Native Traditional Recovery In a Contemporary Western Environment

1. The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services Native Traditional Recovery In a Contemporary Western Environment Dale Walker, MD Patricia Silk Walker, PhD Doug Bigelow, PhD Laura Loudon, MS Michelle Singer Oregon Health and Science University Clinical Update on Substance Abuse and Dependence Portland, Oregon June 26, 2007

2. Native Communities Advisory Council / Steering Committee One Sky Center

3. One Sky Center Partners Tribal Colleges and Universities Cook Inlet Tribal Council Alaska Native Tribal Health Consortium Prairielands ATTC Red Road Northwest Portland Area Indian Health Board One Sky Center Harvard Native Health Program United American Indian Involvement Jack Brown Adolescent Treatment Center National Indian Youth Leadership Project Tri-Ethnic Center for Prevention Research Na'nizhoozhi Center

4. One Sky Center Outreach

5. Goals for Today • Background: The environment and the system of care • The problem • Contributing factors • Prevention strategies • Indigenous Knowledge + Evidence Based Knowledge = Best Practice • Promising programs • Integrated care approaches are best for treatment of these chronic illnesses

10. Adolescent Problems In Schools 1. School Admin 2. Law 3. FBI 4. DEA 5. State MH 6. State A&D 7. Courts 8. Child Services Alcohol Drug Use Fighting and Gangs Bullying Weapon Carrying School Environment Sale of Alcohol and Drugs Sexual Abuse Unruly Students Truancy Attacks on Teachers Staff Domestic Violence Drop Outs 12

11. Key Adolescent Risk Factors Aggressive/Impulsive Substance Abuse Depression Trauma

12. Six behaviors that contribute to serious health problems: • Tobacco use • Poor nutrition • Alcohol and other drug abuse • Behaviors resulting in intentional or unintentional injury • Physical inactivity • Risky sex

13. Native Health Problems Alcoholism 6X Tuberculosis 6X Diabetes 3.5 X Accidents 3X Poverty 3x Depression 3x Suicide 2x Violence?

14. AmericanIndians • Have same disorders as general population • Greater prevalence • Greater severity • Much less access to Tx • Cultural relevance more challenging • Social context disintegrated

15. Percentage reporting dependence on alcohol Total Female Male Total 3.5 2.1 4.9 Native American5.6 6.8 4.3 Non-Hispanic White 3.4 2.2 4.8 Non-Hispanic Black 3.4 2.0 5.2 Hispanic – Central American 2.8 0.8 5.4 Hispanic – Cuban 0.9 0.5 1.3 Hispanic – Mexican 5.6 2.6 8.4 Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).

16. Percentage using any illicit drugs in the past year Total Female Male Total 11.9 9.8 14.1 Native American19.8 23.3 15.6 Non-Hispanic White 11.8 9.9 13.9 Non-Hispanic Black 13.1 10.2 16.6 Hispanic – Central American 5.7 4.2 7.7 Hispanic – Cuban 8.2 5.5 11.4 Hispanic – Mexican 12.7 9.2 15.8 Source: 1999 SAMHSA Treatment Episode Data Set (TEDS).

17. Lifetime History Mental Disorder 22.5% Comorbidity 29% 3.1% 1.5% 1.7% 1.1% Alcohol Disorder 13.5% Comorbidity 45% Drug Disorder 6.1% Comorbidity 72% Regier, 1990

18. Agencies Involved in B.H. Delivery 1. Indian Health Service (IHS) A. Mental Health B. Primary Health C. Alcoholism / Substance Abuse 2. Bureau of Indian Affairs (BIA) A. Education B. Vocational C. Social Services D. Police 3. Tribal Health 4. Urban Indian Health • State and Local Agencies • Federal Agencies: SAMHSA, VAMC, Justice

19. Difficulties of Program Integration • Separate funding streams and coverage gaps • Agency turf issues • Different treatment philosophies • Different training philosophies • Lack of resources • Poor cross training • Consumer and family barriers

20. Different goals Resource silos One size fits all Activity-driven How are we functioning? (Carl Bell, 7/03)

21. Best Practice Culturally Specific Outcome Driven Integrating Resources We need Synergy and an Integrated System (Carl Bell, 7/03)

23. The Intervention Spectrum for Behavioral Disorders T r e a t m e n t C a s e I d e n t i f i c a t i o n S t a n d a r d T r e a t m e n t n o f o r K n o w n i Indicated— Diagnosed Youth M t D i s o r d e r s n a e i n v t e r e P n C o m p l i a n c e a Selective— Health Risk Groups n w i t h L o n g - T e r m c e T r e a t m e n t ( G o a l : R e d u c t i o n i n R e l a p s e a n d R e c u r r e n c e ) A f t e r c a r e Universal— General Population ( I n c l u d i n g R e h a b i l i t a t i o n ) Source: Mrazek, P.J. and Haggerty, R.J. (eds.),Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: National Academy Press, 1994.

24. Treatment Brief Intervention Universal/Selective Prevention Spectrum of Intervention Responses Thresholds for Action No Problems Mild Problems Severe Problems Moderate Problems

25. Ecological Model Society Community/ Tribe Peer/Family Individual

26. Environmental Interpersonal societal Stigma Community Tribal attitudes Parents Peers National attitudes Personality Attitudes beliefs Genetics Individual Cultural beliefs Schools Local legal Interpersonal State attitudes Personal situations Individual Portrayal in media

27. Individual Intervention • Identify risk and protective factors counseling skill building improve coping support groups • Increase community awareness • Access to hotlines other help resources

28. Effective Family Intervention Strategies: Critical Role of Families • Parent training • Family skills training • Family in-home support • Family therapy Different types of family interventions are used to modify different risk and protective factors.

29. Prevention ProgramsReduce Risk Factors • ineffective parenting • chaotic home environment • lack of mutual attachments/nurturing • inappropriate behavior in the classroom • failure in school performance • poor social coping skills • affiliations with deviant peers • perceptions of approval of drug-using behaviors

30. Prevention ProgramsEnhance Protective Factors • strong family bonds • parental monitoring • parental involvement • success in school performance • pro social institutions (e.g. such as family, school, and religious organizations) • conventional norms about drug use

31. Sources of Strength Access to Mental Health Family Support Positive Friends Access to Medical Spirituality Caring Adults Positive Activities Generosity/Leadership

32. Effective Interventions for Adults • Cognitive/Behavioral Approaches • Motivational Interventions • Psychopharmacological Interventions • Modified Therapeutic Communities • Assertive Community Treatment • Vocational Services • Dual Recovery/Self-Help Programs • Consumer Involvement • Therapeutic Relationships

33. Effective Interventions for Youth • Family Therapy • Multisystemic Therapy • Case Management • Therapeutic Communities • Community Reinforcement • Circles of Care • Motivational Enhancement

35. Treatment Settings - Social Support: A Native Advantage • Tribal • Community • Family • Sibs • Peers • Individual

36. Cultural Approach • Original Holistic Approach • Psychopharmacology Approach • The unconscious has always been there • Group Therapy • Network Therapy • Recreational / Outdoors • Traditional Interventions • Indian is...

37. Possible Treatment/Prevention Activities • The Talking Circle • Smudging • Story telling • Traditional Healers • Medicine Person • Herbal remedies • Traditional ceremonies • Sweat Lodge • Traditional Experiences Preservation

38. Use of Traditional Medicine Forty-four percent of respondents used Traditional Healing Services in past year. Kevin Foley, Ph.D.

40. Definitions: Indigenous Knowledge • Is local knowledge unique to a given culture or society; it has its own theory, philosophy, scientific and logical validity, which is used as a basis for decision-making for all of life’s needs.

41. Definitions: Traditional Medicine • The sum total of health knowledge, skills and practices based upon theories, beliefs and experiences indigenous to different cultures…used in the maintenance of health. WHO 2002

42. Definitions: Evidence-based Practices • Interventions that show consistent scientific evidence of improving a person’s outcome of treatment and/or prevention in controlled settings. SAMHSA 2003

43. Definitions: Best Practices • Examples and cases that illustrate the use of community knowledge and science in developing cost effective and sustainable survival strategies to overcome a chronic illness. WHO 2002

44. ID Best Practice Best Practice Clinical/services Research Mainstream Practice Traditional Healing

45. Circle of Care Traditional Healers Child & Adolescent Programs Primary Care Best Practices A&D Programs Boarding Schools Colleges & Universities Prevention Programs Emergency Rooms

46. WHAT ARE SOME PROMISING STRATEGIES?

47. What Is Integrative Medicine? Wellness Basic Science CAM literacy Patient Centered Care Evidence Based Medicine Cultural Sensitivity Power Of the Mind

48. Principles of Integrative Medicine • It is better to prevent than to treat later. • Recognition of the interaction between body, mind, spirit, and environment. • Integrate the best of conventional and traditional medicine. • Belief that bodies respond uniquely, so treatment must be customized. • Belief in innate healing powers of the body.

49. Healing Concepts 1 • Healing takes time and time is healing • Healing occurs within the context of a relationship • Achieving energy of activation is necessary • Biological systems behave similarly across all levels Lewis Mehl-Madrona 2002

50. Healing Concepts 2 • Distractions of modern life “inactivate” catalysts for change • Modern culture teaches us to ignore emotions • Physiological change requires a break in usual daily rhythms • Ceremony helps the spiritual dimension of healing Lewis Mehl-Madrona 2002