Alcoholism in Native Americans: A Halfway House Intervention on the Crow Creek Indian Reservation

1. Abby Bacon, Melissa Kludt, Connie Tschetter, Jill Zuehlke South Dakota State University NURS 760 Alcoholism in Native Americans:A Halfway House Intervention on the Crow Creek Indian Reservation

2. Introduction • Alcoholism is a chronic health problem among the Native Americans on the Crow Creek Indian Reservation • It has a major impact on the quality of life and productivity of the community members • Introduction of a Halfway House on the Reservation may assist recovering addicts in their transition from inpatient treatment to home

3. Identifying an Underserved Population • Crow Creek Indian Reservation • Located on east bank of Missouri River in central South Dakota • Median income: approximately $12,070 per year • Unemployment rate is 57% • 56% of the Reservations population had an income below the poverty line in 2000 (USDC, 2003)

4. Impact of Alcoholism on Quality of Life • Native Americans have a high prevalence (12.1%) of • heavy drinking • 29.6% of Native Americans are binge drinkers • Problems associated with alcoholism • Medical, Social & Economic Hardship (USDHHS, 2009) • CDC (2008) estimates that 11.7% of all Native • American/Alaska Native deaths from 2001-2005 were a • direct result of alcohol use • leading acute cause of death: motor-vehicle traffic crashes • leading chronic cause of death: alcoholic liver disease • age-adjusted alcohol-attributable deaths were the higher in the • Northern Plains region (including South Dakota) than any other • region

5. Impact of Alcoholism on Quality of Life • Negative societal impacts • Approximately 3 million violent crimes occur annually in which the victims perceive the offender to have been drinking at the time of the crime. • Two-thirds of intimate partner abuse cases cite alcohol as a contributing factor (USDJ, 1998)

6. Interviews with Interdisciplinary Colleagues • Patty Juhnke, MSW • Clinical social worker at Sanford Medical Center in Chamberlin, South Dakota • Services consist of assessment, diagnosis, treatment, client-centered advocacy, consultation, evaluation, and prevention of mental illness, emotional, or behavioral disturbances • Feels an important service missing for Native Americans is placement between in-patient alcohol treatment and home • Key informants • the outpatient treatment facilities in the area • the physicians that she directly works with (Personal interview, November 5, 2010)

7. Interviews with Interdisciplinary Colleagues • Patty states • a half way house that the local community could easily access would provide many advantages • A benefit of a half way house would be safety • The average time period for which a person should stay at a halfway (or sober home) is three to six months at the most • By living in a sober house, the recovering addict can continue to work effectively on his recovery process (Personal interview, November 5, 2010)

8. Interviews with Interdisciplinary Colleagues • Michelle Carpenter • Executive Director of Dakota Counseling Institute in Mitchell, South Dakota • Also known as Stepping Stones in Chamberlain, South Dakota • Services offered include a halfway house, adolescent/adult intensive outpatient treatment, detoxification unit, outpatient continued care/after care, DUI education program, intensive prevention education program, outreach program, and the recovery house. • States that the Native Americans would directly benefit from inpatient care before going home (Personal interview, November 12, 2010)

9. Interviews with Interdisciplinary Colleagues • Michelle states • Would like to reduce the use of alcohol and other drugs, forestall children using illegal substances for the first time, increase the perception of risk and harm of the use of illegal substances, and assist community groups, parents, churches, and school personnel in developing coalitions, which focus on reducing the risk of problem behaviors and develop protective factors for individuals, families, schools, and communities • Stepping Stones Prevention Services acts as a catalyst to reinforce messages that promote positive behaviors for youth and adults • Efforts are concentrated to gather community resources to combat substance abuse using asset building to promote healthy behaviors in students and role-modeling skills in adults (Personal interview, November 12, 2010)

10. Interviews with Interdisciplinary Colleagues • Tolly Estes • Program Director of Circles of Care • Short term program in Fort Thompson that has been funded by a three-year grant from the Substance Abuse and Mental Health Services Administration • The goal of the facility is to plan for the implementation of a community bases, family-focused system of care to support mental health for the Native American youth and families of the Crow Creek Reservation • Main goals of the organization are to educate the local providers about their systems of care philosophy, to encourage more family involvement in the care system, and to reduce the stigma associated with mental health issues (Personal interview, November 12, 2010)

11. Interviews with Interdisciplinary Colleagues • Sherry Lulf • Managed-care director of the Indian Health Center in Fort Thompson, South Dakota • Offers outpatient treatment for people with dependency problems of alcohol and other drugs • No inpatient treatment is available to the members of the Crow Creek Indian Reservation within miles of the Reservation (Personal interview, November 18, 2010)

12. Interviews with Interdisciplinary Colleagues • Sherry states • IHS is sending some of their tribal members as far as California for inpatient treatment • Two main issues with starting a halfway house on the Reservation are funding and someone to manage the facility 24 hours a day • It will still be quite some time that Crow Creek members will continue to go to long term treatment off of the reservation (Personal interview, November 18, 2010)

13. The Halfway House as an Intervention • History and Development of Halfway Houses • Concept first appeared in the 1950’s • Provide a stable environment until residents are able to make suitable arrangements for themselves • Often fully staffed by recovered alcoholics (White, 2000a)

14. The Halfway House as an Intervention • Halfway House: a group of recovering alcoholics living together & supporting each other in their recoveries • Possession or use of alcohol, drugs, and/or weapons as well as any criminal activity including threats, violent behavior, and/or vandalism results in immediate eviction • Residents must attend off-site counseling and/or a 12 step program as well as all house meetings • After a period of time during which the resident must stay on-site (30 days is recommended), he must obtain full-time employment • Each resident is responsible for keeping himself and his belongings clean, as well as completing assigned chores throughout the property • Medications are kept and dispensed by the house manager, and each resident must agree to random urine drug testing at his own expense (Murray, n.d.)

15. Health Promotion and Disease Prevention Model • The Transtheoretical Model of Health Promotion describes how people move toward adopting and maintaining behavior change • A person who is trying to make a health-related change moves through five stages • Precontemplation • Contemplation • Planning or Preparation • Action • Maintenance (Pender, Murdaugh, & Parsons, 2011)

16. Health Promotion and Disease Prevention Model • The proposed halfway house intervention as a bridge between inpatient treatment and returning home fits into this model at the action and maintenance stages, during which the person is actively engaged in behavioral change and is sustaining the change over time (Pender, Murdaugh, & Parsons, 2011)

17. Health Promotion and Disease Prevention Model • Model includes 10 processes of change (strategies) • Experiential Strategies • Including consciousness raising, dramatic relief, environmental reevaluation, and self-reevaluation • Most likely implemented during initial, inpatient treatment for alcohol dependence • Behavioral Strategies for Change • Including social liberation, counterconditioning, helping relationships, reinforcement management, and self-liberation • Introduced during inpatient treatment, and continued in the halfway house environment (Pender, Murdaugh, & Parsons, 2011)

18. Nursing Recommendations for Implementing Interventions • Open, culturally respectful communication • Attentive listening skills • Respect personal space (Flowers, 2005) • Don’t teach too much at once (Harrington-Dobinson & Blows, 2007) • Culturally-sensitive treatment methods • Reduce cultural stress • Encourage health promoting behaviors in future generations • Involve family and community in recovery process • Use family as a potential resource and support • Create economic development programs(Milbrodt, 2002)

19. Plan for Implementation and Evaluation in Crow Creek • Plan for Implementation • Funding • Sources would have to be secured, possibly through Indian Health Services or a federal grant • Care • Should be coordinated with the other agencies in the area to include the halfway house as an option in discharge planning • Staff for the halfway house • Ideally come from the Crow Creek community, providing an additional employer for the community

20. Plan for Implementation and Evaluation in Crow Creek • Evaluation of Effectiveness of the halfway house intervention • Tracking all discharges from the area’s treatment centers • Comparing the long-term outcomes of those who visit the halfway house to those who return directly home after inpatient treatment

21. Conclusion • The Native American community free from the dangers of alcohol is not in the near future. The process of implementing interventions for Natives abusing alcohol can be a very involved and complicated process. By utilizing effective, culturally appropriate communication, paying attention to cultural traditions, involving family and the community and by making more resources available, including education, the mission can continue to move toward success for future generations. For the people of the Crow Creek Reservation in South Dakota, a community-based halfway house may be a step toward overcoming the effects of alcohol abuse in their community.

22. References • Centers for Disease Control and Prevention. (2008). Alcohol-attributable deaths and years of potential life lost among American Indians and Alaska Natives -- United States, 2001-2005. MMWR: Morbidity & Mortality Weekly Report, 57(34), 938-941. Retrieved from EBSCO MegaFILE database. • Chartier, K., & Caetano, R. (2010). Ethnicity and health disparities in alcohol research. Alcohol Research & Health, 33(2), 152-160. Retrieved from CINAHL Plus with Full Text database.  • Flowers, D. (2005). Cultural diversity. Culturally competent nursing care for American Indian clients in a critical care setting. Critical Care Nurse, 25(1), 45-50. Retrieved from CINAHL Plus with Full Text database. • Gomez, M. (2008). Discharging patients with behavioral disorders. Hospital Case Management, 16(12), 182-190. Retrieved November 30, 2010, from CINAHL Plus with Full Text database. • Harrington-Dobinson, A., & Blows, W. (2007). Part 3: Nurses’ guide to alcohol and promoting healthy lifestyle changes. British Journal of Nursing (BJN), 17(1), 53-59. Retrieved from CINAHL Plus with Full Text database. • Jackson, K., Booth, P., McGuire, J., & Salmon, P. (2006). Predictors of starting and remaining in treatment at a specialist alcohol clinic. Journal of Substance Use, 11(2), 89-100. Retrieved from CINAHL Plus with Full Text database. • Littlejohn, C., & Holloway, A. (2008). Nursing interventions for preventing alcohol-related harm. British Journal of Nursing (BJN), 17(1), 53-59. Retrieved from CINAHL Plus with Full Text database. • Milbrodt, T. (2002). Breaking the cycle of alcohol problems among Native Americans: Culturally-sensitive treatment in the Lakota community. Alcoholism Treatment Quarterly, 20(1), 19-44. Retrieved from EBSCO MegaFILE database. • Murray, S. (n.d.). How to open a halfway house in the United States. Retrieved November 25, 2010 from the National Institute on Chemical Dependency at http://www.nicd.us/howtoopenahalfwayhouseorhelpstartingahalfwayhouse.html

23. References • National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism. (2010). Rethinking drinking: Alcohol and your health. Retrieved November 28, 2010 from http://www.niaaa.nih.gov/Pages/default.aspx • National Center for Health Statistics. (2010). Health, United States, 2009: With Special Feature on Medical Technology. Hyattsville, MD. Retrieved November 18, 2010 from http://www.cdc.gov/nchs/hus.htm • Pender, N., Murdaugh, C., & Parsons, M. (2011). Health Promotion in Nursing Practice. (6th ed.). Pearson: Upper Saddle River, New Jersey. • Schwartz, S. M. (2006). The arrogance of ignorance; hidden away, out of sight and out of mind. Retrieved November 11, 2010, from http://www.linkcenterfoundation.org • Tsai, Y. (2009). Nurses' perceived facilitators and barriers to assessing for alcohol use in Taiwan. Journal of Clinical Nursing, 18(14), 2078-2086. Retrieved online November 30, 2010, from CINAHL Plus with Full Text database. • US Department of Health and Human Services, Office of Minority Health. (2009). American Indian/Alaska Native Profile. Retrieved November 28, 2010 from http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=3&lvlid=26 • US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2007) National Survey on Drug Use and Health. Retrieved November 29, 2010 from http://oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.cfm • US Dept of Justice, National Criminal Justice Reference Service. (1998). Alcohol and crime: An analysis of national data on the prevalence of alcohol involvement in crime (NCJ 168632). Retrieved on November 28, 2010 from http://bjs.ojp.usdoj.gov/content/pub/pdf/ac.pdf • US Department of the Census. (2003). Census 2000 data for the state of South Dakota. Retrieved November 29, 2010 from http://www.census.gov/census2000/states/sd.html • Villanueva, M., Tonigan, J., & Miller, W. (2007). Response of Native American clients to three treatment methods for alcohol dependence. Journal of Ethnicity in Substance Abuse, 6(2), 41-48. doi:10.1300/J233v06n02-04. • Walle, A. (2004). Native Americans and alcoholism therapy: the example of Handsome Lake as a tool of recovery. Journal of Ethnicity in Substance Abuse, 3(2), 55-79. Retrieved from CINAHL Plus with Full Text database. • White, W. (2000). The history of recovered people as wounded healers: I. From Native America to the rise of the modern alcoholism movement. Alcoholism Treatment Quarterly, 18(1), 1-23. Retrieved from EBSCO MegaFILE database.