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SAMHSA-Funded Projects Highlight American Indians & Alaska Natives

By Melissa Capers

Four SAMHSA grantees published articles about their programs in the January-March 2003 issue of the Journal of Psychoactive Drugs, a publication of Haight-Ashbury Free Clinics, Inc., San Francisco, CA. The issue focuses on efforts in American Indian and Alaska Native communities to address health disparities and provide culturally competent substance abuse and mental health treatment through the integration of traditional, indigenous practices, and Western treatment techniques.

Family and Child Guidance Clinic, Native American Health Center, San Francisco

Founded in 1972, the Native American Health Center provides a variety of medical and social services to urban communities of American Indians and Alaska Natives in the San Francisco Bay Area. This locale has one of the highest concentrations of American Indians living in urban areas of the United States. Outpatient mental health and substance abuse treatment is provided through the Family and Child Guidance Clinic (FCGC).

In "A Holistic System of Care for Native Americans in an Urban Environment," Ethan Nebelkopf, Ph.D., and Janet King describe the strategic planning process used to develop appropriate services to meet critical community needs. In 1998, a 3-year planning grant from SAMHSA's Circle of Care Initiative supported the FCGC in developing a Circle of Care-a local system of care rooted in cultural values within the community. Through interviews with diverse community stakeholders, the FCGC identified key issues and resources in the community of more than 80,000 individuals representing more than 100 different tribes. They created a holistic, solutions-focused model that develops bridges between traditional spirituality and values and community systems of care.

Beginning in a central circle representing the Creator, an illustration of the FCGC Circle-of-Care model represents morbidities such as substance abuse, hunger, domestic violence, and mental illness as imbalances within the quadrants of spirit, body, feelings, and thought. These quadrants of human experience are coordinated to the four traditional elements of creation-fire, earth, water, and air-and to community systems of care, including the criminal justice system; the housing, managed health care, welfare, and mental health systems; and schools. The model focuses on solutions, and highlights both Native "exemplary practices" (e.g., the talking circle) and Western ones (e.g., case management).

In another article, "The Women's Circle Comes Full Circle," Karen Saylors, Ph.D., describes the history and impact of the Women's Circle project of the FCGC. Initiated in 1996, the Women's Circle focuses on HIV prevention for American Indian and Alaska Native women. In 1999, SAMHSA supported expansion of substance abuse treatment services and the provision of mental health services within the Women's Circle, where culturally based interventions are combined with Western psychotherapeutic and medical services.

Ninety-five different tribal affiliations are represented among Women's Circle clients, and individual clients vary in their desire to engage in traditional practices. In response to this individual and cultural diversity, clinical assessment at the Women's Circle includes a spiritual/cultural domain, which is used in the development of an individual treatment plan. The treatment plan may include sage, cedar, or sweet grass smudges, along with singing, drumming, sweat lodge ceremonies, talking circles, and other cultural healing activities.

Dr. Saylors emphasizes that, ". the way cultural interventions often occur is on the individual level, with counselors assessing a client's desire or readiness to work with traditional ways."

Providing individualized, culturally based treatment appears quite effective: Rates of substance abuse among clients decreased sharply after treatment at the Women's Circle.

Dine' Center for Substance Abuse Treatment, Navajo Nation

In October 1993, the Navajo Nation founded the Dine' Center for Substance Abuse Treatment as one of six Rural, Remote, and Culturally Distinct Populations projects funded by SAMHSA. The traditional healing practices used by the Dine' Center in alcohol and substance abuse treatment included sweat lodge ceremonies. In 1994, these ceremonies were made available to inmates in the Navajo Nation's Window Rock Jail. There, 190 men participated in a 3-year study (from 1996 to 1999) of the effect of these ceremonies in jail-based substance abuse treatment. Weekly alcohol education classes were paired with weekly group psychotherapeutic sessions conducted within the context of a sweat lodge ceremony.

"The way cultural interventions often occur is on the individual level, with counselors assessing a client's desire or readiness to work with traditional ways."

The results of this study are reported in "Sweat Lodge Ceremonies for Jail-Based Treatment," by J. Phillip Gossage, Ph.D., Louie Barton, Lenny Foster, Larry Estsitty, Clayton Lone Tree, Carol Leonard, M.P.H., and Philip A. May, Ph.D. The small sample size and data collection challenges faced by investigators limit the conclusions that can be drawn from this study. However, the data show a decrease in the average number of drinks participants consumed at drinking sessions (from a mean of 6.7 to a mean of 5.3) and improvement in participants' world view, suggesting that further efforts and study on the provision of culturally based treatment for American Indians within the criminal justice system are necessary and appropriate.

Village Sobriety Project, Hooper Bay and Scammon Bay, Alaska

The Village Sobriety Project, funded by a 3-year SAMHSA grant (from 1999 to 2002), preserves and honors traditional practices by weaving them into mental health and substance abuse treatment. In "Incorporating Yup'ik and Cup'ik Eskimo Traditions Into Behavioral Health Treatment," Phoebe A. Mills, M.S.W., reports on efforts in the Yukon-Kuskokwim Delta of southwest Alaska to preserve culture and enhance outcomes, as well as to ensure access to services through developing Medicaid-reimbursable treatment plans that incorporate traditional and Western healing practices.

Before the project, the authors say, treatment services for this population "were approached solely from the Western framework, operating with such tools as the DSM-IV, cognitive therapy, rational-emotive therapy, play therapy, and art therapy. One premise behind the incorporation of traditional modalities into behavioral health treatment is that if Western modalities can utilize play and art in therapy, then traditional cultural activities can be considered just as valid in formal treatments."

Some of the traditional cultural practices incorporated into treatment included hunting, chopping wood, taking tundra walks, and gathering edible and medicinal plants. Through making clear correlations between traditional activities and Medicaid service components, and meeting certain requirements regarding staff qualifications and documentation of treatment, program staff were able to develop a service model that is not only culturally competent, but also financially sustainable and accessible to clients.

In Mental Health: Culture, Race, and Ethnicity (1999), the U.S. Surgeon General reported that culture plays a role in the effectiveness of mental health treatments, and that racial and ethnic minorities are less likely than the general population to receive quality services. The efforts highlighted in the Journal of Psychoactive Drugs (Jan-Mar 2003) suggest that both of these concerns might be addressed through culturally competent mental health and substance abuse services blending traditional Native and contemporary Western practices.

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