9.6: Counseling for Native Americans

There are 566 federally recognized American Indian Tribes, and their members speak more than 150 languages (U.S. Department of the Interior, Indian Affairs 2013a); there are numerous other Tribes recognized only by states and others that still go unrecognized by government agencies of any sort. According to the 2010 U.S. Census (Norris et al. 2012), the majority (78 percent) of people who identified as American Indian or Alaska Native, either alone or in combination with one or more other races, lived outside of American Indian and Alaska Native areas. Approximately 60 percent of the 5.2 million people who identified as American Indian or Alaska Native, alone or in combination with one or more other races, reside in urban areas (Norris et al. 2012). The category of Alaska Natives includes four recognized Tribal groups— Alaskan Athabascan, Aleut, Eskimo, and Tingit-Haida—along with many other independent communities (Ogunwole 2006).

Native Americans who belong to federally recognized Tribes and communities are members of sovereign Indian nations that exist within the United States. On lands belonging to these Tribes and communities, Native Americans are able to govern themselves to a large extent and are not subject to most state laws—only to federal legislation that is specifically designated as applying to them (Henson 2008). Although health care (including sub- stance abuse treatment) is provided to many Native Americans by Indian Health Services (IHS), Tribal governments do have the option of taking over those services. Correctional professionals working with these populations should remember that Native Americans, by virtue of their membership in sovereign Tribal entities, have rights that are different from those of other Americans; this distinguishes them from members of other ethnic/racial groups.

American Indians live in all 50 states; the states with the largest populations of American Indians are Oklahoma, California, and Arizona. The 2000 Census allowed people to identify, for the first time, as a member of more than one race. Of persons who checked two or more races, nearly one in five indicated that they were part American Indian or Alaska Native (U.S. Census Bureau 2001a,b).

Beliefs About and Traditions Involving Substance Use

Few American Indian Tribes and no Alaska Natives consumed alcoholic beverages prior to contact with non-Native people, and those who did used alcohol primarily for special occasions and ceremonies. Most Tribes first encountered the use of alcohol when they encountered European settlers and traders. Because of this lack of experience with alcohol, few Native Americans had a context for drinking besides what they learned from these non-Natives, who at the time drank in large quantities and often engaged in binge drinking. Although patterns of alcohol consumption in the mainstream population of the United States changed over time, they remained relatively the same in the more isolated Native American communities. According to an NSDUH report on American Indian and Alaska Native adults, binge drinking continues to be a significant problem for these populations. Both binge drinking and illicit drug use is higher among Native Americans than the national average (30.2 percent versus 23 percent and 12.7 percent versus 9.2 percent, respectively; SAMHSA 2013d).

American Indian drinking patterns vary a great deal by Tribe. Tribal attitudes toward alcohol influence consumption in complicated ways. For example, in Navajo communities, excessive drinking was acceptable if done in a group or during a social activity. However, solitary drinking (even in lesser amounts) was considered to be deviant (Kunitz et al. 1994). Kunitz et al. (1994) observed that during the 1960s, binge drinking was acceptable among the Navajo during public celebrations, whereas any drinking was considered unacceptable among the neighboring Hopi population, wherein regular drinkers were shunned or, in some cases, expelled from the community. Hopi individuals who did drink tended to do so alone or moved off the reservation to border towns where heavy alcohol use was common. The ostracism of Hopi drinkers seemed to lead to even greater levels of abuse, given that there were much higher death rates from alcoholic cirrhosis among the Hopi than among the Navajo.

Native American recovery movements have often viewed substance abuse as a result of cultural conflict between Native and Western cultures, seeing substances of abuse as weapons that have caused further loss of traditions (Coyhis and White 2006). To best treat this population, substance abuse treatment providers need to expand their perspectives regarding substance abuse and dependence and must embrace a broader view that explores the spiritual, cultural, and social ramifications of substance abuse (Brady 1995; Duran 2006; Jilek 1994).

Substance Use and Substance Use Disorders

According to 2012 NSDUH data, American Indian and Alaska Native peoples have the highest rates of substance use disorders and binge drinking (SAMHSA 2013d). Although rates of substance abuse are high among Native Americans, so too are rates of abstinence. American Indians and Alaska Natives are more likely to report no alcohol use in the past year than are members of all other major racial and ethnic groups (OAS 2007). The American Indian Services Utilization and Psychiatric Epidemiology Risk and Protective Factors Project (AI-SUPER PFP) also found that rates of lifetime abstinence from alcohol for American Indians in the study were significantly higher than lifetime abstinence rates among the general population (Beals et al. 2003). Data on alcohol consumption also show that Alaska Natives are significantly more likely to abstain than are other Alaskans (Wells 2004).

The most common pattern of abusive drinking among American Indians appears to be binge drinking followed by long periods of abstinence (French 2000; May and Gossage 2001). A similar pattern is seen among Alaska Natives (Seale et al. 2006; Wells 2004). As an example, the Urban Indian Health Institute (2008) found that binge drinking was significantly more common among the Native American population (with 21.3 percent engaging in binge drinking in the prior 30 days compared with 15.8 percent of non- Native Americans) and that, among those who drank, 40.7 percent of Native American participants engaged in binge drinking compared with 26.9 percent of non-Natives.

In addition to alcohol, methamphetamine and inhalant abuse are major concerns for a number of Native American communities. Nonetheless, there are considerable regional differences in patterns and prevalence of drug use (Miller et al. 2012). According to the National Congress of American Indians (2006), 74 percent of Tribal police forces ranked methamphetamine as the drug causing the most problems in their communities. Methamphetamine abuse can be even more serious for Native Americans living in rural areas than for those in urban areas, but it is also a serious problem for growing numbers of American Indians, especially women, entering treatment in urban areas (Spear et al. 2007).

American Indians and Alaska Natives are more likely to report having used inhalants at some time during their lives, but use tends to peak in 8th grade and then decrease (Miller et al. 2012). In some Native American communities (e.g., on the Kickapoo reservation in Texas), inhalants have been a major drug of abuse for adults as well as youth. During the early 1990s, about 46 percent of the adult population on that reservation were thought to abuse inhalants (Fredlund 1994). Although more recent data are not available, reports from the area suggest that inhalant abuse remains a significant problem (Morning Star 2005).

Mental and Co-Occurring Disorders

According to the 2012 NSDUH, 28.3 percent of American Indians and Alaska Natives report having a mental illness, with approximately 8.5 percent indicating serious mental illness in the past year (SAMHSA 2013c). Native Americans were nearly twice as likely to have serious thoughts of suicide as members of other racial/ethnic populations, and more than 10 percent reported a major depressive episode in the past year. Common disorders include depression, anxiety, and substance use.

As with other groups, substance use disorders among Native Americans have been associated with increased rates of a variety of different mental disorders (Beals et al. 2002; Tann et al. 2007; Westermeyer 2001). The 2012 NSDUH revealed that 14 percent of Native Americans reported both past-year substance use disorders and mental illness. Among those who reported mental illness, nearly 5 percent reported several mental illnesses co-occurring with substance use disorders (SAMHSA 2013c).

Native American communities have experienced severe historical trauma and discrimination (Brave Heart and DeBruyn 1998; Burgess et al. 2008). Studies suggest that many Native Americans suffer from elevated exposure to specific traumas (Beals et al. 2005; Ehlers et al. 2006; Manson 1996; Manson et al. 2005), and they may be more likely to develop PTSD as a result of this exposure than members of other ethnic/racial groups. PTSD comparison rates taken from the AI-SUPER PFP study and the National Comorbidity Study show that 12.8 percent of the Southwest Tribe sample and 11.5 percent of the Northern Plains Tribe sample met criteria for a lifetime diagnosis of PTSD compared with 4.3 percent of the general population (Beals et al. 2005). Trauma histories and PTSD are so prevalent among Native Americans in substance abuse treatment that Edwards (2003) recommends that assessment and treatment of trauma should be a standard procedure for behavioral health programs serving this population. For example, Native American veterans with substance use disorders are significantly more likely to have co-occurring PTSD than the general population of veterans with substance use disorders (Friedman et al. 1997).

Treatment Patterns

Despite a number of potential barriers to treatment (Venner et al. 2012), Native Americans are about as likely as members of other racial/ethnic groups to enter behavioral health programs. According to data from the 2003 and 2011 NSDUH (SAMHSA, CBHSQ 2012), Native Americans were more likely to have received substance use treatment in the past year than persons from other racial/ethnic groups (15.0 percent versus 10.2 percent). Other studies indicate that about one-third of Native Americans with a current substance use disorder had received treatment in the prior year (Beals et al. 2006; Herman-Stahl and Chong 2002). The 2012 NSDUH reported that approximately 15 percent of Native Americans received mental health treatment (SAMHSA 2013c).

Native Americans were least likely of all major ethnic/racial groups to state that they could not find the type of program they needed and were the next least likely after Native Hawaiians and other Pacific Islanders to state that they did not know where to go or that their insurance did not cover needed treatment. Among Native Americans who identified a need for treatment in the prior year but did not enter treatment, the most commonly cited reasons for not attending were lack of transportation, lack of time, and concerns about what one’s neighbors might think (SAMHSA 2011c).

The same research also found that Native Americans were somewhat more likely than the general treatment-seeking population to enter residential programs. Native Americans were more likely to enter treatment as a result of criminal justice referrals than were White Americans or African Americans: 47.9 percent of American Indians and Alaska Natives entering public treatment programs in 2010 were court-ordered to treatment compared with 36.6 percent of White Americans and 36.4 percent of African Americans (SAMHSA, CBHSQ 2012). The lack of recognition of special needs and knowledge of Native American cultures within behavioral health programs may be the main reasons for low treatment retention and underuse of help-seeking behaviors among Native Americans (LaFromboise 1993; Sue and Sue 2013e).

Beliefs and Attitudes About Treatment

Duran et al. (2005) evaluated obstacles to treatment entry among American Indians on three different reservations; most frequently mentioned were the perception that good-quality or suitable services were unavailable and the perceived need for individuals to be self-reliant. They also found social relationships to be extremely important in overcoming these barriers. Jumper-Thurman and Plested (1998) reported that focus groups of American Indian women listed mistrust as one of the primary barriers for seeking treatment. This is due, in part, to the women’s belief that they would encounter people they knew among treatment agency staff; they also doubted the confidentiality of the treatment program.

Treatment Issues and Considerations

Each Tribe and community will likely have different customs, healing traditions, and beliefs about treatment providers that can influence not only willingness to participate in treatment services, but also the level of trust offender have for providers. Correctional professionals and other behavioral health workers must develop ongoing relationships within local Native American communities to gain knowledge of the unique attributes of each community, to show investment in the community, and to learn about community resources (Exhibit 5- 3). Identifying and developing resources within Native communities can help promote culturally congruent relationships. To provide culturally responsive treatment, providers need to understand the Native American offender’s Tribe; its history, traditions, worldview, and beliefs; the dimensions of its substance abuse problem and other community problems; the incidence of trauma and abuse among its members; its traditional healing practices; and its intrinsic strengths. Providers who work with Native Americans but do not have an understanding of their cultural identity and acculturation patterns are at a distinct disadvantage (Ponterotto et al. 2000).

Native Americans often approach the beginning of a relationship in a calm, unhurried manner, and they may need more time to develop trust with providers. Concerns about confidentiality can be an important issue to address with Native American offender, especially for those in small, tightly knit communities. For providers, it is very important to make clear to offender that what they say to the counselor will be held in confidence, except when there is an ethical duty to report. Native American cultural groups generally believe that health is nurtured through balance and living in harmony with nature and the community (Duran 2006; Garrett et al. 2012).

They also, for the most part, have a holistic view of health that incorporates physical, emotional, and spiritual elements (Calabrese 2008), individual and community healing (Duran 2006; McDonald and Gonzalez 2006), and prevention and treatment activities (Johnston 2002). For many, culture is the path to prevention and treatment. However, not all Native Americans have a need to develop stronger connections to their communities and cultural groups. As Brady (1995) cautions, culture is complex and changing, and a return to the values of a traditional culture is not always desired. An initial inquiry into each offender’s connection with his or her culture, cultural identity, and desire to incorporate cultural beliefs and practices into treatment is an essential step in culturally competent practice. When appropriate, providers can help facilitate the offender’s reconnection with his or her community and cultural values as an integral part of the treatment plan. In addition, treatment providers need to adapt services to be culturally responsive. In doing so, outcomes are likely to improve not only for Native American offender, but for all offender within the program. Fisher et al. (1996) modified a therapeutic community in Alaska to incorporate Alaska Native spiritual and cultural practices and found that retention rates improved for White and African American offender as well as Alaska Native offender participating in the program.

In working with Native American offender, providers should be prepared to address spirituality and to help offender access traditional healing practices. Culturally responsive treatment should involve community events, group activities, and the ability to participate in ceremonies to help offender achieve balance and find new insight (Calabrese 2008). Stronger attachment to Native American cultural groups protects against substance use and abuse; therefore, strengthening this connection is important in substance abuse treatment (Duran 2006; Moss et al. 2003; Spicer 2001; Stone et al. 2006).

Family Therapy

Family involvement in treatment leads to better outcomes for Native Americans at the time of discharge from treatment (Chong and Lopez 2005). Research also suggests that family and community support can have a significant effect on recovery from substance use disorders for this population (Jones- Saumty 2002; Paniagua 1998). Family therapy can be quite helpful and perhaps even essential for American Indian offender (Coyhis 2000), especially when other social supports are lacking (Jones-Saumty 2002).

American Indians place high value on family and extended family networks; restoring or healing family bonds can be therapeutic for offender with substance use disorders. Moreover, Native American offenders are sometimes less motivated to engage in “talk therapy” and more willing to participate in therapeutic activities that involve social and family relationships ( Joe and Malach 2011). Treatment approaches should remain flexible and include offender’s families when appropriate. Correctional professionals should be able to recognize what constitutes family, family constellations, and family characteristics. The Native American concept of family can include elders, others from the same clan, or individuals who are not biologically related. In many Tribes, all members are considered relatives. Families can be matrilineal (i.e., kinship is traced through the female line) and/or matrilocal (i.e., married couples live with wife’s parents).

Group Therapy

Although researchers and providers once viewed group therapy as ineffective for American Indian offenders (Paniagua 1998), opinion has shifted to recognize that, when appropriately structured, group therapy can be a powerful treatment component (Garrett 2004; Garrett et al. 2001; Trimble and Jumper- Thurman 2002). Garrett (2004) notes that many Native American Tribes have traditional healing practices that involve groups; for many of these cultural groups, healing needs to occur within the context of the group or community (e.g., in talking circles). Thus, if properly adapted, group therapy can be very beneficial and culturally congruent. It is important, however, to determine Native American offender’s level of acculturation before recommending Western models of group therapy, as less acculturated Native offender are likely to be less comfortable with group talk therapy (Mail and Shelton 2002). Group therapy for Alaska Natives should also be non- confrontational and focus on offender’s strengths.

Group therapy can incorporate Native American traditions and rituals to make it more culturally suitable. For example, the talking circle is a Native tradition easily adapted for behavioral health treatment. In this tradition, the members of the group sit in a circle. An eagle feather, stone, or other symbolic item is passed around, and each person speaks when he or she is handed the item. Based on a review of the literature, Paniagua (1998) recommends that providers using group therapy with Native American offender:

• Earn support or permission from Tribal authorities before organizing group therapy.
• Consult with Native professionals.
• If group members consent, invite respected Tribal members (e.g., traditional healers or elders) to participate in sessions.

Mutual-help Groups

Native American peoples have a long history of involvement in mutual-help activities that predates the 12-Step movement (Coyhis and White 2006). Depending on acculturation, availability of a community support network, and the nature of their presenting problems, Native American offenders may be more likely to solicit help from significant others, extended family members, and community members. Contemporary manifestations of Native American mutual-help efforts include adaptations of the 12 Steps (Exhibit 5-4) and of 12-Step meeting rituals and practices (Coyhis and White 2006). Another modified element of the 12 Steps is use of a circular, rather than a linear, path to healing. The circle is important to American Indian philosophy, which sees the great forces of life and nature as circular (Coyhis 2000). In addition, staff members of the White Bison program have also rewritten the AA “Big Book” from a Native American perspective (Coyhis and Simonelli 2005). The principles of the 12 Steps, which involve using the group or community to provide support and motivation while emphasizing spiritual reconnection, appeal to many Native Americans who see treatment as social in nature and who view addiction as a spiritual problem.

The Native American Wellbriety movement is a modern, indigenous mutual-help program that has its roots in 12-Step groups but incorporates Native American spiritual beliefs and cultural practices (Coyhis and Simonelli 2005; Coyhis and White 2006; White Bison, Inc. 2002; also see www.whitebison.org). Although the Wellbriety movement is popular with many Native Americans in recovery, a considerable number also continue to participate in traditional 12-Step groups. In the AI- SUPER-PFP, 47 percent of Northern Plains Tribe respondents and 28.8 percent of South- west Tribe respondents with a past-year substance use disorder reported 12-Step group attendance in the prior year (Beals et al. 2006). Mohatt et al. (2008b) found that more Alaska Natives in recovery reported participation in 12-Step groups than in substance abuse treatment. In Venner and Feldstein’s (2006) re- search with American Indians in recovery, 84 percent of respondents had attended some mutual-help meetings.

Relapse Prevention and Recovery

Despite limited data on long-term recovery for Native Americans who have substance use disorders, a few studies have found high rates of relapse following substance abuse treatment (see review in Chong and Herman-Stahl 2003). White and Sanders (2004) recommend that long-term recovery plans for Native Americans make use of a recovery management rather than a traditional continuing care approach. Such an approach emphasizes the use of informal recovery communities and traditional healing approaches to provide extended monitoring and support for Native Americans leaving treatment.

Researchers have conducted interviews with both American Indians (Bezdek and Spicer 2006) and Alaska Natives (Hazel and Mohatt 2001; Mohatt et al. 2008; People Awakening Project 2004) who have achieved extended periods of recovery. Bezdek and Spicer (2006) identified two key tasks for American Indians entering recovery. First, they need to learn how to respond to family and friends who drank with them and to those who supported their recovery. Next, they have to find new ways to deal with boredom and negative feelings. By accomplishing these tasks, Native offenders can build new social support systems, develop effective coping strategies for negative feelings, and achieve long-term recovery. The People Awakening Project found that, among Alaska Natives who had a substantial period of recovery, the development of active, culturally appropriate coping strategies was essential (e.g., distancing themselves from friends or family who drank heavily, getting involved in church, doing community service, praying; Hazel and Mohatt 2001; Mohatt et al. 2008; People Awakening Project 2004).