Columbia University School of Social Work
SOCWT302 Social Work Practice in Alcohol & Substance Use

Native Americans, also called American Indians, First Nations, and Indigenous peoples, are referred to as the first population who are said to inhabit the North and South American continents. Alaskan Natives (AN) are also included under the term ‘Native American’. Today there are 5.2 million Native Americans accounting for less than 2 percent of the U.S. population. Alaska has the highest rate of people that identify as Alaskan Native and American Indian. There are currently over 500 federally recognized First Nation tribes and about 325 Native reservations. Native Americans who live on reservations have disproportionally higher rates of poverty at 29.4 percent compared with the national average of 15.3 percent (HHS). Each tribe has their own language, cultural customs and traditions. For example, a Northeastern Woodlands tribe will be different than a tribe of the Desert Southwest. This is important to note to professionals working with this population.

Although Native Americans and Alaska Natives only comprise of 1.7 percent of the total U.S. population, they have the highest rates of substance abuse compared to other racial groups. According to the 2018 National Survey on Drug Use and Health, 10 percent of Native Americans have a substance use disorder and 7.1 percent have an alcohol use disorder. The survey also shows that 1 in 5 young adults (18-25) are reported to have a substance use disorder (NSDUH, 2018).

The high rates of substance use disorders among Indigenous people are linked to social determinants of health, including poverty, poor healthcare, inadequate resources and accessibility, chronic stress, and culturally incompetent behavioral health services (Gone & Trimble, 2012). The prevalence of substance abuse and mental health disparities can be viewed as a response to intergenerational trauma and historical oppression. Native Americans have experienced a legacy of violent colonization including, but not limited to, genocide, removal of children and the breaking up of families, bans on language and cultural practices, and forced assimilation (Ehlers, 2013). Substance Use Disorders can also be considered a spiritual problem as individuals use drugs to cope with being disconnected from their cultural and spiritual identities which are both significant to their well-being.

Developing culturally appropriate and effective treatment interventions with Native people has been slow in progress. Substance use disparities have plagued NA/AN populations for years but they continue to have the greatest unmet treatment of all populations. Only a small percentage of those with SUDs receive treatment (Chartier & Caetano, 2010). NA/AN populations are underrepresented in clinical intervention studies due to both mistrust from NA/AN people of those conducting research and lack of opportunity to participate. For example, in the largest study on alcohol disorder treatment called Project MATCH, only 1.4 % of the total sample that participated identified as NA/AN (DiClemente, 2011). One of the dilemmas of mistrust stems from the history of power the federal government used to wage war on Indigenous peoples. Some service providers and community members believe that mainstream treatment methods and research are another form of colonization and would do more harm to their communities (Gone, 2007).

Though the substance abuse treatment system for Native populations was managed separately, it emerged from the same federal service system as the rest of the U.S. during the 1960s and 1970s before being transferred to the IHS (Indian Health Services). The counselors who are trained to work with this population were trained based on the 12-step program model that is widely accepted in the U.S. (Miller, 2006). Although there is evidence of its success, the 12-step approach has also been met with resistance because of conflicts with traditional Native beliefs. A few leaders in the NA/AN community later adapted the approaches and advocated for a stronger emphasis on combining the 12-step program with traditional practices (Coyhis, 2006).

The IHS reports that there are over 400 behavioral health programs serving Native communities but there is a lack of reliable data about the quality of these programs (IHS). In one study on the use of evidence-based treatments (EBT) in substance use treatment programs serving Native communities, 192 clinicians participated in a survey on treatment methods. Results found that 96% of programs implemented a psychosocial treatment and 54% used a medication treatment. Of the psychosocial treatments, the most concentrated were Cognitive Behavioral Therapy, Motivational Interviewing, Relapse Prevention Therapy, and Twelve-Step Facilitation. Another four EBTs; Contingency Management, Behavioral Couples Therapy, Reinforcement and Family Training, and Multisystemic Training were mostly unheard of which indicates that treatment options and modalities are limited. The study also found that the three of the most common modalities were rated to be culturally inappropriate (Novins et al., 2011). The results of the study confirm that EBTs have yet to be acceptable approaches to treating substance use disorders among NA/AN communities.

Effective treatment is necessary to improve healthy equity in Native communities, but the issue is that it is not known whether evidenced-based treatments would significantly improve SUD disparities among native populations. If there are treatments that are confirmed to be effective, other factors to consider are cultural sensitivity and accessibility.

In one of the most comprehensive studies on Native adolescents in residential substance abuse treatment, participants went through a 12-step program, received cognitive behavioral therapy, and had access to medication for comorbidities for non-substance use psychiatric disorders. The program was also tailored to incorporate a traditional healing component. The panel on this study found that incorporating cultural values is necessary to effectively work in treatment for NA/AN populations with SUDs (Novins et al, 2011).

Culturally appropriate treatment methods are necessary because cultural traditions and social practices influence behavior. In relation to substance use, research indicates racial and ethnic differences of drug histories, substances most used, health outcomes from drugs, and attitudes about drugs relating to spirituality and acculturation (Burlew et al, 2013). Bronfenbrenner’s ecological systems theory illustrates the importance of social and cultural factors in changing behavior (Brofenbrenner, 1979). Researchers have also found that treatments compatible with a client’s culture are more effective (Tharp, 1991).

Euro-American psychotherapeutic interventions are individualistic in nature, focusing on the client-therapist relationship. However, most Indigenous cultures value communal interventions. Community and family are usually present and participating when one person is healing. The therapist is also less centralized and there is emphasis on the patient being his own healer.

Another thing to consider is the use of plant medicines which is a factor that Western biomedicine is just beginning to accept with the research and legalization of cannabis, psilocybin, ibogaine, and other healing plants. For example, Peyote has been used to successfully treat alcohol use disorder among members of the Native American Church. Native American healing involves the emotional, physical, mental, and spiritual aspects of people and their environment.

Some programs have sought to utilize culturally relevant treatments and prevention for NA/AN populations. Culturally Grounded Health Interventions is a program that uses traditional ways of teaching to prevent recreational tobacco use. They utilize teachings by elders, crafts, stories, and videos. It has been shown to improve dietary attitudes among youth. Bii-Zin-Da-De-Dah (Listening to One Another) is a family-centered substance abuse program that offers 15 weekly experiential learning sessions for youth and their families. Parents and families are encouraged to connect with each other. Tribal communities can also adapt the program to their local culture. The program has shown success in delaying the initiation of drinking alcohol for youth and improvement in behavior management.

Another technique that has been used for lifestyle change is Narrative Therapy. Narrative Therapy is a culturally sensitive approach to working with the client and understanding the world they live in. The process of storytelling is common in Native American communities which makes it a compatible and appropriate technique. It has been used as a therapeutic intervention for Native recreational tobacco users (Haring, 2013).

Because healing is communal, treatment would need to include the client’s family or close members from their community. Treatment would need incorporate Indigenous identity and spirituality to empower clients to view their healing with meaningful engagement with the world.

In response to the need for a culturally relevant treatment program, I would like to propose a multifaceted trauma-informed program that would target SUDs and complex trauma among Native populations. The program I propose would be a social services center that would not only provide substance use treatment, but also provide resources and advocacy to Native people. The center would be Native oriented. The cultural, spiritual, and tribal values of the local population would be reflected in the mission and philosophy of the organization.
The substance use program would be an outpatient program that focuses concurrently on a group of 20-30 people. It would be staffed by substance use treatment counselors, social workers, clinical psychologists, case managers, traditional healers, tribal leaders, and administrators. Most of them would be Native and/or have experience working with Native populations. This would ensure that staff are culturally competent. The substance use program would integrate western treatment modalities such as MAT, CBT, and a twelve-step facilitation. MAT along with CBT is associated with improvement in substance use outcomes (Saunders et al., 2015). Often individuals who have substance use disorder exhibit cognitive distortions about their own feelings that serve as reasons for their substance use and consequences of their substance use.

One of the goals of CBT is to regulate their emotions and restructure negative thoughts associated with their desire to abuse substances (Stotts & Northrup, 2015). MAT helps target psychiatric symptoms for patients with co-occurring opioid use and as a result improves decreased rates of continue substance use and overdose, greater functioning, and an overall better quality of life (Saunders, 2015). A twelve-step facilitation program that is culturally tailored to Native spirituality can be a culturally appropriate way of incorporating storytelling and influencing personal change. One of the twelve step programs that is used is based upon the teachings of the medicine wheel, the cycle of life, and the four laws of change. The teachings are by Native Elders and follow a similar guideline as the more well-known 12-step programs but also incorporate storytelling and cultural teachings (“Medicine Wheel and 12 Steps”, 2013).

Trauma-informed treatment is significant because many Native people who have SUDs also experience complex trauma, which is the experiences of multiple forms of interpersonal trauma. For example, many Native women who have SUDS have experienced sexual assault in their life (Kaliszewski, 2022). It is important for clinicians to be understanding of the many layers of trauma that could affect their client and how their clients’ past trauma could affect the way they perceive their current trauma.

Also incorporated into substance use treatment is treatment with the community. Healing with the community is a vital aspect of healing for Native people. Community based treatment encourages prevention, treatment, and after-care to take place within the community. Part of community healing includes healing historical trauma together. I would propose that there are community events and programs that focus on four pillars of wellness; physical, mental, emotional, and spiritual. For example, there may be workshops that focus on traditional foods and herbs which incorporates the mind-body aspect of healing. There may be community events spent in nature. There is also research that supports the benefits of meditation, prayer, and drum circles, which are important aspects of Native culture.

Ceremonies are an essential part of Native healing. Traditional healing ceremonies connect body and spirit as spirituality is an integral part of their being. Some Native communities use hallucinogenic substances for religious and spiritual ceremonies. One hallucinogen used is Peyote, which is a small cactus native to parts of southwestern states and Mexico. It has been used in rituals for several thousand years. In the late 1800s, the Native American Church (NAC)formed and they held Peyote ceremonies as part of their religious rituals. In 1994, an amendment to the American Indian Religious Freedom Act allowed peyote to be used in this context (Jones, 2007). Although there is no significant relationship between substance use and NA/AN cultural identity, some Native Americans may positively relate to peyote use because of its spiritual significance. In a study on the psychological and cognitive long-term effects of peyote use among Native peoples, there was no evidence of cognitive deficits from long-term use (Halpern, 2005).

Peyote has shown to be associated with improvements in depression and anxiety. In one study, 452 participants responded to a questionnaire about their use of mescaline, a psychedelic substance derived from peyote. Among those who reported to have experienced depression at the time of their mescaline use, 86 percent reported improvements in their condition after use. The study also indicated that peyote can improve mental health by making people more accepting of distressing events in their life (Agin-Liebes et al., 2021).
On a study on the drinking patterns of Winnebago Indians, researchers found that peyote was used to help control excessive drinking. In another study, researchers found that peyote had was associated with thoughts about changed drinking behavior of Native people with alcohol use disorder. In a reflection on his study, Dr. John Halpern said that his research was humbling because he could hear the stories of people whose lives were changed for the better through their spiritual connection with peyote. He quotes, “It seems to me that likely it “works” not just because of the chemical components of the peyote itself, but even more because of the context within which it is engaged with. A ritual context.” (Webb, 2011).

Although more research needs to be done for peyote and other psychedelics to be used in the treatment of mental health disorders. Currently western medical model dominates in the treatment of SUDs for Native American populations, but there are culturally relevant alternatives being explored. My proposed program would integrate both western modalities and Native spirituality. It is vital that community heals together, while at the same time there is space for individuals with SUDs to receive appropriate treatment with therapy and/or MAT. The goal of SUD treatment with Native populations is to provide spiritually and culturally relevant coping skills while developing their support network and resources.

References

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