Foreword

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the U.S. Department of Health and Human Services agency that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.

The Treatment Improvement Protocol (TIP) series fulfills SAMHSA's mission by providing science-based best-practice guidance to the behavioral health field. TIPs reflect careful consideration of all relevant clinical and health service research, demonstrated experience, and implementation requirements. Select nonfederal clinical researchers, service providers, program administrators, and client advocates comprising each TIP's consensus panel discuss these factors, offering input on the TIP's specific topic in their areas of expertise to reach consensus on best practices. Field reviewers then assess draft content.

The talent, dedication, and hard work that TIP panelists and reviewers bring to this highly participatory process have helped bridge the gap between the promise of research and the needs of practicing clinicians and administrators to serve, in the most scientifically sound and effective ways, people in need of behavioral health services. We are grateful to all who have joined with us to contribute to advances in the behavioral health field.

Executive Summary

Introduction

American Indians and Alaska Natives have consistently experienced disparities in access to healthcare services, funding, and resources; quality and quantity of services; treatment outcomes; and health education and prevention services. Availability, accessibility, and acceptability of behavioral health services are major barriers to recovery for American Indians and Alaska Natives. Common factors that influence engagement and participation in services include availability of transportation and child care, treatment infrastructure, level of social support, perceived provider effectiveness, cultural responsiveness of services, treatment settings, geographic locations, and tribal affiliations.

In response to existing behavioral health disparities, this TIP illustrates strategies for facilitating American Indian and Alaska Native individuals' access to and engagement in behavioral health services. It outlines promising practices for providers to apply in working with American Indians and Alaska Natives, and it includes tools and strategies that will help program administrators facilitate implementation of these practices.

Through this TIP, behavioral health workers will learn to identify how and to what extent a client's cultural background affects his or her behavioral health needs and concerns. It offers practical ideas and methods for addressing the realities of service delivery to American Indian and Alaska Native clients and communities, and it provides programmatic guidance for working with their communities to implement culturally responsive services. Throughout, the TIP emphasizes the importance of inclusivity, collaboration, and incorporation of traditional and alternative approaches to treatment and recovery support when working with American Indian and Alaska Native clients.

This TIP was developed through a consensus-based process that reflected intensive collaboration with American Indian and Alaska Native professionals. These professionals, who represented diverse tribes and native cultures, carefully considered all relevant clinical and research findings, traditional and culturally adapted best practices, and implementation strategies. American Indian and Alaska Native contributors shared their behavioral health-related experiences and stories throughout the process, thereby greatly enriching this important resource.

Overall Key Messages

Importance of historical trauma. Providers should learn about, acknowledge, and address the effects of historical trauma when working with American Indian and Alaska Native clients. Most American Indians and Alaska Natives believe that historical trauma, including the loss of culture, lies at the heart of substance use and mental illness within their communities.

Acceptance of a holistic view of behavioral health. Among many American Indian and Alaska Native cultures, substance use and mental illness are not defined as diseases, diagnoses, or moral maladies, nor are they viewed as physical or character flaws. Instead, they are seen as symptoms of imbalance in the individual's relationship with the world. Thus, healing and treatment approaches must be inclusive of all aspects of life—spiritual, emotional, physical, social, behavioral, and cognitive.

Role of culture and cultural identity. Providers need to understand how clients perceive their own cultural identity and how they view the role of traditional practices in treatment. Not all American Indian and Alaska Native clients recognize the importance of culture or perceive a need for traditional practices in their recovery. Nonetheless, providers and administrators must be ready to address their clients' cultural identity and related needs. Helping clients maintain ties to their native cultures can help prevent and treat substance use and mental disorders. Through reconnection to American Indian and Alaska Native communities and traditional healing practices, an individual may reclaim the strengths inherent in traditional teachings, practices, and beliefs and begin to walk in balance and harmony.

Recognition of sovereignty. Tribal governments are sovereign nations. Each nation adopts its own tribal codes and has a unique history with the U.S. federal government. Providers in native and non-native programs need to understand the role of tribal sovereignty and governance systems in treatment referrals, planning, cooperative agreements, and program development.

Significance of community. American Indian and Alaska Native clients and their communities must be given opportunities to offer input on the types of services they need and how they receive them. Such input helps match services to clients, increase community use of services, and use agency and tribal financial resources efficiently. Providers must involve themselves in native community events and encourage native community involvement in treatment services.

Value of cultural awareness. If providers are aware of their own cultural backgrounds, they will be more likely to acknowledge and explore how culture affects their interactions, particularly their relationships with clients of all backgrounds. Without cultural awareness, providers may discount the influence of their own cultural contexts—including beliefs, values, and attitudes—on their initial and diagnostic impressions of clients and selection of healing interventions.

Figure

Commitment to culturally responsive services. Organizations have an obligation to deliver high-quality, culturally responsive care across the behavioral health service continuum at all levels—individual, programmatic, and organizational. Not all American Indian or Alaska Native clients identify or want to connect with their cultures, but culturally responsive services offer those who do a chance to explore the impact of culture, history (including historical trauma), acculturation, discrimination, and bias on their behavioral health.

Significance of the environment. An environment that reflects American Indian and Alaska Native culture is more engaging for, and shows respect to, clients who identify with this culture. Programs can create a more culturally responsive ethos through adapted business practices, such as using native community vendors, hiring a workforce that reflects local diversity, and offering professional development activities (e.g., supervision, training) that highlight culturally specific American Indian and Alaska Native client and community needs.

Respect for many paths. There is no one right way. Providing direction on how something should be done is not a comfortable or customary practice for American Indians and Alaska Natives. For them, healing is often intuitive; it is interconnected with others and comes from within, from ancestry, from stories, and from the environment. There are many paths to healing.

Content Overview

Through this TIP, providers can explore how they interact with American Indian and Alaska Native clients and how they can incorporate culturally responsive ways of healing into their work. First, the TIP explores the basic elements of American Indian and Alaska Native cultures. Second, it emphasizes the importance of becoming aware of and identifying cultural differences between providers and clients. Third, it highlights native cultural beliefs about illness, help seeking, and health. Fourth, it offers culturally adapted, practice-based approaches and activities informed by science and the restorative power of native traditions, healers, and recovery groups.

Terminology

Before you read Part 1, Chapter 1, you will want to be familiar with the terms this TIP uses, along with explanations for why they are used. Of course, different people have different preferences; some people will prefer different terms. The intent and usage of these key terms are explained below. Clinical diagnostic terms (e.g., “substance use disorder,” “social anxiety disorder,” “major depressive disorder”) are used in accordance with definitions in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013).

American Indians and Alaska Natives. This TIP uses the term “American Indians and Alaska Natives” to refer to the indigenous peoples from the regions of North America now encompassed by the continental United States and Alaska. The term includes a large number of distinct tribes, pueblos, villages, and communities, as well as a number of diverse ethnic groups. On occasion, “native” or “Native American” is used for the sake of brevity, and this usage is not meant to demean the distinct heterogeneity of American Indian and Alaska Native people. The Native American peoples of the continental United States are known as American Indians, and those from Alaska are known as Alaska Natives. American Indians and Alaska Natives are considered distinct racial groups. In the U.S. Census, for example, the federal government considers American Indian and Alaska Native to be racial categories. However, this TIP is concerned with the cultural identity of American Indian and Alaska Native people. A person may have American Indian and Alaska Native ancestry but very little cultural identification with it, or he or she may have a large percentage of non-native American ancestors but still identify as a member of his or her native culture. A number of other terms used to describe American Indian and Alaska Native people are not used in this TIP, including “Amerindians,” “Amerinds,” “Indian,” “Indigenous People,”“Aboriginal People,” and “First Nations” (the last two are commonly used in Canada). This TIP sometimes refers to people from other racial or ethnic groups as “non-native” for brevity's sake.

USE OF DIAGNOSES WITH AMERICAN INDIAN AND ALASKA NATIVE CLIENTS

Some providers working with American Indian and Alaska Native clients find diagnostic terminology in clinical work to be problematic because the process of “naming” can have spiritual significance and may have negative consequences for the individual, family, and community. For those reasons, providers should be careful when using such terminology with clients, although the use of such terminology may be essential in other clinical contexts.

Behavioral health. The term “behavioral health” is used throughout this TIP. Behavioral health refers to a state of mental/emotional being and choices and actions that affect wellness. Behavioral health problems include substance use disorders, serious psychological distress, suicide, and mental illness. Such problems range from unhealthy stress to diagnosable and treatable diseases like serious mental illness and substance use disorders, which are often chronic in nature but from which people can and do recover. The term is also used in this TIP to describe the service systems encompassing the promotion of emotional health; the prevention of mental and substance use disorders, substance use and related problems; treatments and services for mental and substance use disorders; and recovery support. Because behavioral health conditions, taken together, are the leading causes of disability burden in the United States, efforts to improve their prevention and treatment will benefit society as a whole. Efforts to reduce the impact of mental and substance use disorders on America's communities, such as those described in this TIP, will help achieve nationwide improvements in health.

Cultural competence. This TIP uses the term “cultural competence” to describe the process in which services are delivered that are sensitive and responsive to the needs of the cultural group being served. Cultural competence is an ongoing process that involves developing an awareness of culture, cultural differences, and the role that culture plays in many different aspects of life, including behavioral health. TIP 59, Improving Cultural Competence (SAMHSA, 2014a), contains more information on cultural competence in a general sense, whereas this TIP discusses how to provide culturally responsive treatment to American Indians and Alaska Natives specifically. It is worth noting that there is no single Native American culture, but rather many hundreds of diverse cultures with their own languages, traditions, beliefs, and practices, and providers must try to understand the cultures of all the clients they serve.

Culture. The term “culture” is defined in this TIP as the product of a shared history and includes shared values, beliefs, customs, traditions, institutions, patterns of relationships, styles of communication, and similar factors (Castro, 1998). An individual may belong to more than one culture or cultural subgroup and may not accept all the values and beliefs of his or her primary culture, but culture will play a role in defining the individual's basic values and beliefs. TIP 59 (SAMHSA, 2014a) has more information on how cultures work and their importance in behavioral health services.

Indian Country. The term “Indian Country” is often narrowly defined in legal terms. In this context, the term includes reservations, native communities, Indian allotments located inside or outside reservations, towns incorporated by non-native people if they fall within the boundaries of an Indian reservation, and trust lands. This includes lands held by federal, state, or local (nontribal) governments, such as wildlife refuges, as well as sacred sites that are not on tribal lands. Many American Indians and Alaska Natives use the term more broadly to include any native community, independent of land designation, this TIP uses the term in that sense.

Medicine versus healing practices. Traditional healers may be referred to as “medicine men” and “medicine women,” but to avoid confusion among different meanings of “medicine,” this TIP refers to American Indian and Alaska Native healing practices rather than to medicine.

Provider and client. The TIP refers to someone who provides behavioral health services as a “provider” and someone who receives them as a “client.” These terms are not intended to be pejorative in any way or to reduce the relationship between the two to a purely business relationship; they are merely intended to highlight the fact that a client is someone seeking a service from a provider and that the provider has a responsibility to provide the service that the client requests. The consensus panel invested considerable energy in selecting the most appropriate terminology when referring to providers and clients. Members gave voice to traditions and beliefs surrounding healing, as well as some traditions established within behavioral health programs. Different programs may use different terms, and different terms may be used for providers with different roles (e.g., “psychiatrist,” “counselor,” “prevention specialist”). Certain programs refer to individuals as “relative,” “family,” or “cousin,” regardless of whether they are the provider or client. Some American Indian and Alaska Native programs use the term “participant” rather than “client” and “counselor” rather than “provider.” This TIP generally uses the term “provider” rather than “counselor,” except in specific examples where “counselor” is appropriate. As you read the document, recognize that there are certain phrases in the English language that would or could be perceived as paternalistic. For example, the term “your client” occurs a few times. This phrase is not meant to denote ownership or to reinforce paternalistic attitudes, but rather to reference the specific clients that the provider is working with in the healing process.

Substance abuse. The term “substance abuse” is used to refer to both substance abuse and substance dependence. This term was chosen partly because it is commonly used by substance abuse treatment professionals to describe any excessive use of addictive substances. In this TIP, the term refers to use of alcohol as well as other substances of abuse. Readers should note the context in which the term occurs to determine its meanings. In most cases, however, the term will refer to all varieties of substance use disorders described by DSM-5 (APA, 2013). The term “addictive disorders” is used to describe other mental disorders that are now classified under the category “Substance-Related and Addictive Disorders” in DSM-5 (APA, 2013), including tobacco use disorder and gambling disorder.

Traditional versus mainstream. When referring to American Indian and Alaska Native cultures, this TIP uses the adjective “traditional,” which is widely used by native people to refer to their own cultures. The term is not intended to imply that such cultures are static or out of date, but merely that American Indian and Alaska Native traditions reside in those cultures. This TIP uses the term “mainstream” to refer to the American culture that is endorsed by the majority of Americans. American society is pluralistic, and many diverse cultures contribute to that mainstream culture (including American Indian and Alaska Native cultures); for this reason, the TIP avoids terms like “European culture.” The term “mainstream” also avoids the hierarchy implied by terms such as “dominant culture.”

TIP Development Participants

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