Substance Abuse and Effective Treatment for Adult American Indians and Alaska Natives: Culture and Resilience over Addiction

MICHELE HENSON, B.S., C.H.E.S.

MPH CANDIDATE, UNIVERSITY OF ARIZONA

Abstract

From a life-course perspective, adults play an important role in shaping proximal environments

Substance abuse has a bi-directional relationship with health disparities

Substance abuse rates vary greatly among AIAN communities

Overall substance abuse rates have not changed in decades

Many have concluded that the lack of culture in substance abuse treatment is a downfall in current treatment regimes

Methods

Literature search of PubMed Central using the search term “adult American Indian Alaska Native substance abuse treatment programs”

Inclusion criteria were:

(1) written in English

(2) discuss substance abuse treatment

(3) population of interest is adult American Indians and/or Alaska Natives

(4) peer reviewed publications between 1970-2013

Results

A total of 26 articles met

all criteria and were

included in this literature

review

Results: 4 Main Themes Emerged from a Nominal Classification

Persistent Challenges

Protective/Recovery Factors

Current Trends in Treatment

Culture in Treatment

Culture as Treatment

Protective/Recovery Factors

Positive family relationships

High degree of social support and spiritual involvement as both a protective and recovery factor

Brave Heart, 2011

More likely to recover if:

Married

Gilder et al., 2010

Have children

Torres Stone et al., 2005

Protective/Recovery Factors

Enculturation

“…Enculturation serves as a resiliency factor that may protect against alcohol misuse or serve as an important curative factor in alcohol treatment programs”

Torres Stone et al. (2006)

Those with low traditional culture orientation were 4+ times more likely to drink heavily

Herman Stahl et al. (2003)

Protective/Recovery Factors

Biculturalism Feeling comfortable in identifying with both traditional culture

and the majority culture

The lowest rates of substance abuse were found in AIANs who processed healthy biculturalism

Blume & Escobedo (2005)

Szlemko et al. (2006)

Trends in Current Treatment

General requirement for the use of Evidence-Based Treatments (EBTs) Required for grant funding and Indian Health Service and

Medicaid reimbursement

AIANs are typically not included in study population of the evaluation of EBTs

Sklemko et al. (2006); Novins et al. (2011)

Trends in Current Treatment

Problems with the use EBTs in the AIAN population: Culturally inappropriate

Naquin et al. (2008); Hartmann & Gone (2011); Novins et al, (2011); Wexler (2011)

Self-reported feelings of incompatibility and lack of comfort Walls et al. (2006); Hartmann & Gone (2011); Novins et al, (2011); Wexler

(2011)

“No room” for culture in EBTs Sklemko et al. (2006); Novins et al., (2011)

Many AIANs have stated preference for cultural (non-EBT) treatment that is rooted in traditional healing and indigenous knowledge

Walls et al. (2006); Hartmann & Gone (2011)

Culture in Treatment

Inherent within AIAN culture are traditional ways of healing and

ways of knowing

Many AIANs who have successfully recovered attribute that

success to a return to his or her tradition culture

Torres Stone et al. (2006); Walls et al. (2006); Gone and Calf Looking

(2011)

Culture in Treatment

AIANs identify with their traditional cultures in

different ways and to different degrees

AIANs may not want to abandon the use of Euro-

American (‘western’) models of treatment completely

Appropriate treatment will depend on degree of

personal cultural identification

Choices between or integrating both healing methods

is preferred and necessary

Culture as Treatment

High substance abuse rates are a result of loss of traditional beliefs and culture

Szlemko et al. (2006)

Brave Heart (2011)

Culture revitalization has the potential to create health benefits beyond sobriety including: Ability to relieve stress and treat co-morbidities

Root causes of substance addiction

Strengthen AIAN families (protective factor)

Create healing effects on entire AIAN communities Trauma (a root cause of substance abuse) is shared by AIAN populations

and communities

Brave Heart (2011); Gone and Calf Looking (2011)

Successful Treatment Recommendations

Increase the capacity to incorporate culture into treatment Culture as a dominant force in treatment

Bicultural skills training

Shift community social norms (passive acceptance)

Resilience in AIANs in regards to Substance Use

Remission rates of AIAN substance abusers have been reported to be as high as 75%

Successful AIAN driven sobriety movements: Eskimo Spirit Movement (Inupiaq Ilitqsat)

Ceremonies sponsored by the Native American Church

Handsome Lake Movement

Red Road Sobriety movement

AIAN communities self-determining alcohol policies

Many AIAN communities report higher rates of abstinence than the general population

Discussion

35% listed the lack of accessible health care and substance abuse treatment as a major barrier to reducing substance abuse rates

58% outlined the efficacy of culture incorporation in AIAN substance abuse treatment

38% made the claim that EBTs are not improving but limiting the successful outcomes of substance abuse treatment

Discussion- Where do we go from here?

EBTs are not the best treatment method for everyone

EBT requirement are limiting innovative treatment practices

If the EBT requirement is to remain, some have suggested testing cultural healing and substance treatment practices

Problems with ‘testing’ cultural substance abuse treatment methods: Some AIAN communities may not feel comfortable ‘testing’ their sacred

healing methods Differences/uniqueness of cultures

Recommendation

Reevaluate the EBT requirement for funding and reimbursement for AIAN substance abuse treatment regimes Move from ‘Evidence-based’ to ‘Practice-based’ requirement Enables AIANs to access treatment that works for them Allows for further AIAN self-determination

Seek out those who have successfully recovered from addiction and identify factors that contributed to recovering Give voice to those who have recovered in peer-reviewed

literature

Contact Info and Special ThanksMichele Henson michelehenson@email.arizona.edu

Special thanks to the Center for American Indian Resilience

This work was supported by the Center for American Indian Resilience (CAIR) a NIH-NIMHD P20 Exploratory Center of Excellence

(1P20MD006872) awarded to Northern Arizona University with subcontracts to University of Arizona and Dine College

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Brave Heart, M. Y. H. (2011). The Historical Trauma Response Among Natives and Its Relationship with Substance Abuse: A Lakota Illustration. Journal of Psychoactive Drugs 35 (1), 7-13.

Gilder, D.A., Lau, P., Corey, L., Ehlers, C. (2008). Factors Associated with Remission from Alcohol Dependence in an American Indian Community Group. American Journal of Psychiatry 165(9), 1172-1178.

Gone, J.P., Calf Looking, P.E. (2011). American Indian Culture as Substance Abuse Treatment: Pursing Evidence for a Local Intervention. Journal of Psychoactive Drugs 43(4), 291-296

Hartmann, W.E., Gone, J.P. (2012). Incorporating Traditional Healing Into an Urban American Indian Health Organization: A Case Study of Community Member Perspectives. Journal of Counseling and Psychology 59(4), 542-554.

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SourcesNaquin, V., Manson, S.M., Curie, C., Sommer, S., Daw, R., Maraku, C., Lallu, N., Meller, D., Willer, C., Deaux, E. (2008). Indigenous Evidence-Based Effective Practice Model: Indigenous Leadership in Action. The International Journal of Leadership in Public Services 4(1), 14-24.

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Walls, M.L., Johnson, K.D., Whitbeck, L.B., Hoyt, D.R. (2006). Mental Health and Substance Abuse services Preferences among American Indian People of the Northern Midwest. Community Mental Health Journal 42(6), 521-5356. 3

Wexler, L. (2011). Behavioral Health Services “Don’t Work for Us”: Cultural Incongruities in Human Services Systems for Alaska Native Communities. American Journal of Community Psychology 2011(47), 157-169.

Questions?