Daniel Dickerson, D.O., M.P.H., Inupiaq Assistant Research Psychiatrist UCLA, Integrated Substance Abuse Programs (ISAP

1. Utilization of Drumming for Native Americans with Substance Use Disorders: A Discussion on the Role of Complementary and Alternative Medicine in Substance Abuse Treatment Daniel Dickerson, D.O., M.P.H., Inupiaq Assistant Research Psychiatrist UCLA, Integrated Substance Abuse Programs (ISAP)Addiction Psychiatrist United American Indian Involvement, Inc. (UAII) East Tennessee State University, Dept. Psychiatry Grand Rounds January 20, 2012

2. Agenda • The role of drumming in American Indian/Alaska Native (AI/AN) cultures • The neurobiological effects associated with drumming • The potential role of drumming in substance abuse treatment for AI/ANs • Drum-Assisted Recovery Therapy for Native Americans (DARTNA) R-21 study review • Discussion on the role of Complementary and Alternative Medicine in the field of substance abuse

3. Historical Perspective of Drumming Rock Art (Univ. Arkansas)

4. American Indians/Alaska Natives and Drumming • The drum is a sacred instrument within AI/AN cultures. • The drumbeat symbolizes heartbeat of Mother Earth, the heartbeat of Indigenous Nations. • Used in religious ceremonies, social dances, feasts, special ceremonies, in preparation for hunting. • It was and still is used to help heal the sick and as a way of carrying songs and prayers. • A way of bringing people together.

5. Drumming and AI/ANs • May offer a connection with the spirit world, ancestors, and culture and identity. • A sick person’s psychological and physiological states are believed to be altered by the rhythmic drumbeats and accompanying song. • Every tribe has their own sets of rules when it comes to how the materials for drums are gathered, who has the right to prepare a drum, and what types of behavior are allowed near a drum. • The drumbeat evokes many powerful forms of energy and is an aid in helping to focus one’s attention and to see clear intentions.

6. Drumming and Alaska Natives • The drum, called the suayaq or kilaun, has a driftwood frame which is steamed and bent into an oval shape, then covered with a stretched walrus stomach, the lining of a whale’s liver, or scraped caribou hide. • The oral history of Inupiaq culture has survived in songs, stories and legends passed on from one generation to the next on dark winter evenings, accompanied by drumming. • The Inupiaq Shaman's use of the drum in ceremonies and to communicate with spirits disturbed missionaries and was subsequently “forbidden.” • Songs and drumming are often used to tell of stories and hunting traditions.

7. AI/AN and cultural identity • Many U.S. historical actions, i.e., removals and relocation acts, have resulted in a fragmented AI/AN community • Many American Indians strongly believe that their problems with alcohol stem from their sudden disconnection with traditional American Indian culture • American Indian traditions, customs, rituals, and values may assist in discovering positive coping strategies during recovery. • Denying AI/ANs the opportunity to rely on those strategies may contribute to ongoing drug/alcohol use.

9. (Native Peoples Magazine, 2009)

10. Therapeutic effects of drumming • Several studies have demonstrated physical and psychological effects associated with drumming (Winkelman, 2003). • Drumming may also have biological effects that may mitigate various behaviors. • Rhythmic auditory stimuli (including drumming, singing, and chanting) may generate auditory drive leading to increased alpha and theta wave production, which may contribute to a desired meditative state (Wright, 1991; Maxfield, 1991; Winkelman, 2000; Mandell, 1980). • This response is produced by activation of the limbic brain's serotonergic circuits to the lower brain. These slow-wave discharges produce strongly coherent brain-wave patterns that synchronize the frontal areas of the brain with ascending discharges, integrating nonverbal information from lower brain structures into the frontal cortex and producing insight.

11. Electroencephalography (EEG): Brain Wave Activity

13. Limbic Brain and Frontal Lobe connections

14. Group drumming Research by Barry Bittman, M.D. • Natural Killer cell activity and Cytokines activity were compared between a group of group drummers vs. controls. • Results revealed natural killer cell activity was boostered in subjects who drummed compared to controls. • Natural killer cell activity stimulated by cytokines (orchestrators or modulators of immune function) was boosted in subjects who drummed compared to controls.

15. Women and drums • In many tribes, drumming is not the “role traditionally prescribed for women.” • Men usually are seated in a circle around a drum, while women stand around the outside of the circle and sing. • Red Drum Women Society Singers, an all female American Indian drum group was created after four years of prayer at Bear Butte near Sturgis, S.D. • “Culture always changes. It’s controversial, and it’s something I think is pretty interesting,” Amber Annis, president of UND’s Indian Studies Association. • Greg Gagnon, an associate professor of Indian Studies at UND, said female drum groups are comparable to women seeking positions as priests in the Roman Catholic religion. It’s a break from long-held tradition and values. • “We don’t compete against our men; we are equals with our men,” she said. “This drum is about women healing.” Jermaine Tremmel, Red Drum Women Society Singers. (Indian County News, 2008)

16. American Indians/Alaska Natives and Drug/Alcohol Abuse • American Indians/Alaska Natives (AI/ANs) have the highest rates of using alcohol, marijuana, cocaine, nicotine, and hallucinogens compared to any other racial/ethnic group in the U.S. • AI/ANs also have the second highest rates of methamphetamine abuse, with another indigenous group, Native Hawaiians, having the highest rates(USDDH, 2005).

17. Questions relating to drumming and AI/ANs • Can the use of the drum be used in a culturally-appropriate manner for substance abuse treatment? • How important culturally is it to accompany singing with drumming? • Roles of AI/AN females in drumming? • Approaching diversity of AI/AN drumming traditions (562 federally-recognized tribes)

18. Drum-Assisted Recovery Therapy for Native Americans (DARTNA) • Daniel Dickerson, D.O., M.P.H. and Anthony Robichaud, CADC II, developed a preliminary substance abuse treatment protocol utilizing drumming for AI/AN with substance use disorders. • R-21 NIH/NCCAM grant awarded (Principal Investigator: Daniel Dickerson, D.O., M.P.H.) to complete the development and pilot-test a new drum therapy treatment protocol for AI/ANs with substance use disorders.

19. DARTNA Treatment Protocol • Initially proposed to be 3 days/wk x 12/wks (changed to 2 days/wk as recommended through focus groups) • Each day consists of a 3-hour treatment format. • Each wk focusing sequentially on the12-steps of AA/NA and concepts of the Northern Plains Medicine Wheel

20. Daily treatment structure(Monday and Friday) • Hour 1: Education/Cultural Discussion: drumming, teaching of songs, Medicine Wheel concepts,12-steps, White Bison concepts • Hour 2: Drumming Activities Corresponding to Medicine Wheel Concepts • Hour 3: Talking Circle/Processing Group

22. White Bison Philosophy • White Bison, Inc., is an American Indian non profit organization • President Don Coyhis, Mohican Nation, has offered healing resources to Native America since 1988. • White Bison offers sobriety, recovery, addictions prevention, and wellness/Wellbriety learning resources to the Native American community nationwide. • Utilizes AI/AN traditions as a primary focus in substance abuse recovery

23. Primary Grant Activities • Series of focus groups (treatment providers, AI/AN substance abuse patients, and Community Advisory Board (CAB) to discuss initial treatment format • Pretest of DARTNA among 10 AI/ANs • Follow-up focus group to finalize protocol. • Randomized controlled trial DARTNA (n=30) vs. Treatment-as-usual (TAU) (N=30) at United American Indian Involvement, Inc. (UAII) in Los Angeles

24. Initial Focus Groups • Focus groups conducted among 1) AI/AN substance abuse providers (n=9), 2) AI/ANs with substance abuse hx. (n=9) 3) Community Advisory Board (n=4) • Purpose to obtain feedback with regard to the preliminary DARTNA treatment protocol. • Feedback received to be used for a follow-up pretest of DARTNA

25. DARTNA focus group overarching conceptual themes • (1) drumming can be especially beneficial for AI/ANs with substance abuse issues • (2) assuring a culturally-based focus is necessary as it relates to drumming for AI/ANs with substance abuse issues • (3) providing a treatment format which will provide a foundation of cultural ideals which cross the landscape of diverse tribes while recognizing tribal diversity is necessary • (4) addressing gender roles as it relates to drumming activities must be addressed within the treatment setting.

26. Focus group: Community Advisory Board (CAB) member quote “You want to teach definitely the significance of drumming and Native people feel the drumming is sacred. It’s the heartbeat of the earth and mother earth. The target is also educating and hands on experience and to have your own creativity to you making the drum and on top of that teaching how to create the drum.”

27. CAB member quote “I think it’s important, to me, if you’re going to integrate our culture and the drum into this, that it needs to be done in a proper way-in the way it was intended to be. Because that healing power is there in the drum and the songs if we use it in the right way…”

28. CAB quote “I think there are a lot of native people who haven’t even been to very many traditional ceremonies of their culture. So it’s really important to keep that going. I know the main thing has to do with sobriety and recovery but again it goes hand in hand. And this is the most excellent way to facilitate that and to reintroduce the blending of these things. Because it works.”

29. CAB quote “Even if clients have no knowledge of their culture, our culture is part of our ‘cultural DNA,’ Even though we haven’t been exposed to it, once we start getting exposed, it comes back to use. It enables us. It’s spiritual memory. To me, our spiritual memory is about the songs. Because we carry the traditions through song and that’s where our culture is going to come from.”

30. CAB and cultural identity “So we know there is a relationship with someone’s cultural identity and their substance use or other behavior problems. So there is already that relationship. So by being more connected to the culture is really going to help them whether they’ve drummed before or whether they’ve ever had any knowledge about their tribal culture. I think it’s their first step that will really help.”

31. CAB quote “It’s (drumming) going to lead them down a new path you know a better path than before. And even one’s who have lost track with who they are or where they’re from will realize where they’re at and how they got away from it…When you start getting that connection whole again with who we are. It’s what makes us complete.”

32. CAB member quote “That base has to be understood before you even sit at the drum.” “There also has to be that respect value.”

33. CAB: Drumming and singing “You have no reason to beat a drum unless you have a song. We just don’t beat on a drum. There is a song for a certain specific reason and you have to sing that song for that reason and the drum accompanies that song.”

34. Substance abuse provider quote “People understand that it (education) has to be covered before they start making those drums and singing. If there’s no foundation, there’s no building. Whoever facilitates your groups has to understand when they’re teaching these songs to a group, that all those people understand the song they are teaching it and not take their own interpretation into it.”

35. Substance Abuse Provider quote: “There are steps to putting the drum together; history in it, there’s a lot of things to learn about that drum and how it came to be and the respect that you should have for it and what it takes to put one together and the responsibility involved.”

36. Substance abuse patient quote: “The urban Indians are really Natives not learned in their cultures and where they are. This is important to know for their part of the nation. Urban Indians need teachings also as well as the people from the reservation. The people from the reservations are no different than urban Indians because on the reservation, we abused all the other drugs and that’s what strays us away from our culture.”

37. Substance abuse provider quote: Regarding women and drumming “In our tribe, the women don’t touch the drum, it’s bad luck for our drum.”

38. Substance abuse provider quote “If you’re going to teach them traditional (gender) roles so to speak that level of who’s facilitating your group is going to come into play. I use the word support because they (women) have always been our strength. To support the women in standing and singing behind the drum is something that you want to be taught first.”

39. Substance abuse provider quote: “I kinda feel like I go against the norm, which is that women should stand behind the men.” “I’m not opposed to either or and mixing men and women but I’ve heard it’s not suppose to be done. But I think it would be grand.”

40. After treatment quote (CAB) “The tools that they use in treatment should be implemented in their lives. It’s up to them to continue to go to Pow Wows or to sweat…to cultivate it in their lives and for drumming to be a part of their lives. It will be the responsibility of the service providers to create opportunities for the clients after their participation in treatment.”

41. Pretest of DARTNA • 10 AI/ANs with current substance use disorders (5 males, 5 females) will be provided the preliminary treatment protocol. • Follow-up focus groups among participants, providers and CAB will be conducted to aid in the development of the final treatment protocol. • Completed 12/2011

42. DARTNA Pretest Assessments • Brief Symptom Inventory (BSI) • Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) (Physical well-being, Social /Family well-being, emotional well-being, functional well-being) • FACIT-Spiritual Questions • Functional Assessment of Cancer Therapy (FACT)-Cognitive Function • General AA Tools of Recovery (GAATOR) 2.1- a12 step questionnaire • American Indian Alaska Native Cultural Identity Scale • Addiction Severity Index (ASI), Native American version

43. Pilot study DARTNA • A pilot study will be conducted comparing the following 2 study groups: DARTNA (n=30) vs.TAU at United American Indian Involvement, Inc. (UAII) (n=30) • The current outpatient treatment protocol at UAII is similar in time length to DARTNA (6 hours/week over 12 weeks).

44. Conclusions • Drumming may have a role in the treatment of substance abuse for AI/ANs. • Recognition and adherence to cultural traditions is necessary when using drumming as a treatment option for AI/ANs. • Further research investigating traditional-based healing strategies are needed.

45. Complementary and Alternative Medicine • Defining Complementary and Alternative Medicine (CAM) • Types of CAM: -Natural Products -Mind Body Medicine (Mindfulness) -Manipulative and Body-Based Practices -Other CAM Practices

46. Contact Info • Daniel Dickerson, D.O., M.P.H. • Phone: 562-277-0310 • E-mail: daniel.dickerson@ucla.edu