. An alternative might have been to adopt the view that collaboration could occur only if it accomplished a specific team goal that had already been identified, thereby eliminating the more general forms of collaboration that entailed overly high trade-offs. Most prevention funding sources ask for or require the program to demonstrate affiliations with other programs but do not spell out the nature of such associations. These funding sources generally want to convey the idea that programs cannot work in a vacuum and that competition and turf battles are self-destructive, yet they have offered little concrete assistance to prevention programs on how to ensure the mutual success of these collaborations. Key questions include: What percentage of time is recommended for collaborative activities? What types of collaborative activities or organizations should have the highest priority? Do funding sources consider it a legitimate accomplishment to demonstrate substantial time contributed to the successful activities of other programs? Even rough guidelines on these issues would be helpful, especially for those beginning community-based programs in inner-city neighborhoods, where there may be a plethora of potential collaborators.

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CONCLUSION This article has described the experiences of a community-based prevention program in facing challenges and dilemmas in program implementation. Areas of learning for project staff included the realization that a discrete period of time should have been designated for capacity building, for the recruitment and orientation of multicultural prevention trainers, and for skill training among community leadership team members whose participation proved more demanding of staff time than had been anticipated. Resistance from community human service organizations came in the form of reluctance to commit time to intensive training, as well as difficulty in seeing alcohol as a serious drug with dangers similar to those of cocaine and heroin. Recovering team members were valuable additions to the project, and workshops on coping with grief and loss built group cohesion in the project and filled an important void in the community. A central challenge involved reconciling and integrating two prevention frameworks, the community organizing or empowerment framework and the public health framework. In the end, the public health perspective contributed the goals--it offered the beacon shining the way to where we hoped to be in another generation or two regarding alcohol and drug use. The empowerment perspective contributed the value base-the ideal of community self-determination and ownership on a grassroots level. It also contributed the process for reaching the goals-methods and specifications for recruitment, needs assessment, group development, and skill building--so that what was left behind was a durable community infrastructure ensuring local control. Further research and writing is necessary to continue the process of describing the "technology" of prevention. Many questions about goals, structure, and the empowerment process remain. Identifying effective change strategies in this increasingly multicultural society, in these more difficult economic times, and in this climate of proliferating prevention efforts based on community and grassroots models, will prove to be an ambitious undertaking for all program planners, implementers, and evaluators.

ACKNOWLEDGMENTS The Dorchester Alcohol and Drug Abuse Prevention Project was made possible through funds from the New England Telephone Company, Carlisle Services, Inc., The Boston Foundation, and Highpoint, during the period March 1989--February 1993.

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The authors would like to thank the editors of The Journal of Primary Prevention for their helpful suggestions concerning portions of this article.

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