by Joel Chisholm, MD

 Historical Overview
 Cultural Influences
 Genetics
 Epidemiology
 Psychosocial Component
 “The Modern Native American”
 Treatment Options

 Traditional Ways: General similarities amongst
Native American tribes
 Decimation  Colonization
 Broken Treaties
 Genocide
 U.S. Government policies and organizations

 Common Beliefs: Mother Earth and Father Sky
 Mother Earth represents all earth including water and all living creatures
 Father Sky represents wind, weather, sun, stars, and moon
 Humans not superior to other living creatures
 Cooperation  form of balance amongst all living things (plants, insects, birds, animals)

 Tribes: Clan System (i.e. Cherokee-thousands of villages linked by one common social system) and Band System
(i.e. Sioux-3 subdivisions: Lakota, Santee, Yankton all with their own bands)
 History: Oral story telling
 Language: main connection within individual tribe
 Medicine Man: spiritual leader and healer
 Elders: someone who has developed themselves in a balanced way (not just an old person)
 Ceremonies: healing, spiritual, celebrations

 Traditional psychoactive agents  peyote, cocoa leaves, tobacco, alcohol
 Divided year into horticulture and hunting/warfare, which were highly regulated
 Group Emphasis: traditionally, the first decision is always for the good of the tribe and then the clan and the group are considered
 Medicine Wheel: balance between physical, spiritual, emotional, and mental health

 East - Physical
 South - Emotional
 West - Mental
 North - Spiritual

 1800s, not that long ago…
 Exploration to “discover new territory”
 Manifest Destiny: Western expansion for territory, religious freedom, and material gain (i.e. gold)
 Epidemic disease was the overwhelming cause of the population decline of the Native Americans because of their lack of immunity to new diseases brought from Europe.

 Focus on two tribes: Cherokee and Sioux
 Main players: Europeans initially and then U.S. government and military
 Tactics: Government agents, treaties and more treaties, and forceful takeovers
 Initially to form alliances to help support against other governments and settlers, then for their own settlements
 Eventually to gain all valuable resources

 Branch of the Iroquois in the southern Appalachian Mountains
 Territory consisted of western North and South Carolina, northern Georgia and Alabama, southwest Virginia, and the
Cumberland Basin of Tennessee, and Kentucky
 7 Clans: Bird, Paint, Deer, Wolf, Blue, Long Hair, and Wild
Potato
 Region was divided into the Upper, Middle, and Lower towns
 Matriarchal society with a married couple and children moving into the wife’s clan and could only marry into different clan. Kinship was traced through the mother's family.
Women had an equal voice in the affairs of the tribe.

 Their society was based on hunting, trading, and agriculture, living in towns until they encountered the first Europeans in
1540, when Spanish explorer Hernando de Sota led an exploration through Cherokee territory.
 In 1760s, Cherokees began battling the first European settlers due to broken promises and treaties that were not kept. This time period was known as the Cherokee War.
 The result of these battles was the massacre of many Cherokee
Chiefs imprisoned at Fort Prince George after the fort commander was killed in an attempted rescue
 By the end of these battles the Cherokee agreed to migrate to the Middle town

 1830-Indian Removal Act  authorized the government to negotiate relocation, did not forcefully relocate
 1835- Treaty of Echota  gave up all Cherokee land east of the Mississippi River. It gave them 2 years to leave
 1836-39- “Trail of Tears”  16,000 Cherokee people led west by 7,000 U.S. soldiers. Estimated 4,000-6,000
Cherokee people died.
 Cherokee  11 British treaties
 29 U.S. treaties

 Territory divided into three regions: Santee or Dakota residing in the extreme east of the Dakotas, Minnesota, and northern Iowa;
Yankton or Nakota, considered to be the middle Sioux resided in the Minnesota River area; and the Teton or Lakota, the westernmost residing in eastern Dakotas, Montana, and
Wyoming.
 Sioux tribe is known as great warriors/hunters. War was the underlying principle of the Sioux people, because through it men gained prestige, and their prestige was reflected in the family honor.
 Family was considered the key unit of Sioux life. Children, called
"Wakanisha" (Waka meaning sacredness)
 The Sioux were a deeply spiritual people, who communed with the spirit world through music and dance.

 First exposure to Europeans took place in 17 th century and by the late 1700s had made alliance with the French who were trying to gain advantage against the British in the fur trades.
 Throughout the late 1850s, treaty violations by the
United States and late or unfair annuity payments by
Indian agents caused increasing hunger and hardship among the Dakota.
 Many battles and wars broke out between the U.S. government and Sioux due to land territory and broken treaties including the Dakota War of 1862, Red Cloud’s
War (1866-68), and the Great Sioux War 1876-77

 1868- Treaty of Fort Laramie guaranteeing to the Lakota ownership of the Black Hills (sacred spiritual grounds), and further land and hunting rights in South Dakota, Wyoming, and Montana. Military protected this agreement until gold was discovered by Custer’s Expedition in 1874 and multiple gold prospectors began encroaching on the Sioux territory.
President Grant subsequently pulled out the troops protecting
Black Hills and the Black Hills Gold Rush ensued leading to eventual war. The U.S. government seized the Black Hills in
1877.
 The Dawes Act adopted by Congress in 1887, authorized the
President of the United States to survey Indian tribal land and divide it into allotments for U.S. citizens. In 1891 alone, Indian
Affairs Commissioner Thomas Morgan stated that 1/7 all
Indian lands (17,004,000 acres) were taken.

 The Ghost Dance was originated by Wovoka or Jack
Wilson, who announced that he was the messiah come to earth to prepare the Indians for their salvation. Message for Native Americans suffering that through a circle dance or meditation, their could be resurrection of dead ancestors and live in harmony on a “New Earth”.
 1890- Wounded Knee Massacre: US government became alarmed about the Ghost Dance and that the Sioux were considering an armed attack. In an attempt to disarm the
Sioux during a gathering shots were fired and 153 Sioux were killed and additional 150 died of exposure in the days to come.

 George Washington, 1779, instructed Major General John Sullivan to attack Iroquois people.
Washington stated, "lay waste all the settlements around...that the country may not be merely overrun, but destroyed”…also instructed his general not "listen to any overture of peace before the total ruin of their settlements is effected”
 Thomas Jefferson, 1807, instructed his War Department that, should any Indians resist against America stealing Indian lands, the Indian resistance must be met with "the hatchet".
Jefferson continued, "And...if ever we are constrained to lift the hatchet against any tribe, " he wrote, "we will never lay it down till that tribe is exterminated, or is driven beyond the
Mississippi.”
 Abraham Lincoln…In 1862, President Abraham Lincoln ordered the execution, by hanging, of
38 Dakota Sioux prisoners in Mankato, Minnesota. Most of those executed were holy men or political leaders of their camps. None of them were responsible for committing the crimes they were accused of. Coined as the Largest Mass Execution in U.S. History
 Theodore Roosevelt…The fourth face you see on Mt Rushmore. This Indian fighter firmly grasped the notion of Manifest Destiny saying that America's extermination of the Indians and thefts our their lands "was ultimately beneficial as it was inevitable". Roosevelt once said, "I don't go so far as to think that the only good Indians are dead Indians, but I believe nine out of ten are, and I shouldn't like to inquire too closely into the case of the tenth".

 Bureau of Indian Affairs (BIA), first called the Office of Indian
Affairs, the agency was created as a division in 1824 within the
War Department. Designed to administer and manage affairs on tribal lands by the U.S. government. Involved in many controversial policies, including the late nineteenth-early twentieth century decision to educate native children in separate boarding schools, with an emphasis on assimilation that prohibited them from using their indigenous languages, practices, and cultures.
 1883- Code of Indian Offenses: designed by Secretary of Interior
Henry M. Teller purpose to suppress “evil practices” to further progress towards assimilation. Outlawed traditional dance, feast, gift giving, and the practice of medicine men. The penalties prescribed for violations ranged from 10 to 90 days imprisonment and loss of government-provided rations for up to 30 days.

 In his State of the Union Address on December 4, 1871,
Ulysses Grant stated that "the policy pursued toward the
Indians has resulted favorably...many tribes of Indians have been induced to settle upon reservations, to cultivate the soil, to perform productive labor of various kinds, and to partially accept civilization. They are being cared for in such a way, it is hoped, as to induce those still pursuing their old habits of life to embrace the only opportunity which is left them to avoid extermination".
 After the end of the Indian Wars, in the late 19th and early 20th centuries, the government outlawed the practice of traditional religious ceremonies.

 1879-1918 Carlisle Indian Industry School became a model for Indian boarding schools. Introduced new haircuts, uniforms, new names, no native language, and attend Christian church.
 Indian boarding school refers to one of many schools that were established in the United States during the late 19th and early 20th centuries to educate Native American children and youths according to Euro-American standards.

 During the 1950-60’s The Indian Relocation Program was a central part of the Bureau of Indian Affairs (BIA) that intensified efforts to move American Indians from reservations into eight metropolitan areas of the United
States where more jobs were available to better provide employment assistance and vocational training. The
Urban Indian Relocation Program participants were given money for transportation and some soft money for lodging until a job could be secured and permanent housing could be found. A common outcome of the program was disrupted cultural ties and ended up on
Skid Rows in large concrete metropolises.

 IHS was established in 1955 to take over health care of American
Indian and Alaska Natives from the Bureau of Indian Affairs.
 The Indian Health Service (IHS) is an operating division (OPDIV) within the U.S. Department of Health and Human Services
(HHS). IHS is responsible for providing medical and public health services to members of federally recognized Tribes and Alaska
Natives. IHS is the principal federal health care provider and health advocate for Indian people, and its goal is to raise their health status to the highest possible level. IHS provides health care to American Indians and Alaska Natives at 33 hospitals, 59 health centers, and 50 health stations.
 The IHS currently provides health services to approximately 1.8 million of the 3.3 million American Indians and Alaska Natives who belong to more than 557 federally recognized tribes in 35 states.

 American Southwest, a beverage of fermented corn called tesvino was used during rites of passage rituals. The Pimas and Papagos created alcohol from the Saguaro cactus and used it as part of a spiritual ritual believed to bring rain. Because spiritual power was derived from the drink, its consumption was strictly controlled.
 First Europeans (French and British) used it as a method of fur trading with Native American tribes.
 Explorers used it in negotiations for access into new territories due to their distrust of Native Americans they encountered.
 Initially alcohol was used by the U.S. government to aide in placing
NAs on desolate lands and pacifying them with alcohol to keep them submissive in order for further control and manipulation. In 1897, an amendment to the Indian Appropriations Act banned the sale of alcohol to Indians.

 One other theory is that American Indian traditional culture may help explain the attraction of drinking. American Indians may "drink rapidly to induce an altered state of consciousness, a practice congruent with some Native American practices," the NIH survey said.
 It just another “drunken Injun”, the stereotype demonstrates the thought of Native Americans with alcoholism as a sign of weakness. Used as a justification for not hiring for employment, not allowing in various establishments, landlords not renting, etc…
 The Native American will shamelessly pander to the white man for a taste of the “fire water” while he sits on the reservation free-loading off the taxpayers money and wasting
Uncle Sam’s resources.

 Alcohol Metabolism may affect the regulation of alcohol intake, because interference with production or elimination of the alcohol metabolite acetaldehyde has behavioral effects. Researchers have analyzed the frequencies of variants in the alcohol-metabolizing enzymes alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH) in some Native American populations. So far the studies have yielded no evidence that an ALDH2 variant, which has shown protective effects in other populations, is found in either American Indians or Alaska Natives.
 One particular study looked at the potential alterations in drug and alcohol responses may be caused by amino-acid differences at the GABA(A)alpha6 and
GABA(A)gamma2 subunits. The study looked at whether variation at the 5q34
GABA(A) gene cluster is implicated in differential susceptibility to alcohol dependence. Two large psychiatrically interviewed samples, a Southwestern Native
American population sample (N = 433) and a Finnish sample (N = 511) with alcoholdependent subjects and unaffected individuals, were genotyped for 6 single nucleotide polymorphisms at the 5q34 GABA(A) gene cluster. The study detected sib-pair linkage of 5q34 GABA(A) receptor genes to alcohol dependence in Finns and in Southwestern Native Americans, which may explain an increased prevalence of alcohol and drug dependence amongst Native Americans.

 11.7 percent of deaths among Native Americans and
Alaska Natives between 2001 and 2005 were alcohol-related, compared with 3.3 percent for the
U.S. as a whole. The two leading causes of alcoholrelated deaths among Indians were traffic accidents and alcoholic liver disease, each of which cause more than a quarter of the 1,514 alcohol-related deaths over the four-year period. Also listed are homicide (6.6 percent of alcohol-related deaths), suicide (5.2 percent) and injuries in falls (2.2 percent).

 American Indians/Alaska Natives (AI/ANs) have the highest rates of using alcohol, marijuana, cocaine, nicotine, and hallucinogens compared to any other racial/ethnic group in the U.S.
 AI/ANs also have the second highest rates of methamphetamine abuse, with another indigenous group, Native Hawaiians, having the highest rates
(USDDH, 2005).

 Serious psychological distress among adults 18 years of age and over, AI/AN 4.7% as compared to non-Hispanic whites
2.8%
 AI/AN are almost three times as likely to experience feelings of sadness or hopelessness as compared to non-Hispanic
Whites (7.4% to 2.4% and 4.6% to 1.8%, respectively)
 AI/AN are over twice as likely to experience feelings of nervousness or restlessness as compared to non-Hispanic
Whites (8.8% to 3.8% and 15.4% to 5.2%, respectively)
 AI/AN who received counseling for mental health treatment or received prescription medications for mental health treatment in the past year as compared to non-Hispanic
Whites (10.7% to 14.0% and 8.9% to 12.0%, respectively)

 Between 1999 and 2007, the nationwide suicide rate among non-Hispanic Native Americans was 14 per 100,000, about 25 percent higher than the overall national rate of 11.
 While the overall death rate from suicide for American
Indian/Alaska Natives is comparable to the White population, adolescent American Indian/Alaska Natives have death rates two to five times the rate for Whites in the same age groups.
Suicide has become the second-leading cause of death (after accidents).
 Pine Ridge Oglala Lakota Sioux reservation of South Dakota is another tragic example, with a suicide rate more than three times the average for the rest of the nation.

 Among those are high unemployment and poverty rates on reservations, NIH said. Of the five counties in the United States with poverty rates greater than 39 percent, four are located within
American Indian reservations, according to the U.S. Census Bureau.
 The U.S. government recognizes 562 unique tribal cultures, and there are an additional 245 non-federally recognized tribes. Approximately
60% of the AI/AN population lives in urban areas with less than half
(1.9 million persons) living on reservations or other land trusts
 Starting in the 1970s, gaming became a viable source of income for many American Indians living on economically-unproductive land.
Although a get-rich-quick stigma has been placed on American Indian gaming, only about half of the federally recognized tribes operate any gaming business and nearly 50% of American Indian families are still below the poverty line

 The trauma suffered by generations of Native Americans has contemporary effects in both the community as well as the individual consciousness. Some literature points to a developmental history of psychological distress that has resulted from genocide, ethnic cleansing, and forced acculturation.
 Many of the elders in AI/AN communities bear the trauma of forced government attempts to assimilate Native Americans into the dominant society, such as evidenced by placement of children in boarding schools, or relocations to urban centers.
 Cultural Disintegration has promoted a society filled with guilt, shame, powerlessness, surrender, and helpless dependency.

 Environment is plagued with poverty, family dysfunction, and lack of resources.
 Enormous amount of unresolved grief at the loss of culture, connection, kinship, and self-esteem.
 Mental illness has higher prevalence in AI/AN communities in combination with being underserved and undertreated leads to an increase in substance abuse as a form of self medicating

 Don’t Talk  sealing off the pain of oppression
 Don’t Trust  distrust of the oppressor is a survival skill
 Don’t Feel  numbing and restricting the range of emotions

 Native American families incorporate a range of cultural practices and acculturation patterns, with some families strictly following tribal traditions and avoiding mainstream cultural practices, and others incorporating mainstream cultural practices at differing degrees
 Indigenous people, in general, value group membership, natural connections to spirituality, honor, wisdom of the elders, and respect for the environment as a necessary component for sustaining future generations. Community well-being and group success are the primary goals of its members
 Some tribes have improved economic infrastructure due to gaming industry and other business ventures. This has improved quality of life through employment opportunities, education, health services, and cultural based facilities.

Traditional AI/AN vs. Euro-American
Cooperation Competition
Group Emphasis Individual Emphasis
Passivity/Calmness Activity/Restlessness
Generosity Saving
Patience Impatience
Work to Meet Need Puritan Work Ethic
Respect for Age Respect for Youth

Traditional AI/AN vs. Euro-American
Right-Brain Orientation Left-Brain Orientation
Religion—Way of Life Religion—Segment of Life
Listening-Observational Skills Verbal Skills
No Eye-to-Eye Contact Eye-to-Eye Contact
Illness=Imbalance Illness=Physical issue
Respect for Tradition Progress-Oriented
Cooperate with Nature Control over Nature

 12 Step Model: NA/AA programs and Al Anon/Alateen
 Inpatient Drug/Alcohol Addiction programs
 Outpatient Drug/Alcohol Addiction programs with emphasis on individual and group therapy
 Medication Treatment: naltrexone, acamprosate, and disulfiram (all
FDA approved for treatment of alcohol dependence), methadone, buprenorphine
 Residential Programs are highly structured programs in which patients remain at a residence, typically for 6 to 12 months.
 Behavioral Therapy: Cognitive-Behavioral therapy, Supportive,
Multidimensional family therapy

 Typically, when addressing problems associated with mental illness and behavioral concerns, the first preference for parents of children with difficulties is to seek help from community sources and other family members. They are less likely than White families to seek psychiatric help initially
 Native American people typically refrain from in-depth, one-to-one disclosure within clinical settings. Individual counseling is generally not as successful as group counseling. In mental health service provision, trustworthiness can be addressed by demonstrating authenticity, respectfulness, concern, visible signs of listening behavior, some degree of self-disclosure, and slow pace
 Retention in treatment is directly related to cultural competence within service providers structure. Treatment programs or interventions that address AI/AN clients’ from their own cultural perspectives, retain a culturally competent staff, are able to accept the inclusion of alternative and traditional healers in treatment efforts have higher success rates for AI/AN treatment completions. Programs are most effective when providers see their approach as “working with communities” rather than “doing for” the individual or group.

 Spirituality is a main concept for AI/AN to be incorporated in the healing process for addiction treatment.
 Incorporate traditional cultural into treatment through ceremonies, talking circles, sweat lodges, drumming/dance, song, and language
 Healing occurs on an individual level in the context of the family and tribe, ritual/ceremony, and cultural values that emphasize connectedness. Individual recovery is linked with communal well-being.

 Twelve Steps of AA/NA placed in a culturally specific context by combining it with the Medicine Wheel and change the wording to bring it closer to a AI/AN philosophy
 Integration of western and traditional medicine practices as a model in order to provide increased trust by AI/AN patients and improved adherence to treatment
 Group and family based treatment which emphasizes the traditional core AI/AN patients belief systems. Talking circles and healing circles give each individual a chance to speak while all others listen respectfully

 Southcentral Foundation's Access To Recovery (ATR) III
Program from Anchorage, AK established in 1982 to improve the health and social conditions of Alaska
Natives, enhance culture, and empower individuals and families to take charge of their lives.
 Mash-Ka-Wisen (“Be Strong Enough to Accept Our
Help”) Treatment Center in Northeast Minnesota on
Fond Du Lac Reservation offers 30 residential beds, outpatient service, and 21 bed half way house. Founded in 1978, the center emphasizes a combination of physical and spiritual healing society.

 Cultural trauma that Native Americans experienced in the form of mass genocide and assimilation has created lasting negative effects on future generations.
 Addiction in the form of alcohol and other drugs is directly related to continued oppression and disconnection from traditional ways.
 Differences in the value systems between AI/AN and white culture places significant obstacles in evaluation and treatment of AI/AN from a westernized medicine prospective.
 Most effective addiction treatment programs for AI/AN are culturally based re-establishing traditional beliefs