The Role of Culture in Substance Abuse Treatment Programs for American Indian and Alaska Native Communities

Eighteen substance abuse treatment programs serving AI/AN communities participated in the program case study component of this study, which is the focus of these analyses. These 18 programs reside within three tribes, one tribal consortium, and three urban organizations from seven Indian Health Service regions and seven states. Ten programs are located on reservations, three in nonreservation rural areas, and five in urban areas. Tribes or tribal nonprofit organizations operate these programs, all of which receive additional funding from Indian Health Services. The advisory board identified programs on the basis of their reputations for innovative clinical services and to ensure adequate representation of the geographic and cultural diversity of AI/AN communities. Each program approached agreed to participate. Seventy-seven service providers (22 individuals in clinical administrative positions and 55 frontline clinicians) at these 18 programs participated. Twenty gave interviews as key informants, and others participated in 15 focus groups. To assure participants that confidentiality would be protected, we did not collect demographic information from individuals. We maintained confidentiality in order to minimize participant discomfort (which is not uncommon in AI/AN communities given concerns about prior research abuses) (30,31) and to facilitate candid responses to our questions. Host tribes and organizations were also assured about maintaining confidentiality, which was a condition of their decision to participate in this research project.

Data collection took place from August 2009 through July 2010. The Colorado Multiple Institutional Review Board reviewed and approved all procedures, which also underwent local review processes that always included an administrative review and sometimes included review by a research review committee or a formal institutional review board. At each participating program, we conducted one or more key informant interviews with program staff in clinical administrative positions as well as a focus group with program staff in frontline clinical positions. Because programs from a single tribe, tribal consortium, or urban organization often participated together, focus groups usually included representatives from multiple treatment programs. This arrangement required more effort from the interviewer to collect information about each program, but it allowed for richer conversation, especially given the small size of many of these programs. Key informant interviews lasted 60 minutes, and focus groups lasted 90 minutes (with additional time reserved for completing the consent process). Project directors had the option of distributing interview and focus group guides before the research team's visit. The principal investigator (DN) conducted all interviews, which were recorded; detailed notes were taken as a backup. For their participation, programs received clinical or training materials of up to $300 value. After reviewing a complete description of the study, each participant completed written informed consent.

All interviews were taped and transcribed. In only one instance was the recording quality so poor that we relied on detailed notes for analytic purposes. After transcription, all recordings were destroyed. Qualitative data were analyzed with NUD*IST Vivo software (32). We applied the principles of grounded theory (33) to code interview transcripts for key themes relevant to the purpose of this study (34–36). [Grounded theory is a research method used mainly in qualitative research. Key points extracted from text are marked as a series of codes. The codes are then grouped with similar concepts in order to generate categories. Through this process, major themes (categories) and subthemes (codes) are identified.] An initial review of the transcripts generated a tentative list of themes; we expanded and modified the coding framework in subsequent reviews. Theme and subtheme prevalence were also noted. RL performed the initial coding, which was reviewed by DN to establish consensus. After confirming major themes and subthemes, we identified exemplary quotes that captured these ideas.

Programs utilize various cultural practices, most frequently ceremonies and rituals, such as talking circles, sweat lodges, and sun dances. Group prayers, powwows, drumming, and musical performances also fall under this category. Clinicians considered these activities an opportunity to interact with clients personally. Clinicians also emphasized connecting clients to their traditional culture in order to reconnect them to their communities, to help them “find out who they are,” and to illustrate a positive aspect of treatment (as opposed to the pathology of substance abuse). Almost all programs hire staff who themselves are AI/AN and described a “different kind of relationship” between AI/AN staff and clients—one based on cultural ties and shared experience that facilitates trust and openness. Other common practices include teaching culture classes or hiring a cultural director to engage clients in community-based activities and mentoring from elders. Participants also noted arts and crafts projects, such as beading, pottery, and carving; field trips to sites of cultural significance; outdoor activities, such as camping, hunting, and fishing; and inviting a traditional healer to participate in treatment.

Relying on established, Western models of care and adapting them for AI/AN communities is the second discrete way that alcohol and substance abuse treatment programs for AI/AN communities integrate culture into their services. This practice takes place formally through the implementation of Wellbriety and other Western models (for example, the Matrix [37]) that have already been adapted for AI/AN communities. Individual programs also create novel “blended” treatment manuals that incorporate AI/AN imagery, such as medicine wheels, totem graphics, and circular motifs. More commonly, however, adaptations transpire informally when a clinician spontaneously makes minor alterations (usually verbally) in his or her interactions. For example, clinicians may incorporate historical trauma or allude to medicine wheel imagery. Most frequently, programs emphasized their reliance on Wellbriety, which combines the 12-step approach of Alcoholics Anonymous with AI/AN teachings. Programs either directly utilize the Wellbriety model or integrate aspects of it into their Western models of treatment.

An emphasis on community and family, the importance of relationships and respect for clients, an open-door policy that welcomes clients into a homelike setting, and the conviction that AI/AN culture and tradition support sobriety represent the most critical beliefs and values guiding treatment at alcohol and substance abuse treatment programs for AI/AN communities. Along with flexibility and offering individualized care, these principles provide the foundation and context that facilitate implementing specific cultural practices and adapting Western models. More important, these foundational beliefs and values function independently as critical components of culturally based care that validate and incorporate AI/AN experience and world view.

Community and family involvement, the most frequently cited foundational component, is stimulated by organizing community-wide social and cultural events, supporting clients beyond program walls (at home or at school, for instance), and bringing spouses and children into programming. One clinician described how “you have to be involved in the community [to] work here—that's part of the program.” Multiple participants reported reintegrating clients into their families and communities in order to sustain sobriety. Conveying an equally prominent foundational value, one clinician related, “It's all about building relationships with people. … If you don't have that …, there's no hope for change.” Meaningful relationships based on respect facilitate empowerment and self-esteem, considered critical given AI/AN communities' shared history of oppression and mistreatment. Such relationships are also therapeutic. One clinician explained, “Our people are traumatized. … What they need is a lot of TLC coming in …. When you give TLC to people who need it, it's amazing what it does to their level of motivation.”

Numerous programs endorse open-door policies that allow clients to ask for help beyond their scheduled appointment times. “Because if you refuse them help, like you close the door and say ‘I'm too busy,’ ” one clinician explained, “they will never come back.” Creating such a receptive environment facilitates a homelike atmosphere where clients feel comfortable asking for help. Flexibility, specifically bending rules and modifying treatment modalities, emerged as another therapeutic approach that allows clinicians to accommodate their clients' multiple, complex needs. For clients who do not meet criteria for treatment, one clinician described how “we may change some things and try to help them through those challenges … and help them complete their program versus just discharging them.” Another clinician, capturing the importance of flexibility, described shaping treatment “so that it fits our population instead of trying to get our population to fit the therapy.” Individualized, client-centered care works in conjunction with flexibility to generate the most therapeutic (and at times, unconventional) care. Last, multiple programs underscore how culture protects against substance abuse by restoring clients' identity and nurturing the values necessary to heal AI/AN communities. “When they set foot into a Native organization where they feel comfortable, they start to heal,” one clinician related. “It's that cultural identity coming back.”

The complex diversity of AI/AN populations represents the most frequently identified challenge of implementing culturally based services, with diversity stemming from degree of acculturation, tribal affiliation, religious beliefs, and rural versus urban background. Clinicians and administrators described how culturally sensitive care for one AI/AN client might be insensitive or offensive to another. Lack of resources, specifically traditional healers and the funds to hire staff knowledgeable about cultural practices, emerged as another significant barrier. Other challenges include pressure from grants to implement evidence-based treatments, billing insurance companies for cultural practices, and the potential for burnout and personal boundary violations among clinicians in the context of offering comprehensive, individualized care. Beyond the challenges unique to implementing culturally based care, programs emphasized barriers affecting all aspects of care more broadly, citing, for example, inadequate public transportation and child care services in rural regions and limited socioeconomic resources.