BEHAVIORAL HEALTH SERVICES FOR TIP 61 AMERICAN INDIANS AND ALASKA NATIVES Part 3: Literature Review For behavioral health service providers, program administrators, clinical supervisors, and researchers Part 3 of this Treatment Improvement Protocol describes the available literature on behavioral health services for adult American Indians and Alaska Natives. It examines epidemiological studies and culturally responsive adaptations to standard behavioral health services. TIP Navigation Executive Summary For behavioral health service providers, program administrators, clinical supervisors, and researchers Part 1: Pr actical Guide to the Provision of Behavioral Health Services for American Indians and Alaska Natives For behavioral health service providers Part 2: Imple mentation Guide for Behavioral Health Program Administrators Serving American Indians and Alaska Natives For behavioral health service providers, program administrators, and clinical supervisors Appendix and Index Part 3: Literature Review For behavioral health service providers, program administrators, clinical supervisors, and researchers TIP 61 Behavioral Health Services for American Indians and Alaska Natives Contents PART 3: LITERATURE REVIEW Part 3, Section 1: Literature Review ..........................................3 Introduction .................................................................3 The American Indian and Alaska Native Population and Their Behavioral Health Needs ...5 Large Epidemiological Studies on the Prevalence of Mental and Substance Use Disorders ....................................................5 Epidemiological Data on Mental Disorders From Other Studies.....................12 Epidemiological Data on Addictive Disorders From Other Studies ...................18 Substance Use and Misuse Patterns for American Indians and Alaska Natives .........20 Epidemiological Data on CODs ...............................................29 Risk and Protective Factors for Mental and Substance Use Disorders ................30 Diferences in the Behavioral Health of American Indian and Alaska Native Subpopulations ..........................................................54 Behavioral Health Services for American Indians and Alaska Natives ................66 Motivation for Treatment and Access to Care ...................................66 Retention and Outcomes....................................................72 Screening and Assessment ...................................................73 Mental Health Promotion and Substance Misuse/Use Disorder Prevention ...........76 Adapting Standard Mental and Substance Use Disorder Treatment Modalities ........80 Using Traditional Practices in Mental and Substance Use Disorder Treatment .........87 Mutual Help ..............................................................93 Relapse Prevention and Recovery Promotion ....................................95 Systems Issues ..............................................................99 Program Management and Sovereignty Issues ..................................99 Community Involvement ....................................................99 Telephone- and Computer-Based Services .....................................103 Vocational Training ........................................................105 Reference List .............................................................106 Part 3, Section 2: Links to Select Abstracts ..................................133 Part 3, Section 3: General Bibliography .....................................141 Exhibits Exhibit 3.1. Lifetime Substance Use Disorders Among American Indians in the AI-SUPERPFP.........................................................10 Exhibit 3.2. Lifetime Rates of DSM-IV Mental Disorders Among American Indians in the AI-SUPERPFP ..................................................11 Exhibit 3.3. Lifetime Substance Use Among American Indians in the AI-SUPERPFP .......23 Exhibit 3.4. Inter-Tribal Diferences in Trauma Histories .............................42 2 BEHAVIORAL HEALTH SERVICES FOR TIP 61 AMERICAN INDIANS AND ALASKA NATIVES Part 3, Section 1: Literature Review Introduction diverse ethnic/cultural groups, including American Indians and Alaska Natives. Because cultural This Treatment Improvement Protocol (TIP) is competence and responsiveness to clients’ cultural concerned with behavioral health services for backgrounds are discussed at length in that TIP, indigenous people whose ancestors lived in North they are not covered in this TIP or its literature and South America before the arrival of Europeans review in any detail. and thus includes American Indians and Alaska Natives. Although the term “American Indians and According to the Census estimates released in Alaska Natives” is used to describe people from 2018, 6.8 million people in the United States iden- a wide range of diverse tribal and cultural groups, tifed as Native American, either alone or in com- these groups do share several things in common. bination with another race, which was 2.1 percent They are all indigenous to North and South of the U.S. population. Of those 6.8 million people, America; they have retained a traditional culture 4.1 million identifed solely as American Indian and that varies signifcantly—in some ways—from Alaska Native (1.3 percent of the population), and White, mainstream American culture; and they 2.7 million identifed as American Indian and Alaska have been displaced and oppressed to varying Native in combination with another race (Census degrees during the process of colonization and its Bureau, Population Division, 2018). aftermath. Despite the limitations of using a single term to discuss this wide range of people, the The American Indian and Alaska Native population authors believe that it provides the best working is largely concentrated in certain areas of the model for understanding shared concerns that country, and in 2010 there were 187 counties affect mental and substance use disorders (SUDs) where American Indians and Alaska Natives made and their treatment. In instances where a given up 8 percent or more of the population (Norris, study identifes the population as either American Vines, & Hoeffel, 2012). Most of these individuals Indian or Alaska Native, those terms are used. did not reside in American Indian and Alaska Native areas, which include reservations, trust Because various American Indian tribes and lands, tribal statistical areas, and Alaska Native Alaska Native peoples also inhabit land in Canada, villages; 67 percent of those who identifed solely research from Canada is included in the review. as American Indian and Alaska Native resided This research uses the terms “First Nations” or outside those areas, and 92 percent of those who “Aboriginal” peoples to identify Canadian Indian, identifed as American Indian and Alaska Native Métis, or Inuit peoples, and those terms are used in combination with another race resided outside in relation to those studies. those areas also. About one-third of American Indians and Alaska Natives migrate back and forth TIP 59, Improving Cultural Competence (Substance between urban and rural areas (Forquera, 2001). Abuse and Mental Health Services Administration [SAMHSA], 2014b), is intended as a guide for clini- Providing services to these individuals is further cians and administrators to help them in fostering complicated by the fact that there are more than the provision of culturally responsive behavioral 560 federally recognized American Indian tribes health services to a diverse group of clients. TIP 59 and Alaska Native groups. Additionally, some tribes provides guidance on developing and implement- are recognized by states but not by the federal ing culturally responsive treatment and prevention government, and more than 300 have petitioned services as well as specifc guidelines on making for recognition but remain unrecognized (Bureau of services culturally responsive for members of Indian Affairs, 2010; National Conference of State 3 TIP 61 Behavioral Health Services for American Indians and Alaska Natives Legislatures, 2016). This group of tribes represents practices with [American Indian and Alaska Native] a diverse set of cultures, spiritual traditions, and participants” (p. 143). The review also includes histories, but many of them share commonalities a number of studies that are older than typically with regard to the cultural and spiritual customs found in TIP reviews because more recent data are and historical factors. Providers should be aware not available. It also sometimes refers to studies of the cultures and practices of the specifc tribe that combine data from some earlier yearly studies or tribes to which their clients belong. Wherever rather than referring to the most recent versions possible, this literature review identifes the region, of those studies; the relatively small number of not the tribe, from which a study draws its sample. American Indian and Alaska Native participants The TIP honors tribal anonymity, as well as in in the new yearly studies makes it hard to draw personal anonymity, for participants. signifcant conclusions. The likelihood that a person will self-identify as Research on mental disorder and SUD treatment American Indian and Alaska Native has been for American Indians and Alaska Natives is sparse increasing since the 1960s at a faster rate than in part because of the small number of American can be accounted for by normal demographic Indians and Alaska Natives included in national trends (Hack, Larrison,