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Cultural Diversity as a Positive Force in the Treatment of Native American Alcohol and Other Drug Abuse

Anne Muldoon
Menomonie, Wisconsin

This paper examines cultural research done by experts in Native American studies to identify a path for overcoming cultural barriers in the effective treatment of alcohol and other drug abuse (AODA). The first section of this paper briefly summarizes data relevant to the incidence and prevalence of AODA and their health consequences for Native Americans.

The second section looks at the cultural uniqueness of traditional Native Americans and focuses on value preferences and extended family relationships. The survivor syndrome theory explains perceived negative attitudes and tolerance of AODA in Native American communities.

The third section advocates acceptance of the cultural diversity of Native Americans as fellow Americans and advocates continued education for human services workers. Cultural barriers often lead to common errors when human services workers communicate with Native Americans. These errors include stereotyping, assuming affiliation, fearing silence, discounting denial, and trust busting. Summarized research findings and conclusions support the use of information about cultural diversity as a positive force in AODA treatment. Recommendations include training

in cultural diversity, supporting community outreach programs that involve whole communities, suggesting a celebration of sobriety within State and national parks, and advocating the revision of existing AODA treatment programs to reflect a more flexible attitude regarding cultural diversity.

Introduction

This paper is based on the following four basic premises:

• Rural and frontier areas of America need cost-effective AODA treatment for Native Americans.
• High rates of AODA incidence and prevalence, along with their pathology and mortality, are destroying Native Americans.
• Cultural barriers block the success of conventional AODA treatment methods for Native Americans.
• Understanding and accepting cultural diversity can be a positive force in AODA treatment.

This paper explores cultural research in Native American studies to identify a path for overcoming cultural barriers and for providing desperately needed, effective treatment services that involve the community.

Methods

Demographics and orienting facts underscore the prevalence of AODA and its health consequences for Native Americans. Prominent research identifies cultural differences, uncovers barriers to effective treatment, and finds existing positive aspects on which to build a service base. Research findings are used to draw conclusions and to recommend strategies to break through cultural barriers, and thus to improve existing service delivery and to develop new AODA prevention policies for Native American communities.

Orienting Facts Relevant to Native American AODA

States designated as rural areas have a high proportion of Native American residents, although the overall State populations count 50 or fewer people per square mile. Thus, politically, fewer voters, along with uninvolved electors, equal less policymaking power in Alaska, Arkansas, Arizona, Colorado, Iowa, Kansas, Maine, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Utah, and Wyoming.

Demographic information from researchers in Native American studies is briefly summarized below to identify the scope of the AODA issue in rural States.

The Native American population nearly tripled between 1960 and 1980—from 551,669 in 1960 to 1.4 million in 1980. As of 1980, 46 percent of Native Americans resided on identified reservations or tribal trust lands (Liebowitz 1991). The Bureau of Indian Affairs (Marshall et al. 1990) recognizes 312 tribes and 500 tribal villages, varying by entity size from under 100 persons to over 150,000 culturally diverse Americans (Marshall et al. 1990).

Morgan, Hodge, and Weinmann compared recorded diagnoses of alcohol dependence at all U.S. short-stay hospitals with those within Indian Health Services (IHS) delivery systems (cited in Marshall et al. 1990). IHS rates were 3.28 times higher.

Marshall and others (1990) compare Native Americans with all races in alcohol-related deaths by age group. The Native American death rate in the 15-24 age group was 11.4 times higher. Native Americans aged 25-32 had death rates 11.2 times higher, the 35-44 age group had rates 7.7 times higher, and the 45-54 age group had rates 4.8 times higher than rates for all races (Marshall et al. 1990). "Between 1983-85, one third of all Native Americans who died were under age 45 compared to 10 percent for the total U.S. population. The excess death of younger people is attributed to higher rates for homicide, suicide, accidents, and death attributed to alcoholism" (Project Cork, p. 2).

A survey of health indices related to AODA identifies thirteen different conditions among Native Americans that account for 92 percent of years of productive life lost before age 55 (Rhoades et al. 1987). These conditions represent 46 percent of all IHS outpatient visits and 73 percent of total inpatient days. For Native Americans ages 15-45, the rate of productive life-years lost is twice that of the U.S. population as a whole. Unintentional injury (accidents) and violence (suicide and homicide) (first and third) represent non-disease-related needless deaths.

The health indices related to AODA, in order of productive life lost and number of deaths per 100,000, are listed in table 1.

The Cultural Uniqueness of Traditional Native Americans

Many of the attitudes of Native Americans in need of AODA services depend on the progression of the disease, the adjustment to the dominant culture, the known and practiced degree of heritage consistency, and previous life experiences. The ideas presented here are common threads of understanding found in sociological research and reflect a personal interest in traditional Native American heritage. However, service providers need to emphasize the individual over the culture.

Cultural Value Preferences

Attneave (1981) compares the cultural value preferences of Native Americans with those of middle class Americans. Traditional values were observed and discussed in 50 tribal groups. U.S. white middle class data are derived from research performed at Brandeis University, Massachusetts. Three answer choices were given in order of value preference regarding a life concept. For example, if the number one answer choice of "harmony with" given for the concept of "man's relationship with nature" were to become impossible, the second choice "subject to" would be used. Table 2, condensed from Attneave's work (1981), illustrates the striking differences between the ways an average white middle-class person would choose to live life and the traditional ways of Native Americans. The information could help the human services worker who cannot communicate with a Native American client.

Extended Family Relationships

The peer and family groups are the strongest forces in most Native American lives. The value preferencecollateral interpersonal relationships is often symbolized by the "circle of life or "sacred hoop" in Native American culture. Decisionmaking is generally a group process and must consider all the people who will be affected by such decisions People related by blood, by marriage, and by community are all considered family.

The prevalence of alcoholism among white Americans is estimated as follows: 1 in every 10 Americans is alcoholic; each person's alcoholism pathologically affects four family members' lives and up to 40 lives in the community workplace, highway, economy, and so on). Johnson reported that the alcoholic cirrhosis death rate for Native American women in the 15-35 age group was 36 times that of Whites (cited in Hurlburt and Gade 1984). When these two estimates are correlated, entire family and community groups of Native Americans are devastated by AODA and its mortal consequences.

Even when a Native American successfully completes AODA treatment, the return home is hazardous to sobriety. The tradition of peer group sharing is a powerful cultural tie; accepting what is offered, even alcohol, is just as important a sign of friendship as the act of offering. Even when a Native American intends to maintain sobriety, being excluded by the group may erode those intentions. In addition, isolation and boredom are common among younger and unemployed members of the community. Drinking adventures may be the most exciting, yet dangerous, activity. As noted earlier, unintentional injury or accident is the leading cause of death among Native Americans. This cause is closely related to the "drinking party."

Because of the community's uncertainty on how to react to intoxication, considerable enabling contributes to AODA among native Americans. Enabling is the conscious, or very often unconscious, aid of AODA by family and extended family members. Moreover,because an intoxicated person is not considered to be in control of any actions, he or she is not punished tor crimes committed while intoxicated. This lack may explain Why intoxication is used to forgive erratic or violent actions that occurred during intoxication.

Survivor Syndrome Theory

Phoenix Indian Health Center researchers Beane, Hammerschlag, and Lewis (1980) define the active pathology in the Native American culture as survivor syndrome. They postulate that attempts by Christian settlers to subdue the "savage" prompted 100 years of enforced dependency on Federal Native American policy; the constant erosion of sacred culture, dislocation from homelands, controlled poverty, and humiliation have resulted in survivor syndrome.

Repetitive psychodynamic themes exhibited by survivors of long-term persecution include "guilt and self-loathing, an inability to cope with anger, chronic depression, impoverished object relationships, and long-term personality changes to persecution, distress and apathy.... Survivors feel an incredible rage, but have an inability to express the rage at the intended object because of real or fantasized threats of retribution" (Beane et al. 1980, p. 15). Unexpressed anger is internalized and acted out against self or extended family members. The researchers cite clinical manifestations such as high AODA rates, suicides, homicides, family disintegration, and social/ educational failures (Beane et al. 1980).

Cultural Barriers to Effective AODA Treatment

Whereas the major barrier to AODA treatment, diminished funding, will require strong political action to solve, other important cultural barriers can be destroyed by information. Is it perhaps because white Americans share their country with Native Americans that they cannot accept the cultural diversity? Throughout history, white Americans have expected Native Americans to accept Christianity, greed for gold, land acquisition, formalized education, governmental systems, and various diseases. This attitude is a counter-productive debate over who did what.

Fortunately, the cultural diversity classes required by today's higher educational institutions will help graduates to overcome these cultural biases. In addition, social workers and counselors are being offered continuing education opportunities. The barriers examined here are related to communication—a human services worker's most powerful tool. Common communication barriers include stereotyping, assuming affiliation, fearing silence, discounting denial, and trust busting.

Stereotyping

The Old West stereotype of the drunken Native American is the shamed brave, enslaved by the whiskey jug, begging by the trading-post gate. The modern version has the crazy-drunk Native American fighting in the bars until passing out.

Neither of these accounts depicts the true disease and consequences of AODA. Moreover, the more charitable view of Native Americans as poor unfortunates to be pitied and coddled is equally false. The image of the Native American who needs AODA services is not static but reflects changes in the Native American community as well as the global community. Above all, human services workers must treat each person as an individual who has a serious disease.

Assuming Affiliation

When human services workers counsel anyone outside their ethnic group, they should obey the following advice: "Be yourself." "Above all, the therapist should not assume some affinity based on novels, movies, a vacation trip, or an interest in silver jewelry. These are among the most offensive, commonly made errors when non-Indians first encounter an American Indian person or family. Another is the confidential revelation that there is an Indian "Princess" in the family tree-tribe unknown, identity unclear, but a bit of glamour in the family myths" (Attneave, p. 57).

St. Germaine (1989) warns against the disaster of using tribe-specific information on a member of the wrong tribe; with over 250 tribes and years of migration, the chances of being right are very slim. Instead, human services workers need to taLk to the client about heritage consistency. Through such dialogue, individuals can place themselves along a heritage continuum between traditional ways and contemporary lifestyle; in the process, valuable knowledge will be gained about the client.

Fearing Silence

Experts advise "staving" with the person by using quiet attentiveness and open body language. Whereas extended silence in the white culture may be interpreted as a defense mechanism, Native Americans often consider it a sign of respect. Forcing a client to open up and tell all is considered therapeutic by many AODA counselors; when working with a person raised to revere emotional restraint, counselors may need patience.

Discounting Denial

In 12-step recovery programs, admitting to being powerless is step one. A historical (and probably well-placed) mistrust of the white man makes "admitting we are powerless" seem like cowardice to many Native Americans. Added to this mistrust is the power of denial. Counselors working with the chemically dependent person are aware of the denial process that impairs the client's reality concept. This denial process is a cross-cultural phenomenon.

However, as AODA counselors are learning to accept the cultural diversity of the Native American client, the denial process may be used to hide or minimize the consequences of AODA, to blame others for troubles, to divert attention to another topic, or to use emotional blackmail to avoid reality. With any or all of these forms of denial, counselors must confront the clients about their denial of AODA as a powerful disease and must reflect a true picture of its consequences and progressive ruination of lives.

Trust Busting

In these davs of short-stay AODA treatment, it is more difficult to build the strong trust relationship between client and counselor that is essential to effective work. The communication barriers between most Native American clients and their caseworkers make this task even more formidable.

Trust is, at best, fragile. To avoid breaking the painstakingly established trust, (1) be yourself, and (2) do not promise anything you cannot deliver.

Findings

Rates of AODA-related deaths for Native Americans aged 15-32 are greater than 11 times that for other Americans; one-third of Native Americans who die are under age 45, and accidental death is the leading cause.

Health problems related to AODA account for 46 percent of IHS outpatient visits and 73 percent of inpatient days.

According to the Bureau of Indian Affairs, Native Americans are a culturally diverse group of people belonging to 312 tribes. Traditional Native Americans differ from the U.S. white middle class in their value preferences regarding major life concepts. Their priorities emphasize harmony with nature, a present time orientation, a large circle of extended family relationships, and the process of becoming a better person idealized as a goal (rather than achieving material success).

Family and peer group violence—along with mistrust, depression, and apathy—directly relate to survivor syndrome and to the tolerance of AODA within Native American communities.

Cultural barriers are formed by mistakes in communication. False judgments result from stereotypical thinking. Counselors should be themselves while encouraging the client to talk about heritage; in addition, counselors need to remember that among Native Americans, extended silences do not signify a defensive attitude.

Denial of the consequences of AODA is a cross-cultural phenomenon that must be confronted during treatment of the disease; at the same time, the fragile trust relationship must be protected.

Conclusions

AODA is culminating in the destruction of Native American populations. Native American death rates are far greater than that of other Americans, particularly for those under age 45 who are dying in AODA-related accidents.

Sparsely populated States, such as the designated rural and frontier States, face fewer allocated AODA treatment days and diminished program funding. These same States, all of which have high proportions of Native Americans, need to improve the costeffectiveness of their programs.

Cultural diversity has been a barrier to effective AODA treatment largely because of misinterpretations. Focusing on the individual always takes precedence over cultural background; nevertheless, counselors must consider the person's heritage as a frame of reference to form a positive therapeutic environment.

Cultural value preferences regarding major life concepts differ greatly between traditional Native Americans and average white middle-class Americans. This diversity accounts for miscommunication and false judgments.

Because extended family circles encompass large numbers of people within Native American communities, the pathology affects more people. Workers providing AODA services need to address the power of the peer group.

A knowledge of survivor syndrome w ill help human services workers to understand clients and their negative attitudes of violence, mistrust, depression, and apathy. Because knowledge is power, newly required classes in cultural diversity will help to eliminate biases through information sharing and open communication.

Recognizing commonly made mistakes, such as stereotyping, assuming affiliation, fearing silence, discounting denial, and trust busting, will give the human services worker a much better chance of helping Native American clients succeed in AODA therapy.

Finally, human service workers can use the knowledge of cultural diversity as a positive force in communication. Such knowledge will help workers break through cultural barriers and reach plateaus of progress in the battle of AODA treatment.

Recommendations

The following recommendations are made based on extensive research on Native American AODA, along with much thoughtful consideration regarding attainable goals:

• All human services workers, beginning with those in direct client contact, should have mandatory training in how cultural diversity relates to communication in the helping relationship.
• Community outreach programs for young people, such as Drug Abuse Resistance Education (DARE), must be developed, and Native Americans must assume leadership roles.
• Prevention programs must begin with young children and continue throughout the extended family, maximizing peer power within Native American communities.
• State parks and national parks in rural and frontier States should be used as host sites for integrated campouts for all persons who maintain sobriety; a fitting theme for these crosscultural celebrations is "Harmony with the Universe."
• Existing AODA treatment programs need to be revised to reflect a more flexible, positive attitude about cultural diversity.

References

Attneave, C. The Paradigms. Westport: Greenwood, 1981.

Beane, S.; Hammershlag, C.; and Lewis, J. "Federal Indian policy: Old wine in new bottles." White Cloud Journal 2(1): 14-17, 1980.

Duncan, E. North American Indian Family Counseling-A New Challenge. Native Program Development Office, Alcoholism Foundation of Manitoba, 1990.

Estes, G.; and Zitzow, D. Heritage Consistency as a Consideration in Counseling Native Americans. Institute of Social Studies, University of South Dakota, 1975. Hurlburt, G.; and Gade, E. Personality differences between Native American and Caucasian women alcoholics: Implications for alcoholism counseling. White Cloud Journal 3(2): 7-26, 1984.

Liebowitz, H. "Review. Indigenous Americans and Rehabilitation." Rehab Brief 13(8): 1991.

Mail, P. American Indians, stress, and alcohol. American Indian and Alaska Native Mental Health Research 3(2): 7-26,1989.

Marshall, C.; Martin, W.; and Johnson, M. Issues to consider in the provision of vocational services to American Indians with alcohol problems. Jounnal of Applied Rehabilitation Counseling 21(3): 45-47, 1990.

Marshall, C.; Martin, W.; Thomason, T., and Johnson, M. Multiculturalism and rehabilitation counselor training: Recommendations for providing culturally appropriate counseling services to American Indians with disabilities Journal of Counseling and Development 70: 225-234, 1991.

Project Cork. Institute of Dartmouth Medical School. Native American Alcohol and Substance Abuse. Timonium, MD: Milner-Fenwick, Inc., 1989.

Rhoades, E.R; Harnmond, J. et al. The Indian burden of illness and future health intervention. Public Health Reports 102(4): 361-367, 1987.

St. Germaine, R "Communiversity Series on Native American Spirituality." [lecture] University of Wisconsin— Eau Claire, 1989.

Willie, E. "Story of Alkali Lake: Anomaly of community recovery or national trend in Indian country?" Alcoholism Treatment Quarterly 6(3/4): 167-174, 1989.

Last Updated 11-7-02