Meet the National American Indian and Alaska Native ATTC
The National American Indian & Alaska Native ATTC
The principal goal of the National American Indian and Alaska Native ATTC is to bring useful, culturally relevant information about evidence-based addiction treatment and recovery services to American Indian and Alaska Native populations. The National American and Alaska Native ATTC seeks to enhance the effectiveness of the behavioral health workforce by providing training, technical assistance, meeting opportunities, and products which are both culturally relevant and empirically sound through state-of-the-art technology transfer services.
American Indian and Alaska Native Treatment and Recovery Service Opportunities
One of the many myths about American Indians and Alaska Natives is that the majority of them abuse or are dependent on alcohol or other substances. What is not as well known is that more than half (to be precise, 55.3%) of American Indians and Alaska Natives do not currently use alcohol (NSDUH, 2011; SAMHSA, 2012). Furthermore, 30.7% of American Indians and Alaska Natives age twelve and older have never had a drink of alcohol (2011 NSDUH). Despite these figures, we also know that many American Indian and Alaska Native communities are struggling with serious issues like substance use disorders with 18.6% of the population estimated to be in need of treatment compared to 9.6% of the general population (SAMHSA, 2010), and other chronic diseases like diabetes, cardiovascular disorders, and obesity (IHS, 2011). Disproportionate rates of substance use disorders (CDC, 2008) and co-occurring disorders (Gone, 2007; Johnson & Cameron, 2001; Neumeister et al, 2007) within this population compared to the general population suggest opportunities for improved treatment and recovery services.
The addictions treatment and behavioral health workforce that works with American Indian and Alaska Native clients includes substance use disorder and mental health professionals, as well as health and allied health professionals working in primary care. This workforce is based in a variety of settings, including 206 substance use disorder treatment facilities operated by tribal governments and the Indian Health Service (IHS) (SAMHSA, 2005), 38 Urban Indian Health Programs, and an array of private treatment facilities across the country.
The American Indian and Alaska Native population is diverse. It includes 566 federally-recognized tribal communities as well as additional tribal communities with varying degrees of recognition by individual states. American Indians and Alaska Natives live in both rural and urban areas across the country.
Ability to provide culturally relevant evidence-based treatment and recovery programs to American Indian and Alaska Native clients is critical for this workforce. Beliefs about substance use disorders, coping mechanisms, and the influence of social support and stress can be impacted by cultural identity (Terrell, 1993). In this vein, Euro-American approaches to substance use disorder treatment can be alienating to American Indian and Alaska Native clients (Larios, Wright, Jernstrom, Lebron & Sorenson, 2011). For this reason, evidence-based treatment approaches to behavioral health disorders among American Indian and Alaska Native clients need to be adapted to their cultural ways. It is also the case that American Indian and Alaska Native providers have developed culturally-based interventions for their clients that are considered effective by the Native community. Such approaches are often referred to as experienced-based approaches. The non-native behavioral health workforce needs to become aware of the effectiveness of some of these practices for some American Indian and Alaska Native clients with behavioral health disorders.
In addition to cultural differences, experiences of historic trauma and discrimination can complicate the development of therapeutic relationships, requiring acknowledgement and consideration by both counselor and client. Non-Native providers may require special training to appreciate the importance of American Indian and Alaska Native cultural factors and historical awareness in order to navigate the difference in perspective that may distinguish Euro-American and American Indian and Alaska Native perspectives on substance use disorders (Mackey, Zavadil, Baron & Skinstad, 2006). Native providers also encounter this challenge since their formal training is frequently predominantly Euro-American in nature. For this reason, the materials and curricula used by behavioral health professionals may need to be adapted to American Indian and Alaska Native culture. It may also be the case that materials relevant to and effective for one tribal group or community may not be so useful for others; providers must respect tribal sovereignty, as well as the diversity and individuality of American Indian and Alaska Native communities.
Treatment and Recovery Opportunities within Population Subgroups
Several subgroups within the overall American Indian and Alaska Native population present special opportunities and challenges in the delivery of behavioral health treatment and recovery services. They include discharged veterans, women who have been victimized as children or adults, and members of the Two-Spirit community, including youth.
A higher percentage of American Indian and Alaska Native males are members of the U.S. military than males from any other racial or ethnic group in the United States. AGs well, American Indian and Alaska Native veterans have high rates of PTSD and substance use disorders (SUDs) (Noe et al., 2010). In 1991, 46.3% of discharged American Indian and Alaska Native veterans had SUDs, compared to 23.4% all discharged U.S. veterans (Walker, Howard, Anderson & Lambert, 1994). Unfortunately, American Indian and Alaska Native veterans are less likely than other groups to have access to health insurance and, in part for that reason; they must confront more barriers to obtaining appropriate health care than veterans from other ethnic groups (Johnson, Carlson & Hearst, 2010).
American Indian and Alaska Native women experience 2-3 times more violent victimizations than women from other cultural or ethnic groups (Greenfield & Smith, 1999), including high rates of abuse during childhood, sexual abuse, and intimate partner violence. Significant relationships have been found between rates of lifetime abuse, depression and SUDs in American Indian and Alaska Native women (Bohn, 2003). These high rates of SUDs among American Indian and Alaska Native women contribute importantly to the high prevalence rates for fetal alcohol spectrum disorder (FASD) in this group (Parker, Magvilia, Lewis, Gossage & May, 2010); FASD is a serious problem: It is the leading preventable birth defect and the most common preventable cause of mental retardation (Beckett, 2011). Rates of FASD in some American Indian and Alaska Native communities are estimated to be as high as 3.9 – 9 per 1000 births, compared to 0.3 per 1000 births in the general population (Hanson, Winberg & Elliott, 2011). A SAMHSA assessment of 10 reservations and five UIHPs reported that FASD-prevention services in these areas were limited or nonexistent (SAMHSA, 2004).
The Two-Spirit community is another American Indian and Alaska Native population group in need of special attention. Two-Spirit is a culturally relevant term used to connote diverse sexual orientations and gender roles among American Indian and Alaska Native (Lehavot, Walters & Simoni, 2009). Two-Spirit individuals may experience racism in the general LGBT community and homophobia within tribal communities. Hence, they are at compound risk of discrimination and victimization (Brotman, Ryan, Jalbert & Rowe, 2002; Jacobs & Brown, 1997). There is evidence that Two-Spirit individuals may sustain higher rates of lifetime alcohol abuse and PTSD (Walters, Horwath & Simoni, 2001) and greater suicide rates than the general American Indian and Alaska Native population (Monette, Albert & Waalen, 2001; Morris & Balsam, 2003). Two-Spirit youth are at particular risk for both suicide (Halpert, 2002) and early- onset alcohol use (Balsam, Huang, Fieland, Simoni & Walters, 2004). Additionally, Two-Spirit individuals may be less likely to utilize SUD and mental health (MH) services because of concerns about privacy and stigma surrounding their sexuality (Walters, Simoni & Evans-Campbell, 2002).
These findings, overall, suggest a clear and substantial opportunity for more culturally-relevant programs and options for American Indians and Alaska Natives within existing addiction treatment and recovery systems.
American Indians and Alaska Native workforce development issues
In preparation for the implementation of the Affordable Care Act, many tribal providers wish to enhance their credentials and educational level. To this end, one important continuing effort by the National American Indian and Alaska Native ATTC has been to assist tribal providers in enhancing the ability of behavioral health providers to acquire these credentials.
Recovery Oriented Systems of Care (ROSC) is an approach to recovery support and care integration which aligns well with American Indian and Alaska Native values of community and holistic care. A ROSC is a coordinated network of community-based services and supports that is person-centered and builds on the strengths and resilience of individuals, families, and communities to achieve abstinence and improved health, wellness, and quality of life for those with or at risk of alcohol and drug problems (SAMHSA/CSAT, 2010). The alignment of ROSC with traditional American Indian and Alaska Native values presents the opportunity for its use as a model in the implementation of the Affordable Care act. Because of these opportunities, the National American Indian and Alaska Native ATTC has conducted presentations and talking circles on ROSC through the Aberdeen and Bemidji IHS regions, and intends to expand this project to the rest of the nation.
Leadership development is another essential element in the implementation of the Affordable Care act, as are the implementation of evidence-based practices and the continued integration of experience-based practices into the behavioral health care of American Indians and Alaska Native clients. Systematic and effective clinical supervision in the provision of regular behavioral health care enhances the quality of that care; it also reduces the incidence of counselor burn-out and turnover in staff. For these reasons, the National American Indian and Alaska Native ATTC will initiate a leadership development program enhance the frequency and effectiveness of clinical supervision in behavioral health practice.
Sensitivity to American Indian and Alaska Native culture, as well as to cultural differences among different tribal communities, is essential in providing training and technical assistance to providers and communities. Oftentimes, American Indian and Alaska native providers and trainers are the professionals who are best suited to provide the training and technical assistance (TA) to their communities. Building capacity for training and TA in American Indian and Alaska communities is an essential goal of our efforts.
Projects and Products the center has developed
During the time the center was responsible for providing services to the tribal communities in the upper Midwest, many products were developed. The center will continue to offer these products. Many of these products are available in printed form or downloadable from our web page. Other projects are offered through face-to-face training opportunities
Here is an overview of already developed or finished products:
- Alcohol and Drug Exam Review Course – A review course for individuals preparing for an alcohol or drug certification exam
- Native American Curriculum for State Accredited, Non-Tribal Substance Abuse Programs – A cultural competency course for non-native substance abuse treatment program staff
- The Spirit of Communication: Motivational Interviewing and Native American Teaching – A culturally adapted training on motivational interviewing
- Proceedings of the Summit: Tribal Prescription Drug Abuse Summit: Moving from Information Sharing to Action Plan – A proceedings document from a tribal prescription drug abuse summit
- Addendum to TAP 21-A: Adapting Clinical Supervision Core Competency Standards to Native American Culture – A cultural adaption of TAP 21-A: Competencies for Substance Abuse Treatment Clinical Supervisors
- Healthy Women, Healthy Lives – A holistic psycho-educational group program for women
Finding Purpose: Recruiting Native Americans into Behavioral Health – A recruitment video highlighting opportunities for American Indians and Alaska Natives in the Behavioral Health Field
- Nagi Kicopi – A video which provides a narrative of struggles and successes over alcohol abuse on reservations
- Sucker Punched – A video of Native American, Delaney Apple’s story of drugs, alcohol and violence.
Principal American Indian and Alaska Native ATTC Goals
In the effort to facilitate the further development of experience- and evidence-based addiction treatment and recovery services for American Indian and Alaska Native populations the following goals will guide the National American Indian and Alaska Native ATTC’s work:
- Advance the American Indian and Alaska Native substance use disorder treatment field by enhancing communications and collaborations with stakeholders and relevant organizations.
- Conduct ongoing assessment of needs and workforce development issues.
Facilitate and promote the use of culturally legitimate evidence- and experience-based practices.
- Emphasize state of the art technology transfer principles in our educational events.
- Enhance the American Indian and Alaska Native workforce through workforce development initiatives.
- Offer technical assistance and training opportunities to American Indian and Alaska Native organizations to better integrate behavioral health into primary care, based on SAMHSA and Health Resources and Services Administration (HRSA) Center for Integrated Health Solutions.
- Facilitate the development of Recovery Oriented System of Care (ROSC) in American Indian and Alaska Native communities. Karen, should we discuss this somewhere?
Throughout our efforts to achieve these goals we will strive to maintain cultural sensitivity, inclusivity, and respect in our collaborations and interactions with AI/AN communities, service providers, researchers, and individuals.
Partnerships and Collaborations
National American Indian and Alaska Native ATTC’s efforts will be guided by a nationally representative Advisory Council. Advisory Council members currently include: Dan Dickerson, DO, MPH, Inupiaq, UCLA, California; Dennis Norman, S. EdD, ABPP, Cheyenne and Cherokee, Harvard University, Massachusetts; Wayne H. White Wolf-Evans, EdD, Teton Sicangu Lakota, University of South Dakota, South Dakota; Clyde McCoy, PhD, Eastern Cherokee, University of Miami, Florida; Lorrie Miner, JD, Lower Bruel, Lower Brule Sioux Tribal Court, South Dakota; Ralph Forquera, MPH, Juaneno Band of California Mission Indians, University of Washington, Seattle; Dolores Subia BigFoot, PhD, Caddo Nation, University of Oklahoma, Oklahoma; Richard Bird, MMS, CCDCIII, Sisseton-Wahpeton Oyate, Dakota Pride Center, South Dakota; Ray Daw, MA, Navajo, Yukon-Kuskokwim Health Cooperation, Alaska; and Sean Bear, Sr. MA, Sac & Fox Tribe of Mississippi, , MADAC, Iowa. Ex-officio members include: Juanita M. Mendoza, Bureau of Indian Education, and Cheryl Peterson, Interim Director of the Division of Behavioral Health, Indian Health Service (IHS) Headquarters. In addition, the center is working with consultants from across the country. Equally important to the success of the National American Indian and Alaska Native ATTC’s efforts are the other National ATTC Focus Centers and Regional ATTCs.
The Home office of the National American Indian and Alaska Native ATTC is in the College of Public Health at the University of Iowa. The center’s staff and major consultants:
Anne Helene Skinstad, PhD
Karen Summers, MPH, CHES
Program Manager: Evaluations and Curriculum
Project Coordinator: Fiscal and Contract
Erin Thin Elk, MSW
Sicangu Lakota Oyate
Senior Behavioral Health Consultant
Dale Walker, MD
Member of the Cherokee Nation
Consultant, One Sky Center
Donovan Sprague, MA
Member of the Cheyenne River Sioux Tribe
Kate Winters, MA
Attend the ATTC Network’s Third Thursday iTraining:
Get to Know the New National American Indian & Alaska Native ATTC
May 16, 2013, 2:00-3:30p.m. Eastern
Presenters: Nancy Roget, MS, MFT, LADC
Authors: Skinstad, A.H., Summers, K. Nathan, P.E. & Bock, J