The author reviews the literature on the treatment of Native Americans who have alcohol abuse or dependence disorders and provides an interpretation of the research on this topic. The most common alcohol treatment modalities used with Native Americans are described and critiqued, including adapted versions of standard treatments. Several practical recommendations are made regarding revising standard treatments to make them more culturally appropriate for Native Americans.
This article focuses on the most significant reports regarding treatment modalities and their efficacy for Native Americans with alcohol problems. The literature on alcoholism in Native Americans is comprehensive and includes information on the social and psychological aspects of alcoholism among this population (Beauvais, 1992; May, 1994) and information on incorporating traditional healing methods into standard treatment methods (Edwards & Edwards, 1988; Hall, 1986; Parker, 1990). See May for an excellent summary of general information about alcohol abuse among Native Americans.
According to leading researchers, "there is no universal and all encompassing explanation for drug and alcohol abuse among American Indians" (Trimble, Padilla, & Bell, 1987, p. 5). Factors that seem to be related to alcohol abuse in this population include cultural dislocation (the feeling of not fitting into either traditional Native American culture or the general U.S. culture), the lack of clear sanctions or punishments for alcohol abuse, and strong peer pressure and support for alcohol abuse (Bell, 1988; Edwards & Edwards, 1984). Many researchers in this area speculate that alcohol abuse is related to poverty, school failure, unemployment, poor health, feelings of hopelessness, and the breakdown of the Native American family (Duran & Duran, 1995; Edwards & Edwards, 1984; Trimble, 1984). Griffith (1996) pointed out that compared with the majority population, Native Americans experience four times as much alcohol-related mortality, three times as much alcohol-related illness, and increased rates of alcohol-related accidental deaths, suicides, and homicides. Royce and Scratchley (1996) emphasized that there is no single reason for the prevalence of alcoholism among Native Americans and state that 42 different theories have been proposed. It is important to know the causes of alcohol problems in Native Americans because prevention and treatment efforts could be more focused if specific causes were known. It is clear that there is not consensus on this issue.
Many different alcohol treatment programs and modalities have been used with Native Americans. Weibel-Orlando (1989) described five common treatment models: the Medical Model, the Psychosocial Model, the Assimilative Model, the Culture-Sensitive Model, and the Syncretic Model. The Medical Model is based on the Disease Model of alcoholism, which is also a basic assumption of Alcoholics Anonymous (AA) and of U.S. society. At the other extreme is the Syncretic Model, which has primarily a Native American orientation, including the use of techniques such as the medicine wheel, talking circles, the sweat lodge, and tribal healers. The Red Road is one example of a specifically Native American treatment approach (Arbogast, 1995; Books & Berryhill, 1991). Nativized treatments are standard treatment modalities that have been adapted to be more culturally appropriate for Native Americans, usually by including discussion of traditional Native American concepts and the use of Native American healing techniques.
The Medical Model of alcoholism is often criticized as being culturally inappropriate when applied to Native Americans. Many Native Americans do not accept the Disease Model, although most would readily admit that alcohol abuse results in dysfunction and various problems in living. "This model [AA] has proven a poor fit for clients who see themselves as neither sick nor diseased" (Kinney & Copans, 1989, p. 12). Other models are likely to be more acceptable to Native Americans, such as Weibel-Orlando's (1989) Psychosocial Model, the Culture-Sensitive Model, or the Syncretic Model.
It is reasonable to think that certain findings from the general literature on the efficacy of alcohol treatments probably apply to the treatment of alcohol abuse in Native Americans. For example, there is no reason to think that there is one treatment modality that is effective with all Native Americans; different treatments probably have various degrees of effectiveness with Native Americans, treatment should be tailored to each individual Native American client, and Native American clients should be matched to optimal treatments, based on the results of controlled research.
All of this is, of course, easier said than done. Given the relatively small number of Native Americans (less than 1% of the U.S. population), treatment programs specifically for Native Americans usually only exist in areas where there are concentrated numbers of Native Americans, such as on reservations and tribal homelands and in some urban areas. Such small programs are rarely able to offer a wide choice of treatment modalities because of practical constraints. There are many alcoholism treatment programs that have special programs for Native Americans (Vanderbilt & Schacht, 1998), but it is difficult to get information on the specific treatments used or their success rates.
There are no empirical, research-based findings on the relative efficacy of various treatments for alcohol problems in Native Americans. According to Kinney and Copans (1989), "studies of Native American alcohol treatment program results have described the outcomes as ranging from mixed to disappointing" (p. 12). Given the lack of controlled studies specifically on Native Americans with alcohol problems, treatment recommendations are usually based on clinical experience. Many researchers call for studies and treatment programs that are sensitive to tribal, cultural, age, and sex differences. They also often state the importance of involving the Native American client's extended family in the treatment, instead of just the nuclear family.
Gordon (1994) stated that treatment programs have been largely unsuccessful in dealing with Native Americans, probably because standard treatments are geared to the culture of the general, middle-class U.S. population. He agrees with other researchers that the Disease Model of alcoholism is not relevant to Native Americans because the development of alcoholism in this population does not fit the pattern defined in the Disease Model, which does not consider social and cultural factors. Gordon described several specifically Native American treatment-related organizations, including the Native American Church, the Indian Shaker Church, the Poundmaker's Lodge, the Red Road, and the Alkali Lake community. Gordon recommended that standard programs incorporate traditional Native American healing practices, although he provided no data to establish that such programs are more effective than programs that do not include them.
According to Duran and Duran (1995), "alcoholism treatment outcome evaluations for Native American patients, although contradictory, indicate a very low level of success" (p. 97). They report that studies on Indian Health Service alcoholism treatment programs rarely have well-defined criteria for success and seldom assess long-term success. They also speculate that AA may not be effective for Native Americans because of its emphasis on alcoholism as a disease, its middle-class orientation, and its lack of cultural relevance.
An example of a tribe that addressed its alcoholism problem successfully with a variety of approaches is the Alkali Lake Band of the Shuswap tribe, which is reported to have reduced its alcoholism rate from 95% to 5% in 10 years (Guillory, Willie, & Duran, 1988). Part of the approach, which was used in a small, isolated community in British Columbia, Canada, was "creating a community culture which no longer tolerated alcoholism as individual behavior, while concurrently revitalizing traditional culture" (p. 30). Members of the Alkali Lake Band got rid of bootleggers, revived traditional ceremonies, joined mutual support groups, and instituted many other changes. The entire effort started with one person who decided to quit drinking. This case study is certainly interesting, but unfortunately it is impossible to determine which specific changes made the crucial difference or whether the effort succeeded only because of the synergy of all the changes made together. It is difficult to generalize from the Alkali Lake experience to other tribal communities, but the methods used are suggestive, especially the emphasis on family and peer pressure to stop drinking. This approach is probably much more applicable to small, isolated communities than large or urban communities or Native Americans who are geographically dispersed. A set of three videotapes dramatize and describe the Alkali Lake experience (Lucas, 1987).
In their treatment of Native American clients with alcoholism, Duran and Duran (1995) seem to use a unique combination of Freudian psychology and Jungian mystical techniques mixed with traditional Native American purification methods, such as smudging therapy rooms with burning sage. Clients are sometimes taught how to work with their subconscious thoughts and feelings, using dream and fantasy interpretation, making drawings, or writing poetry. Alcoholism is seen as a spiritual problem. They also endorse the use of peyote for the treatment of alcoholism, a practice of the members of the Native American Church. Unfortunately, the authors provide no data regarding the effectiveness of any of these treatment methods, and a review of the research literature does not provide support for their use.
Community ties tend to be much stronger in collective societies such as those of Native Americans than in individualistic societies such as the general U.S. society. This suggests that Native Americans may be more successful in stopping or controlling their alcohol use if the treatment approach includes a family, group, or community component. However, this may be true only for traditionally oriented Native Americans who are not highly acculturated to the general U.S. culture. Although acculturation stress, poverty, racism, and many other social factors may influence drinking behavior, and may be correlated to it, there is no evidence that they cause it. As mentioned earlier, the cause of alcoholism is multifactorial, and there are likely to be different causes for different people.
Kinney and Copans (1989) stated that AA has been widely used as part of alcohol treatment programs for Native Americans, but that it is the most controversial treatment modality because it is often seen as incongruent with Native Americans' cultural orientation. "A major problem is the 'confessional' public style of AA that is counter to the private family-centered setting traditionally viewed as the site of handling problems" (p. 11). The authors recommend a comprehensive treatment program, including medical care, rehabilitation, follow-up, family counseling, self-help groups, and traditional healing and purification ceremonies for Native American clients.
Young (1992) reviewed the literature on the treatment of Native Americans with alcoholism and concluded that "very little data assessing the efficacy of the various intervention strategies ... has been published" and "very little information is available about what constitutes a successful treatment strategy" (p. 13). The author speculates that effective programs would include a spiritual component and a concern for Native American culture and values. He states that although AA is a frequently used modality with Native Americans, using it is difficult because many Native American clients are reluctant to express their feelings or confess their problems in counseling sessions or public group meetings. Young suggests that most Native American clients prefer a combination of traditional healing practices and standard U.S. treatment strategies. However, the traditional Native American healing strategies would preferably be tribe-specific rather than pan-Native American. According to Young (1992), at the time his paper was published no such programs existed.
Watts and Gutierres (1997) interviewed 58 Native American clients at three residential treatment facilities in the Phoenix area to get their ideas about what kinds of treatment modalities were most helpful. Most of the clients were in a treatment program that integrated AA meetings with counseling and traditional Native American practices, such as the sweat lodge and talking circles. The participants described both the traditional practices and the AA-related practices as helpful. The researchers provided no data on the actual success rates of the treatment centers or the relative effectiveness of traditional and standard treatment modalities.
Schacht and Baldwin (1997) reported on their research regarding alcohol treatment programs for Native Americans, which included both surveys and qualitative research, including interviews with clients. Programs surveyed were chosen based on the recommendations of rehabilitation counselors who were asked to identify exemplary alcohol treatment centers for Native Americans. The 1993 survey of 31 centers revealed that 90% of the centers that responded to the survey could be categorized as using either a Culture-Sensitive or a Syncretic approach (the most Native American types of treatment). Almost all of the centers used an AA or related twelve step orientation, with adaptations to make them more culturally appropriate for Native Americans. When centers were asked what percentage of their Native American clients were successfully rehabilitated, responses ranged from 1% to 95%. These were simply the claimed success rates of the centers; the actual success rates are unknown. No single treatment approach had a success rate that was statistically superior to the other approaches.
A follow-up survey by Schacht and Baldwin (1997) in 1996 showed that half of the 14 responding treatment centers "Nativized" their program by using traditional Native American methods such as sweat lodges, meditation, and the medicine wheel as a part of treatment. Nine of the centers reported using all of the twelve steps in the AA approach; the other centers used only the first steps. Even among these supposedly exemplary centers, reported success rates over 50% were rare, and centers that used traditional Native American healing methods did not claim to have success rates significantly higher than those of other centers. One of Schacht and Baldwin's conclusions was that "Alcoholics Anonymous is a support group, and should not be used as a substitute for a treatment program" (p. 21).
McCrady and Delaney (1995) reviewed many issues involved in providing or promoting self-help groups for clients with alcohol problems. They pointed out that the current practice of many treatment professionals is to refer most or all alcoholic clients to AA, but that "it is not clear that this is optimal practice, since no evidence suggests that all problem drinkers benefit from what AA has to offer" (p. 161). They add that AA's own surveys show that the vast majority of people who begin attending AA meetings discontinue their involvement in less than a year.
Rather than review in detail the hundreds of treatment suggestions found in the literature relevant to Native Americans with alcohol problems, I refer the reader to a recent annotated bibliography that summarizes 135 articles, book chapters, and program descriptions (Thurber & Thomason, 1998). A review of this literature reinforces the idea that there are very few empirical studies on the effectiveness of alcohol treatment programs for Native Americans. Of course, the suggestions and speculations of treatment program staff and researchers about "what works" are better than nothing.
Very few research studies have been conducted to study the efficacy of using various alcohol treatment modalities when working with Native Americans. Overall, there is no evidence that any single treatment modality works especially well with Native Americans. However, certain suggestions and recommendations are repeated many times in the literature on Native Americans and alcohol treatment. Although these recommendations are rarely based on empirical research, they may at least represent the consensus of many clinicians who work with Native American clients.
Before beginning treatment, it is crucial for treatment providers to assess the identity and acculturation level of Native American clients. Clients who are nominally Native American but who are highly acculturated to the mainstream culture and have little emotional investment in Native American culture can probably be treated similarly to individuals who are not Native Americans. This means they should be treated with modalities such as brief interventions, social skills training, motivational enhancement, community reinforcement, and other approaches with well-documented efficacy for members of the general population (Miller et al., 1995).
Although there is little evidence addressing many of the relevant issues, it is possible to make some limited recommendations, based on the research reviewed above. Just as is done with any other clientele, Native Americans should be offered a variety of treatment modalities, and treatments should be specifically tailored for each client whenever possible. Native American clients who do not respond to one treatment approach within a few weeks should be offered a different treatment approach. Among the first treatments to be offered should be brief interventions, social skills training, motivational enhancement, and community reinforcement. Brief interventions are most appropriate for alcohol abusers rather than alcoholics. Behavioral, marital, or family therapy and cognitive-behavioral approaches should also be considered.
AA and many other approaches that have not been validated cannot be considered treatments of choice unless and until unbiased researchers are able to demonstrate their efficacy in controlled studies. AA support groups may help some clients maintain sobriety but are most likely to be helpful for Native Americans who are highly acculturated to the general U.S. society, because most AA groups are not culturally appropriate for Native Americans.
Native Americans who have a strong Native American identity and are greatly involved in their traditional culture may respond better to a treatment program that takes their culture into account, although there is no empirical data to suggest that this will result in improved outcomes. However, such "Nativized" programs would at least have more "face validity" for traditional clients and might encourage participation. For example, having the client participate in tribal purification and healing ceremonies might be helpful. Some treatment programs report that clients find the use of sweat lodges, talking circles, or medicine wheels, and other traditional Native American rituals and ceremonies helpful. For very traditional clients, especially those from rural and reservation areas, referral to tribal healers where the client lives might also be helpful. Clients who are interested in trying this should be encouraged to do so, with the understanding that if it is not effective, other treatment modalities should be used.
There are some difficulties with the idea of Nativizing standard alcohol treatment models. One problem is that they could only be used with groups of purely Native Americans. Even then, some Native Americans do not have traditional values and might not be interested in Nativized treatment. According to Guyette (1982), only 10% of surveyed Native Americans with substance abuse problems said they preferred an exclusively Native American treatment approach, and 76% said they preferred a combination of Native American healing practices and European American treatment practices.
In many locations, it would be difficult to have an ongoing Nativized treatment group simply because there might not be enough Native Americans in the area to attend it. For example, Young (1992) reported that only 4 of the 21 reservations in Arizona had an alcohol treatment program. It would be even more difficult to form Native American treatment groups in nonreservation rural areas and urban areas. Another problem is that there is a severe shortage of Native American treatment providers, so that even if Nativized treatment groups specifically for Native American clients existed, it would be very difficult to find Native Americans to operate them.
Another problem with Nativizing standard alcohol treatment programs is that there is no standard way to Nativize the treatments. Traditional Native American healing strategies are not written down or systematized, and traditionally the healing methods are meant to be practiced by only trained Native American healers. Not all Native American counselors or therapists are knowledgeable about traditional healing methods or empowered by their tribes to practice them. In addition, given the diversity of Native American tribes, ideally Nativized treatment programs would be tribe-specific rather than pan-Indian although some techniques, such as the sweat lodge ceremony, are used by members of many tribes. See Jilek (1994) for a description of several "Nativized" approaches to alcohol treatment.
More attention should be paid to the importance of teaching Native Americans with alcohol abuse problems (and all people with alcohol abuse problems) skills to manage negative emotions that lead to drinking. Although poverty, racism, and acculturation stress may lead some Native Americans to drink as an escape, treatment programs would probably be better advised to focus on teaching clients the skills needed to stop drinking and resist the recurring urge to drink. Of course, treatment providers should work for social justice for Native Americans (and all other Americans), but this work is likely to be separate from their alcohol treatment programs.
Given the many gaps in the research on the efficacy of alcohol treatments for Native Americans, much work remains to be done. Given the magnitude of this problem, it is very important that researchers address this issue, preferably with controlled studies that have the most likelihood of resulting in useful information.
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By Timothy C. Thomason
Timothy C. Thomason is an associate professor of educational psychology at Northern Arizona University, Flagstaff. Correspondence regarding this article should be sent to Timothy C. Thomason, PO Box 5774, Northern Arizona University, Flagstaff, AZ 86011 (e-mail: email@example.com).
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Source: Journal of Multicultural Counseling & Development, Oct2000, Vol. 28 Issue 4, p243, 10p