Project Safe Overview

Table of Contents

I. Introduction and Project History
II. Program Clients
III. Program Staffing
IV. Program Elements
V. Program Evaluation

I. Introduction and Project History

In 1986, The Illinois Department of Children and Family Services (DCFS) and the Illinois Department of Alcoholism and Substance Abuse (DASA) began piloting a program that intervened with substance abusing mothers who had a history of neglecting or abusing their children. The initiative was funded by the Department of Health and Human Services, Office of Human Development Services, Administration for Children, Youth and Families. Between July 1986 and June 1988, Initially, 105 women and their children were provided services through Project SAFE pilot projects in four Illinois communities. Since 1988, Project SAFE sites have been initiated in communities across the State. Nineteen Project SAFE programs are currently in operation in Illinois. Additional projects have been modeled after Project SAFE, most significantly, the OASA/DCFS Initiative, which has greatly expanded services for substance-involved women, with histories of abusing or neglecting their children.

II. Program Clients

Since its inception in 1986, more than 5,700 women have been provided services through Project SAFE. These women and children were served in settings that ranged from the highly urbanized communities of Chicago and East St. Louis to smaller metropolitan and suburban communities to multiple county rural catchment areas in southern Illinois. A brief synopsis of the characteristics of women and families involved in Project SAFE during its twelve-year history is presented below.

A. The Multiple-Problem Client. As a whole, Project SAFE clients share multiple problems that unfold concurrently and sequentially with a high propensity for intergenerational transmission. While these clients have significant historical contact with social service agencies, the prior focus on one-problem-at-a-time and the essentially crisis orientation of these agencies has thus far resulted in little changes in the quality of life and level of functioning of these women and their children. Project SAFE represents the beginning of a new generation of multi-agency, interdisciplinary intervention designs with increased capabilities of working with such clients.

B. Age. There are two populations of Project SAFE clients: young addicted women with many children entering treatment before their twenty-first birthday and a group of older clients from 22 to 45 years of age for whom the use of cocaine, alcohol and other drugs has become a pervasive and enduring lifestyle.

C. Ethnicity. Non-White women are disproportionately represented in Project SAFE referrals, even in predominately rural areas. Project SAFE sites in Chicago and East St. Louis serve African American clients almost exclusively, while at least eight other sites, African American women are heavily represented (more than 40% of admissions). There continue to be only a small number of Latina women involved in Project SAFE. The growing ethnic diversity of Project SAFE clients is in marked contrast to the early piloting of Project SAFE (1986-1988), at which time 75% of admissions to the four project sites were White.

D. Marital Status. The majority of women entering Project SAFE are single, although most are involved in an on-going intimate relationship at the time of admission. The rural sites were more likely to have women who were married or divorced. The intimate partners of Project SAFE clients figured largely in their treatment via sabotage of the client's treatment, and via vocalizations regarding the safety of SAFE women and their children.

E. Sexual Orientation. Confusion about sexual orientation for some women entering SAFE was exacerbated by their histories of sexual victimization, by prior sexual experiences with women via prostitution, and by a general inability to define and assert boundaries in relationships with either sex. Treatment responses to these issues included more open discussions about sexuality, monitoring of the treatment milieu to prevent homophobic scapegoating of lesbian and bisexual clients, and responding to the disruptive effects of treatment romances between clients.

F. Children. In recent years, trends related to children involved in Project SAFE have included:

• an increased number of infants (treatment referrals related to the infant's prenatal drug exposure) and older children,
• larger families involved in Project SAFE,
• increased recognition of emotional/behavioral disorders among SAFE children,
• increased frequency of a client's children being in placement with a family member of the client, and
• a diminished degree of emotional connection between Project SAFE mothers and their infant children.

G. Socioeconomic and Employment Status. The overwhelming majority of Project SAFE clients report incomes of less than $7,400 per year. Nearly all Project SAFE clientele are unemployed at the time of their admission to the project. Poverty and a lack of vocational skills and opportunity are a consistent part of the profile of the women served by Project SAFE.

H. Sexual Abuse History. Throughout Project SAFE's history, case workers, outreach workers and therapists have explored the clinical significance of, and appropriate service responses to, the sexual abuse so prevalent in the developmental histories of Project SAFE women. Four critical observations summarize current thinking on these issues.

• Prevalence: The prevalence of childhood sexual abuse and/or sexual trauma in the histories of Project SAFE clients has remained quite high. The percentage of clients who self-report childhood sexual abuse ranged from 45-95% across the nineteen service sites in Illinois.

• Traumagenic factors: The historical victimization of Project SAFE clients involves multiple "traumagenic factors":
  1. an early onset of sexual abuse (heightened physical and psychological vulnerability)

  2. long duration of sexual abuse (most often measured in years)

  3. perpetrators from within the family or with a close relationship to family (heightened violation of trust)

  4. multiple sexual perpetrators

  5. violence, or threat of violence, accompanying the sexual abuse (magnification of trauma)

  6. more personally violating (boundary-invasive) forms of sexual abuse

  7. not believed and not protected, or blamed and not protected when silence was broken about the sexual abuse (escalation of abuse following breaking silence).

• Many clinical staff within the Project SAFE sites view a good number of SAFE clients as suffering from a pattern of Post Traumatic Stress Disorder (PTSD) related to their sexual victimization. In this view, substance abuse, depression and anxiety, a propensity for transient and toxic intimate relationships, addiction to crisis, and impaired parenting are all overt manifestations of, or responses to, PTSD. The treatment of addicted women within Project SAFE is increasingly being subsumed under a broader paradigm of the treatment of developmental trauma.

• Risk of SAFE Children for Sexual Abuse: Repeated discussions during SAFE evaluations noted the high incidence of reported sexual abuse in children of Project SAFE women. Discussions indicating why these children might have been at higher risk for abuse than other children included the following points:
  1. Some of the same perpetrators who abused SAFE women have access to their children.

  2. The propensity of SAFE women to become involved with intimate partners with multiple-problems creates an "at risk" environment for their children.

  3. Decreased supervision of children by drug using parents may increase the children's exposure to a broad spectrum of victimizing behaviors.

  4. Having rarely experienced boundaries of appropriateness and having not been protected, Project SAFE mothers may have difficulties teaching such boundaries and affording protection to their children.

  5. The dependence of a drug-using woman on her paramour for drugs, money and shelter contributes to the denial that this same partner may be physically or sexually abusing her children.

I. Prior Substance Abuse Treatment. The majority of women referred to Project SAFE since its inception have no prior experience with substance abuse treatment. Mixed with these treatment neophytes is a very small group of women at each treatment site that have profiles of multiple treatment episodes and chronic problems of relapse.

J. Prior Psychiatric Treatment / Concurrent Psychiatric Illness. Women entering Project SAFE present with concurrent psychiatric disorders that complicate their treatment and on-going efforts at recovery. Affective disorders and personality disorders were the most frequently noted concurrent psychiatric diagnoses of Project SAFE clients.

K. Aggression and Violence. During the past several years, SAFE clients have been at increased risk to be both victims of violence and perpetrators of violence. Project SAFE women tend to be drawn from those communities that have been hardest hit by increased violence. Concerns about protecting clients and their children from domestic and community violence have had to be consciously considered in the design of service activities. There is a clear recognition that many women coming to Project SAFE are in communities and personal relationships that place them at high risk for violent victimization.

L. Primary and Secondary Drug Choices: Cocaine, alcohol, cannabis and heroin are the dominant drug choices of women referred to Project SAFE.

M. Duration and Intensity of Use: Staff from Project SAFE sites have noted that clients are bringing substance abuse histories of greater duration and intensity than in earlier years of the project. Clients are presenting with more intense involvement in the addiction lifestyle and cultures of addiction. This implies more potential sources of sabotage of treatment efforts and the need for a more intensified treatment focus on the construction of sobriety-enhancing lifestyles.

N. Health Status: Women entering Project SAFE often present with acute medical problems, e.g., tuberculosis, hepatitis and sexually transmitted diseases that required immediate medical attention.

O. HIV/AIDS: Impulsive and high risk-taking behavior, substance impairment and involvement in drug-saturated social milieus all contribute to the risk of HIV/AIDS for women involved in Project SAFE. The number of women known to be HIV+ or to be diagnosed with AIDS admitted to Project SAFE has increased through the 1990s. As a result, SAFE sites are intensifying their HIV/AIDS prevention and education efforts and linkages to HIV/AIDS case management and other HIV/AIDS services.

P. Criminal Justice Involvement: Clients entering Project SAFE are more likely than in earlier years to be involved in criminal enterprises to support their addiction.

Q. Overall Level of Functioning: Women referred to Project SAFE are entering treatment with problems of great intensity and duration. Clients as a whole are bringing in lower levels of functioning than in earlier years.

III. Program Staffing

Staff members at Project SAFE sites can be identified as one of several types of employees:

A. Outreach Workers

Initially, Project SAFE outreach workers were hired in order to provide follow-up services to clients who had completed primary treatment. Relatively quickly, however, it became apparent that the efforts of outreach workers would also be required in order to engage women who had been referred by DCFS, but who were reluctant to enter the program, or even speak to a staff person. Currently, outreach workers are the primary mechanism of initial contact for clients entering Project SAFE. In fact, some 90% of Project SAFE clients require multiple outreach worker contacts before they can be successfully engaged to begin intensive outpatient treatment. Outreach workers also function as the primary resource for identifying and linking (and sometimes creating) day care resources to assure that Project SAFE clients may participate in the intensive outpatient treatment design. Outreach workers also worked with women in Project SAFE to address special child care needs, e.g., evening child care so that clients can attend self-help groups which meet at that time.

Detailed information regarding Project SAFE outreach services may be found in the Outreach Services Manual section of this web site.

B. Counselors and Clinical Supervisors
Chemical dependency treatment at Project SAFE sites is provided by professional counselors certified by the Illinois Alcoholism and Other Drug Abuse Professionals Association. Some these counselors also hold Bachelors or Masters degrees in a counseling discipline, and may or may not be recovering themselves. However, academic degrees and/or professional certification may be less important to success as a Project SAFE counselor as are certain values, beliefs, and knowledge, including:
• an understanding in the power of hope as a transforming factor in the lives of SAFE clients

• a non-judgmental attitude toward clients who have abused and/or neglected their children, and may have engaged in prostitution, theft, or other crimes in order to secure money to buy drugs

• the ability to accept the client’s seeming ambivalence toward the counselor, the SAFE program, and her own abstinence and recovery

• an understanding of the developmental model of pre-treatment and recovery which is germane to many SAFE clients.

• familiarity with both the community environment from which the client comes, and that in which the client will pursue her new, abstinence-, health- and recovery-focused lifestyle

• an ability to understand the client’s often tramagenic background and unique needs, and to develop a dynamic treatment plan which is based on that understanding

  Similarly, clinical supervisors (who may supervise both outreach workers and counselors) within Project SAFE are seasoned, masters-level clinicians who also possess certain skills crucial to the delivery of effective client care, such as:

• Involvement: The ability to respect and support the outreach worker and counselor on a personal level without becoming intrusive.

• Flexibility: The capacity to alter the style and focus of supervision to meet the individual needs of each outreach worker. This ability is less applicable to the supervision of counselors.

• Modeling: The ability to teach by modeling appropriate attitudes and skills when relating to clients.

• Encouragement: The ability to convey optimism and faith in clients’ capacity to change, and to convey the important role outreach workers and counselors play in supporting that change.

• Direction: The ability to guide the outreach worker or counselor through the resolution of difficult situations.

• Patience: The ability to nurture the progressive maturation of the outreach workers’ and counselors’ knowledge and skills through evaluation and teaching.

• Advocacy: The ability to represent the interests of the program and the needs of outreach workers and counselors, both within the agency and with outside funding and regulatory agencies.

• Courage: The ability to confront difficult issues that arise in staff-client and staff-staff relationships.

• Humor: The ability to laugh—at oneself, and within one’s daily interactions with staff and clients.

• Communication: The ability to serve as a switchboard for information within the program, linking and coordinating people and activities.

• Technical Competence: The ability to bring to the program and its staff a high degree of clinical knowledge about the treatment of addicted women and their children.

• Self-Awareness: The recognition of one’s own biases, deficiencies, and limitations.

• Accessibility: Availability to respond to questions, provide direction, and help with problem solving.

C. Program Coordinators
Most SAFE programs are coordinated by a masters-level female with extensive training and experience in the delivery of gender-specific addiction treatment services.

D. Child Care Workers
In some cases, SAFE clients have lost custody of one or more of their children, but for clients who retain custody of their children, an integral part of the Project SAFE program is on-site or contractual child care. On-site workers have specific backgrounds in child care, and in addition, receive in-service training which prepares them to effectively work not only with the children of SAFE clients, but with the clients themselves.

IV. Program Elements

A. Outreach ("pre-treatment" and client engagement)
The oral history of Project SAFE is filled with stories of outreach workers knocking on the doors of treatment-resistant clients, building supportive relationships with these clients and somehow motivating them to enter substance abuse treatment. This role has evolved out of a growing understanding that this engagement process that occurs within SAFE reflects the emergence of a new and unnamed treatment modality whose purpose is to bring enough hope and stability to a woman's life so that she is ready for our traditionally defined treatment modalities. It has also become quite clear in recent years that the vast majority of women referred to Project SAFE would not get into treatment without this period of outreach worker engagement.

B. Case Management
Project SAFE clients typically present with a wide range of problems, including:
• addiction to psychoactive substances

• a history of abusing and/or neglecting their children

• mental illness

• homelessness

• medical complications, including HIV+ status or AIDS

• involvement in the criminal justice system

• unemployment and lack of job readiness

• children with histories of educational, behavioral and/or physical problems.

• a history of relationships with violent, drug-involved intimate partners who may pose a secondary risk of child maltreatment

• involvement with a variety of public sector institutions (e.g., public aid, probation or parole services, hospitals or neighborhood clinics) most of which do not coordinate services with the others

  Before the client’s attention can be adequately focused on addiction and child welfare issues, the chaos produced by the multitude of appointments, responsibilities, and paperwork associated with the above must be brought within manageable limits. Thus, aggressive case management is a critical part of involvement with Project SAFE programs.

C. Chemical Dependency Treatment
Although clients may present with a wide range of varied problems, addiction to alcohol, cocaine and/or other drugs remains a primary focus of Project SAFE programs. The SAFE sites offer a variety of levels of care for chemical dependency including residential and intensive outpatient programs. Within these levels of care, a number of clinical services are available, including traditional group and individual counseling. Special groups, such as those for adult survivors of childhood sexual abuse, are also included at SAFE sites.

D. Child Care
The provision of child care services continues to be a crucial dimension in access to treatment by Project SAFE clients. Day care is either provided on-site at the Project SAFE sites or is provided contractually by local day care providers. More specialized resources have been needed as the number of infants, children under three and children with special medical or learning problems have increased during the past few years.

Three Project SAFE sites received special grants to provide specialized services aimed at enhancing the relationships between Project SAFE mothers and their children. Known as Project Joyous and SAFE Futures, the program focuses on:

• improving parent-child bonding,

• enhancing the emotional, cognitive and social development of the children,

• offsetting the damaging effects of having lived with a substance abusing parent, and

• preventing child abuse and neglect.

Service components include therapeutic activity play groups for children, mother/infant and mother/child therapeutic activity groups, and continuing care groups for different aged children.

E. Parenting Training
Between 1981 and 1983, the Illinois Department of Children and Family Services pioneered the design, development, evaluation and refinement of a Parenting Training curriculum that was designed to meet the unique needs and characteristics of parents involved with the agency. The curriculum was specifically designed for parents who were single women between the ages of 25-35, who had up to three children, who were supported by ADC and who were involved with DCFS because of child neglect. The curriculum further targeted parents:
• whose children were at home but were under threat of placement due to impaired parenting skills of the parent;

• who could read at least at the 5th grade reading level and who had a minimal level of verbal skills to allow for participation in a group training environment; and,

• whose children were 12 years of age or younger.

Project SAFE sites use several parenting training curricula. Most sites continue to use elements from the DCFS-developed Parenting Training curriculum. While some sites use this curriculum exclusively, others supplement certain of its elements with material from Effective Black Parenting, Perfect Parenting, Parents are Teachers Too, and It Takes a Village to Raise a Child. A new curriculum, The Nurturing Program, has been used in those sites which are Project Joyous and SAFE Futures demonstration projects. The client response to this curriculum has been very positive and staff who feel The Nurturing Program is much more experiential and congruent with their clients' learning styles than other curricula they have used. Other programs utilized within the parenting training component of Project SAFE include Under the Same Roof, Parents in Recovery, Active Parenting Today, Active Parenting of Teens, Clean and Sober Parenting, Magic 1,2,3, Parents Healing: A Way of Living, Art of Parenting, and the Detroit Family Project Curriculum. Most of the sites have modified these materials for applicability to persons with limited literacy and added highly practical components that address more basic caretaking, homemaking, and situational skills, such as:
• Safety rules in the house,

• How to bathe a child,

• Preparing bottles and food,

• Appropriate dress for weather,

• Checking for (and treating) head lice,

• Home care of rashes,

• How to read a thermometer,

• How to know when to take a child to the doctor,

• How to pack a diaper bag,

• What to do with a wet child when you're out of diapers, and

• Age appropriateness, the timing of speech, walking, toilet training.

F. Linkage with Support Groups
All Project SAFE sites incorporate exposure to traditional 12-step programs (AA/NA/CA) within their treatment design, but most sites are becoming much more flexible in the type of sobriety-based support structures that clients may utilize to enhance their recovery. Sites are leaning more toward creating with the client a menu of options out of which the client can construct a sobriety-based support structure. In their initial orientation groups for SAFE clients, most sites now discuss such groups as Women for Sobriety, Rational Recovery, and Secular Organization for Sobriety, in addition to traditional 12 Step programs. One of the reasons for such flexibility is that obstacles exist for client participation in traditional 12-step groups. These obstacles include:
• a lack of geographically accessible meetings

• a lack of evening child care and transportation

• shyness of clients going to new locations and entering situation in which they don't know anyone

• the discomfort of many African American and Latina clients in predominately Anglo self-help meetings

• concerns of psychological safety in the meetings and physical safety as the women move in and out of their homes at night

• emotional exhaustion from almost daily treatment attendance rendering self-help activity at night less appealing

• cultural prohibitions against self-disclosure ("putting family business on the streets")

Some women in Project SAFE are also using the church as a sobriety-based support structure either by itself or in addition to participation in 12-step groups. In some communities, African American churches are organizing recovery-based support groups that meet at the churches.

G. Continuing Care ("Aftercare")
One of the lessons learned in Project SAFE is that the early recovery of Project SAFE women is fragile. In particular, the shift from primary treatment to aftercare marks a major disruption of this structure and constitutes a high risk period for relapse. Project SAFE sites manage this transition by slowly, rather than abruptly, phasing the client from the high structure of primary treatment to the traditionally low structure of continuing care support groups. Today women in Project SAFE in Illinois participate in a phased program of aftercare services that last at most sites from 18-20 weeks.

As experience increased within each Project SAFE site, there was a growing emphasis on the kind of long term support structures SAFE clients needed to sustain their chemical health and family health. This emphasis has lead to increased attention on the nature of support services that follow completion of the formal intensive outpatient treatment program. Variations in philosophy and approach included the following:

• the mainstreaming of Project SAFE clients within the substance abuse treatment agency's client aftercare groups

• the development of a SAFE-specific aftercare track

• the development of a menu of aftercare activities from which each client can select the combination that best meets her needs

• increased emphasis on shifting support functions from the agency site to community-based self-help groups such as AA/NA

• the use of an open-ended long term sobriety-focused aftercare group as an adjunct or alternative to traditional 12 step programs, and

• the development of a parenting-focused aftercare system in which parenting training classes and parenting support groups become the primary post-treatment support structure.

H. Relapse Prevention
Aftercare programs play an important role in relapse prevention and early intervention into relapse events. There is a consistency across project sites on those circumstances that pose high risk of relapse both during and following treatment. Project SAFE clients are at high risk of relapse when they near completion of the program. Staff attribute this risk to fear of loss of support and fear of success and the assumption of new responsibilities. The following are times and events which pose a particularly high risk of relapse:
• the return of children from placement

• the birth of a child

• the experience of loss, e.g., abandonment by intimate partner, or death of loved one.

• a change in daily structure or routine such as holidays

• "Mother’s day" (days when child welfare checks arrive)

• acts of sabotage (including coerced use) from intimate partners. Acts of coercion and violence in these relationships are particularly disruptive, often triggering the vivid recollection of earlier emotional/sexual trauma.

V. Program Evaluation

A. Major Findings: The major findings of the outcome study based on data collected from the first 105 women who participated in Project SAFE between July 1986 and June 1988, and the debriefing of Project SAFE staff from the original four sites are summarized below:
• The Project design was able to engage a heterogeneous client population in the service delivery process. Project SAFE clients represented wide differences by age, ethnicity, marital status, living environment, and assessed risk of future abuse/neglect.

• Project SAFE was able to identify and treat a new population of alcoholic, neglectful mothers who in all likelihood would have remained undetected and untreated without Project SAFE. Over half of Project SAFE clients had no prior history of either alcoholism or psychiatric treatment.

• Project SAFE clients had both high successful completion rates (81 percent) and high prognosis ratings upon discharge (51 percent left with an excellent or good prognosis as rated by the treatment staff).

• Results from the Home Functioning Scale for Substance Abuse and the Alcohol and Drug Use Severity Index demonstrated that Project SAFE clients were able to achieve a high degree of stabilization of early recovery and were able to extend this sobriety through the duration of the data collection period. Positive ratings achieved in this area included in addition to abstinence from alcohol, involvement in Alcoholics Anonymous (AA) meetings, contact with AA sponsors, and avoidance of situations that would pose high risk of relapse.

• Post-treatment scores on the Self-Analysis of Anxiety Scale, the Personal Assessment Inventory and Home Functioning Assessment for Emotional Health Scale all suggest that Project SAFE clients experienced increased emotional health as a result of project participation. Clients experienced decreased depression, decreased anxiety, and increased self-esteem as measured by both client self-reports and weekly in-home assessments recorded by outreach workers. These results were not statistically significant.

• Home Functioning Assessment for Parenting and Family Functioning and subscores on the Mother-Child Relationship Scale suggest that both the parent-child relationship and overall family functioning improved for Project SAFE participants as indicated by both self-rating scales and by in-home observation and assessment by outreach workers. Project SAFE mothers were significantly less rejecting in their attitudes toward their children after treatment than were the control group mothers to whom they were being compared.

• Improvements in parental functioning are further evidenced by looking at both reunification and abuse/neglect recidivism rates. Through participation in Project SAFE, 30 of the 55 children who had been removed from these mothers were returned home, for a reunification rate of 54.5 percent. The reunification rate for children of mothers in the control group was only 40 percent. Control group mothers experienced a 21.4 percent recidivism rate of subsequent child abuse/neglect reports. In contrast, Project SAFE mothers experienced a recidivism rate of only 6.25 percent, which did not include any incidences of child abuse.

B. Additional Findings and Recommendations
• The overall success of the implementation, operation, evolution and evaluation of a Project SAFE service design requires a high level of coordination and collaboration between substance abuse treatment and child protective agencies at state, regional and local levels. This coordination and collaboration must be actively created and managed through on-going planning and teambuilding activities. State level commitment and designated local leadership are essential elements of project success.

• Curriculum design and training efforts with a Project SAFE model must focus on teambuilding and cross-fertilization between substance abuse and child protection workers and must concentrate primarily on the initial process of interviewing, assessing, confronting, supporting and engaging alcoholic neglectful mothers toward the goal of project participation.

• There was unanimous belief that the role of the outreach worker was the most essential ingredient in motivating entry into treatment, integrating and applying alcoholism treatment and parenting principles outside the treatment center, and sustaining treatment gains after discharge. Aggressive outreach services, which have moved out of fashion in the alcoholism field, were the hallmark of Project SAFE. Service interventions which might be pejoratively labeled "rescuing" or "enabling" for alcoholic men, may be essential ingredients to initiate and sustain early recovery for a significant portion of alcoholic women.

• It was essential that the alcoholism treatment services component of Project SAFE first be designed to meet the specialized needs of women alcoholics, and, secondly, be designed to meet the needs of women alcoholics who shared the unique characteristics of Project SAFE clientele, i.e., 74 percent rate of parental alcoholism, and a 95 percent rate of childhood sexual abuse. Special service designs are essential if replications of this project in other sites are to achieve similarly high success in treatment outcome.

• Parenting training within a Project SAFE model must recognize the post acute withdrawal syndrome experienced by most alcoholics. Alcohol induced neurological deficits, i.e., impairment of concentration and memory, may make it necessary to postpone parenting training to near the end of treatment and to utilize frequent repetition and involve multiple senses in the learning process.

• Evaluation and research components of a Project SAFE must be designed to evolve and adapt with refinements in the service delivery process. Such refinements should not be prevented in the name of maintaining purity of research methodology. Evaluation activities should include process as well as outcome elements. Evaluation efforts should continue to address not only what the project accomplished, but how such accomplishments were achieved.

• There is every indication that the coordinated and concurrent delivery of specialized alcoholism treatment services, parenting training, intensified casework services and in-home outreach worker supports can be effectively combined to successfully treat alcoholic mothers, to enhance family and parental functioning and to reduce the incidence of neglectful behavior.

• The overall findings of Project SAFE warrant wide replication, refinement and further evaluation of this innovative service model.

C. Findings from Additional Project SAFE Studies
During July-August, 1990, the Project SAFE evaluator met with the DCFS workers and outreach workers and treatment staff from the original pilot sites for Project SAFE as well as the expansion sites. The purpose of these meetings was to review past experience with a particular focus on further adaptations which had occurred in the Project SAFE service model based on what had been learned through the experience with an additional 315 women. To understand the nature of the adaptations which occurred in 1989-1990, it is crucial to understand the broader context within which Project SAFE was operating. In FY 1986Cthe year of pilot testing and crystallizing the Project SAFE service designCthere were 297 cases of substance-exposed infants reported to DCFS in Illinois. In FY 1990Cthe year of Project SAFE expansion into major urban sites in IllinoisCthere were 2,399 cases of substance-abused infants reported to DCFS. The SAFE expansion came at a time when cocaine addiction in women was a growing concern and the problem of cocaine- exposed and -affected infants was an overwhelming concern among child welfare and public health professionals. Between 1989 and 1990, the primary drug of choice for women referred to Project SAFE shifted overwhelmingly (in all but one service site) from alcohol to cocaine. Adaptations of Project SAFE during the period 1989-1990 included the following:
• The intensity of cocaine addiction forced treatment sites to alter the treatment structure to initially break the cycle of cocaine use and to prevent/manage relapse. Structural adaptations included:
  1. Increased utilization of referrals for detoxification and residential treatment prior to initiation of SAFE involvement or for women who presented continued relapse.

  2. increased duration of intensive outpatient treatment (from 4-5 week model to 8-12 week model)

  3. increased frequency of contact (more in-home contact, weekend contact)

  4. phased transition from intensive outpatient treatment to aftercare and self-help (levels of decreasing care phased in over weeks, e.g., 20 hours to 15 hours to 10 hours to 5 hours to aftercare groups and self help only)

  5. extended period of total involvement with client (ideal time of total involvement seen as approximately one year)

• The increased involvement of minority women (more than 60 percent of total) required adaptations at many sites, e.g.:
  1. staff training on cultural sensitivity, building relationships between treatment agencies and persons and institutions in minority community, refinements in some treatment protocol and adaptations in the parenting curriculum.

  2. Project SAFE clients continued to present with enormous developmental deficits reinforcing the position that Project SAFE must see and operate itself as an habilitation rather than a Rehabilitation process.

  3. Urban, cocaine-abusing women entering Project SAFE in 1989-1990 presented with a great number of personal and environmental obstacles to recovery (acute medical problems of client and children, housing/homelessness crises, transportation difficulties, legal problems, involvement in violent and treatment sabotaging relationships, etc.) that required intensified outreach worker services and a greater case management focus through the early phases of treatment.

• Project SAFE continues to demonstrate that aggressive outreach worker services can initiate and sustain treatment involvement with women who have been historically viewed as hostile, resistant clients with a poor prognosis.

D. Two additional process evaluations have been conducted Cthe first in the fall of 1991 and the second in the Spring of 1993. The major findings from the FY 1991 and FY 1993 evaluations are detailed below.
• Project SAFE served a total of 1451 women and their children between June 30, 1991 and July 1, 1993. These women and children were served in fourteen settings that ranged from the highly urbanized communities of Chicago and East St. Louis, smaller suburban and metropolitan communities, and multiple county rural catchment areas in southern Illinois.

• While the core treatment design of Project SAFE continued to involve intensive outpatient substance abuse treatment, home-based outreach and case management services and parenting training, the substance abuse treatment component of Project SAFE continued to evolve. The design of the intensive outpatient models utilized at Project SAFE sites in 1993 are illustrated on the following page. The overall themes of this evolution include:
  1. Increased Duration of Treatment: The time required to produce successful treatment outcomes continued to lengthen. The period of intensive outpatient treatment involvement has grown from 4-6 weeks in 1986 to a current length of 8-12 weeks in most SAFE sites. The total length of involvement from initial contact through treatment and aftercare to discharge is now projected in the 12-18 month range at most of the treatment sites.

  2. From Time-based to Criteria-based Length of Service: There was a trend away from defining a set length of program participation. Rather than saying the client will attend treatment for 4 weeks, the client stayed until individualized treatment goals were accomplished. This shift has focused the client's attention from counting time to treatment activities and progress.

  3. Increased Intensity of Treatment: Growing use of residential and detoxification services before or during the client's involvement in Project SAFE has been noted.

  4. Treatment Intensity: Sites found that outpatient treatment intensity had to be increased to compete with the drug experience and the drug culture.

  5. Increased Specialization: Sites continued to evolve more specialized treatment approaches based on the characteristics of women entering each of the Project SAFE sites. Some of these adaptations were multicultural in nature. Others involved special obstacles, e.g., illiteracy, concurrent psychiatric illness, eating disorders, etc.

  Some of the innovations in treatment activities initiated during recent years within Project SAFE sites included the following:

• increased focus on education and trainingClinking clients to specialized community college programs for adult learners, homemakers entering the work force and the homeless,

• refinements in educational programming within treatment to include new lectures on: postpartum depression, sexuality, and symptoms of post-acute withdrawal,

• a more formalized utilization of expressive forms of therapy (art, dance, drama) ,

• more specialized group services: cocaine-specific groups, self-nurturing groups (focus on reparenting and self-care), life skills groups (job skills, educational options, alternative entertainment), survivor's group (abuse and victimization issues), women's issues groups, RAP group (HIV education),

• increased use of community resources, e.g., field trips to jail, recreational therapy in community, etc., and

• development of a special track for relapsed clients.A. Major Findings: The major findings of the outcome study based on data collected from the first 105 women who participated in Project SAFE between July 1986 and June 1988, and the debriefing of Project SAFE staff from the original four sites are summarized below: