Alcohol treatment in American Indian populations: an indigenous treatment modality compared with traditional approaches

What can primary care services do to help First Nations people with unhealthy alcohol use? A systematic review: Australia, New Zealand, USA and Canada

Background

First Nations peoples of Australia, New Zealand, the United States of America (USA) and Canada are more likely to be non-drinkers than other people in these countries. However, those who do drink may be at greater risk of alcohol-related harms (at a population level) due to the ongoing impacts from colonisation and associated oppression. Addressing unhealthy drinking (drinking above recommended limits including alcohol use disorders) in primary care settings is one important way to increase accessibility of treatment.

Methods

This systematic review identifies peer-reviewed studies of alcohol treatments delivered in primary care or other non-residential settings for First Nations peoples of Australia, New Zealand, USA and Canada. Literature searches were conducted in seven academic databases from their inception until March, 2020. We assessed evidence of treatment or implementation effectiveness, perceived acceptability or accessibility, and the study quality as assessed by the AXIS tool and by a measure of community participation in the research process.

Results

Twenty-eight studies were included, published between 1968 and 2018. Studies reported on a range of alcohol treatments, from brief intervention to ambulatory withdrawal management, relapse prevention medicines, and cultural therapies. Brief intervention was the most studied approach. Cultural healing practices and bicultural approaches were a key theme amongst several studies. Four studies measured treatment effectiveness, including one randomised controlled trial (naltrexone vs naltrexone plus sertraline vs placebo) and two uncontrolled trials of disulfiram. Of the six implementation studies, three were (hybrid) effectiveness-implementation designs. Most of the remaining studies (n = 21) focused on treatment accessibility or acceptability. Community participation in the research process was poorly reported in most studies.

Conclusions

Research evidence on how best to care for First Nations peoples with unhealthy alcohol use is limited. Trials of naltrexone and disulfiram presented promising results. Cultural and bicultural care were perceived as highly important to clinical staff and clients in several studies. More effectiveness studies on the full scope of alcohol treatments are needed. Greater community participation in research and more transparent reporting of this in study methods will be key to producing quality research that combines scientific rigour with cultural appropriateness.

Assessing service use for mental health by Indigenous populations in Australia, Canada, New Zealand and the United States of America: a rapid review of population surveys

BACKGROUND

Indigenous people in Australia, Canada, New Zealand and the United States of America experience disproportionately poor mental health compared to their non-Indigenous counterparts. To optimally allocate resources, health planners require information about the services Indigenous people use for mental health, their unmet treatment needs and the barriers to care. We reviewed population surveys of Indigenous people to determine whether the information needed to guide service development is being collected.

METHODS

We sought national- or state-level epidemiological surveys of Indigenous populations conducted in each of the four selected countries since 1990 that asked about service use for mental health. Surveys were identified from literature reviews and web searches. We developed a framework for categorising the content of each survey. Using this framework, we compared the service use content of the surveys of Indigenous people to each other and to general population mental health surveys. We focused on identifying gaps in information coverage and topics that may require Indigenous-specific questions or response options.

RESULTS

Nine surveys met our inclusion criteria. More than half of these included questions about health professionals consulted, barriers to care, perceived need for care, medications taken, number, duration, location and payment of health professional visits or use of support services or self-management. Less than half included questions about interventions received, hospital admissions or treatment dropout. Indigenous-specific content was most common in questions regarding use of support services or self-management, types of health professionals consulted, barriers to care and interventions received.

CONCLUSIONS

Epidemiological surveys measuring service use for mental health among Indigenous populations have been less comprehensive and less standardised than surveys of the general population, despite having assessed similar content. To better understand the gaps in mental health service systems for Indigenous people, systematically-collected subjective and objective indicators of the quality of care being delivered are needed.

Traditional Healing in the Prevention and Treatment of Alcohol and Drug Abuse

This article reviews traditional non-Western approaches to the treatment and prevention of substance abuse and dependence. Therapeutic practices reported here are based on Buddhist, Taoist, Hindu, Islamic and shaman ic traditions as well as on syncretistic Christianized folk beliefs. Traditional practitioners operate outside the official health care system but in some areas in collab oration with it. Analysis of these practices reveals general principles of traditional healing and permits hypotheses on the advantages and disadvantages of traditional approaches.

Alcohol Policy Issues for Indigenous People in the United States, Canada, Australia and New Zealand

This paper reviews the literature on alcohol consumption, alcohol-related problems, and national and local policy issues for indigenous people in four developed countries (United States, Canada, Australia and New Zealand). The growth of domestic self-determination and self-management policies within these countries has had an impact on the relationships between these groups and their national governments, which raises a number of questions regarding the influence of national alcohol policies on indigenous citizens. National “native” policies as well as discriminatory alcohol prohibitions have had long-standing effects, influencing indigenous responses to contemporary interventions in alcohol misuse. While national alcohol policies have had mixed impact, indigenous groups have focused on their own attempts at control, which emphasize local controls over supply; these are particularly prevalent in the far north of Canada and in Australia. Local control policies have been well evaluated in Australia, providing an evidence-based grounding for further interventions.

"The Poison That Ruined the Nation": Native American Men-Alcohol, Identity, and Traditional Healing

Alcoholism and destructive drinking patterns are serious social problems in many Native American reservation and urban communities. This qualitative study of men from a single Great Lakes reservation community examined the social, cultural, and psychological aspects of their alcohol problems through their life stories. The men were in various stages of recovery and sobriety, and data collection consisted of open-ended interviews and analysis utilizing principles and techniques from grounded theory and ethnographic content analysis. Alcoholism and other serious social problems facing Native American communities need to be understood in the sociocultural and historical contexts of colonization and historical grief and trauma. This study suggests that for Native American men, there are culturally specific perspectives on alcohol that have important implications for prevention and treatment of alcohol abuse. The participants' narratives provided insight into the ways reconnecting with traditional cultural values (retraditionalization) helped them achieve sobriety. For these men, alcohol was highly symbolic of colonization as well as a protest to it. Alcohol was a means for affirming "Indian" identity and sobriety a means for reaffirming traditional tribal identity. Their narratives suggested the ways in which elements of traditional cultural values and practices facilitate healing in syncretic models and Nativized treatment. Understanding the ways in which specific Native cultural groups perceive their problems with drinking and sobriety can create more culturally congruent, culturally sensitive, and effective treatment approaches and inform future research.

Reconfiguring the empty center: drinking, sobriety, and identity in Native American women's narratives

Although anthropologists have paid little attention to popular American psychological discourse about addiction and recovery, the cultural politics of its engagement by Native North American communities warrant closer examination. By ethnographically contextualizing personal narratives, this paper describes how addiction/recovery discourse has been selectively engaged by younger generations of women in a northern Plains reservation community. Sobriety is not only a therapeutic transformation but also a socially negotiated identity change in this community and, therefore, engages ongoing local identity politics. Many community members evaluate the legitimacy of claims to Native identity by essentializing boundaries between Native and non-Native, as well as between past and present-a discursive convention that O'Nell has called "the rhetoric of the empty center" (Disciplined Hearts: History, Identity and Depression in an American Indian Community. Berkeley: University of California Press, 1996, p. 55). Yet by selectively appropriating elements of addiction/recovery discourse, younger women in the 1990s increasingly positioned emotional experience and expression as central arbiters of the legitimacy of Native identity. In so doing, they reconfigured the rhetoric of the empty center, eliciting both controversy and support from the larger community. This analysis highlights new dimensions of the social life of addiction/recovery discourse in contemporary Native North America, and calls for increased ethnographic attention to how localized cultural politics can orient the ways in which communities engage therapeutic discourses.

Maintaining Abstinence in a Northern Plains Tribe

In this article, we examine how American Indian individuals with a history of alcohol dependence have been able to maintain their abstinence despite strong pressures to return to drinking. This work builds on close collaboration with individual tribal members who have resolved their problems with alcohol and community-based service providers to develop open-ended qualitative interviews. Using these, we explored how former drinkers respond to the twin challenges raised by their former drinking associates and strong feelings that emerge when alcohol is no longer an option for coping with life's difficulties. The resolution of these challenges is central to abstinence, given the strong ties between drinking and sociality in some American Indian communities (including the one where this study was conducted) and underscores the ways in which alternate relations to alcohol can be established even within a heavy drinking cultural context. Interviews were conducted with 133 individuals from a northern plains tribe who were identified in a previous epidemiological study as having a lifetime history of alcohol dependence. Inquiry into the processes involved in the meaningful constitution of abstinence for these men and women highlights the role of religion and spirituality for some, but by no means all of these individuals and, more broadly, the emergence of what Bea Medicine has characterized as "new ways of coping," which force us to expand on leading conceptualizations of coping in the literature on problems with alcohol.

Outcomes of drug and alcohol treatment programs among American Indians in California

OBJECTIVES

We examined differences in substance abuse treatment outcomes between American Indians and their non-American Indian counterparts in California, during 2000 to 2002.

METHODS

A total of 368 American Indians and a matched sample of 368 non-American Indians from 39 substance abuse treatment programs in 13 California counties were assessed at multiple time points. Records on arrests, driving while under the influence of alcohol or drugs, and mental health care were obtained 1 year before and 1 year after treatment entry. Differences in pretreatment characteristics, services received, treatment satisfaction, treatment completion and retention, and outcomes were examined.

RESULTS

Pretreatment problems were similarly severe among American Indians and non-American Indians. About half in both groups either completed treatment or stayed in treatment more than 90 days; American Indians in residential care had significantly shorter treatment retention. American Indians received fewer individual sessions and out-of-program services, especially for alcohol abuse, but were nevertheless generally satisfied with their treatment. Both groups improved after treatment, with American Indians demonstrating greater reductions in arrests than non-American Indians.

CONCLUSION

American Indians benefit from substance abuse treatment programs, although the type and intensity of services offered could be improved.

Therapeutic landscapes and First Nations peoples: an exploration of culture, health and place

This paper contributes to an expanding body of research within Health Geography that focuses on the role of therapeutic landscapes in shaping health. Therapeutic landscapes demonstrate the importance of places for maintaining physical, emotional, mental and spiritual health. Meanings of place and the relationship between place and health have culturally specific dimensions, yet these tend to be overlooked especially with respect to First Nations peoples. This paper broadens the analysis of therapeutic landscapes by exploring their culturally specific dimensions in the context of the everyday lives of 'Anishinabek' and thus contributes to a better understanding of First Nations peoples. First Nations peoples contend that the relationship they have with the land shapes the cultural, spiritual, emotional, physical and social lives of individuals and communities. While geographic research has explored First Nations peoples health, few studies have attempted to explore the influence of cultural beliefs and values on health-let alone the intricate link between the land and health. This paper presents the results of 17 in-depth interviews conducted with Anishinabek (Ojibway and Odawa) living in one First Nations community in northern Ontario, Canada. The findings from the interviews demonstrate that culture is an important component of the link between health and place in everyday life. Incorporating First Nations peoples' perspectives of health and place reveals that the current conceptualizations of health and place within the Geography of Health literature are only partial.

Sweat lodge ceremonies for jail-based treatment

Sweat lodge ceremonies (SLCs) have been an integral part of Navajo culture for hundreds of year. The Dine' Center for Substance Abuse Treatment staff utilized SLCs as a modality for jail-based treatment. Data were collected from the Spring of 1996 through the Spring of 1999 from 190 men ranging in age from 18 to 64. These inmate/patients (IPs) provided information at intake on a broad range of questions which were important in understanding the problems these men were having with alcohol and other drugs. Experiential data were collected from 123 IPs after each SLC. Several cultural variables showed improvement in the IP's world view following the SLCs. Even though there were few areas where data were statistically significant, several drinking measures changed in a positive direction. For example, among those subjects who were followed-up, analysis revealed a decrease in the number of drinks consumed in drinking sessions from a mean of 6.7 drinks at intake to a mean of 5.3 drinks. This article examines the role of SLCs in traditional counseling in jail-based treatment of alcohol abuse.

Traditional and western healing practices for alcoholism in American Indians and Alaska Natives

The American Indian and Alaska Native population is a culturally diverse population with a current census of 1,959,000. Prior to White contact, there was historically little use of alcoholic beverages except for American Indians in the Southwest. After White contact, use and misuse of alcohol escalated rapidly; however, the prevalence, patterns, and problems of drinking alcoholic beverages vary enormously even in tribes closely linked geographically. American Indians and Alaska Natives have preserved and revitalized a number of traditional healing practices and applied these to the treatment of alcohol-related problems. These healing practices include the following: nativistic movements, sacred dances, sweat lodges, talking circle, four circles, and cultural enhancement programs. Additionally, Western treatment approaches have been applied in the treatment of problems related to alcohol, such as medication for detoxification, disulfiram (Antabuse), Alcoholics Anonymous, and behavioral interventions. Several investigators have completed a small number of naturalistic follow-up studies, but no one has undertaken a randomized controlled trial looking at specific methods of alcohol treatment in American Indians or Alaska Natives. American Indian and Alaska Native communities have adapted and integrated both Traditional and Western approaches to fit their own unique sociocultural needs.

Aboriginal spirituality: symbolic healing in Canadian prisons

Symbolic healing is a complex phenomenon that is still relatively poorly understood. This paper documents a process of symbolic healing which is occurring in Canadian penitentiaries, and which involves Aboriginal offenders in cultural awareness and educational programs. The situation is compounded, however, by the existence of offenders from diverse Aboriginal cultural backgrounds with differing degrees of orientation to Aboriginal and Euro-Canadian cultures. Participants must first receive the necessary education to allow them to identify with the healing symbols so that healing may ensue, and both the healers and the patients must engage in a process of redefining their cultures in search of a common cultural base.

Treatment implications of comorbid psychopathology in American Indians and Alaska Natives

This paper discusses treatment implications of comorbid psychopathology in the context of American Indian and Alaska Native culture and in the context of the Indian Health Service's Mental Health and Alcohol and Substance Abuse Program Branches. Treatment of comorbidity in this population is a particularly difficult problem due to numerous barriers to treatment and a poorly defined treatment system. As in other clinical populations, these patients are high utilizers of the limited treatment services available, but may not receive the type of treatment they need. After describing the extent of comorbidity in this population, we present an historical perspective of mental illness that provides an Indian's view of why we are where we are today in treating these problems. Next, we discuss Western and traditional treatment implications for comorbidity among adults and adolescents. Finally, we suggest directions for future research in this area.