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Executive Summary For Behavioral Health Service Providers, Program Administrators, Clinical Supervisors, and Researchers The Executive Summary of this Treatment Improvement Protocol summarizes substance use and mental illness among American Indians and Alaska Natives and discusses the importance of delivering culturally responsive, evidence-based services to address these behavioral health challenges. 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: Lit erature Review For beh avioral health service providers, program administrators, clinical supervisors, and researchers
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Behavioral Health Services for American Indians and Alaska Natives Contents EXECUTIVE SUMMARY Foreword iii Introduction ..v Overall Key Messages vi Content Overview . viii Terminology ..x TIP Development Participants . xiii Publication Information xvi ii
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Executive Summary 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 ful˜lls SAMHSA™s mission by providing science-based best-practice guidance to the behavioral health ˜eld. TIPs re˚ect 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 speci˜c 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 scienti˜cally 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 ˜eld. Elinore F. McCance-Katz, M.D., Ph.D. Assistant Secretary for Mental Health and Substance Use SAMHSA iii
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Behavioral Health Services for American Indians and Alaska Natives ŁTraditional healers. ŁTribal leaders of governance. ŁOther behavioral health professionals (e.g., social workers, psychologists).ŁResearchers and policymakers. Objectives Addiction and mental health professionals will improve their understanding of: ŁAmerican Indian and Alaska Native demograph- ics, history, and behavioral health. ŁThe importance of cultural awareness, cultural identity, and culture-speci˜c knowledge when working with clients from diverse American Indian and Alaska Native communities.ŁThe role of native culture in health beliefs, help-seeking behavior, and healing practices. ŁPrevention and treatment interventions based on culturally adapted, evidence-based best practices.ŁMethods for achieving program-level cultural responsiveness, such as incorporating American Indian and Alaska Native beliefs and heritage in program design, environment, and staff development.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 de˜ned as diseases, diagnoses, or moral maladies, nor are they viewed as physical or character ˚aws. 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 lifeŠspiritual, 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 agree- ments, and program development. Signi˜cance 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 ˜nancial resources ef˜ciently. 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 in˚uence of their own cultural contextsŠ including beliefs, values, and attitudesŠon their initial and diagnostic impressions of clients and selection of healing interventions. vi
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Executive Summary ˜˚˛˝˚˙ ˙ˆ ˜˚˛˝˚˙ˆ˛ˇ ˜˚˛˝˚˙ˆ˛ˇ ˆ˛ˇ ˆ˛ ˜˚˛˝˚˙ˆ˛ˇ˘ˆ˙ ˆ˙˝ˇ’šˇ ˙ ˆ˙˝ˇ€šˇ ˘ˆ˝ ˆ˙ ˆ˙ Commitment to culturally responsive services. Organizations have an obligation to deliver high-quality, culturally responsive care across the behavioral health service continuum at all levelsŠ 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. Signi˜cance of the environment. An environment that re˚ects 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 re˚ects local diversity, and offering professional develop – ment activities (e.g., supervision, training) that highlight culturally speci˜c 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. vii
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Behavioral Health Services for American Indians and Alaska Natives 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 em- phasizes 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. Part 1: Practical Guide to the Provision of Behavioral Health Services for American Indians and Alaska Natives Part 1 is for behavioral health service providers who work with American Indian and Alaska Native clients and communities to support their mental health and drug and alcohol recovery. Part 1 consists of two chapters. Part 1, Chapter 1, explains the background and context for Chapter 2, so it is strongly recommended that readers examine it ˜rst. Part 1, Chapter 1, includes: ŁA summary of American Indian and Alaska Native history, historical trauma, and critical cultural perspectives on such key topics as health beliefs and help-seeking behaviors.ŁAn overview of American Indian and Alaska Native demographics, social challenges, and behavioral health issues.ŁStrategies to expand providers™ cultural awareness/competence and culture-speci˜c knowledge.ŁSpeci˜c treatment interventions, including traditional American Indian and Alaska Native interventions and cultural adaptations of standard treatment/prevention strategies. Part 1, Chapter 2, content provides: ŁSeveral case histories in the form of story-based vignettes that demonstrate speci˜c knowledge and clinical skills necessary for providing effective counseling to American Indians and Alaska Natives across behavioral health settings. ŁFor each vignette, an outline of the client™s presenting concerns and treatment needs, providerŒclient dialog, and master provider notes.ŁPractical suggestions and guidance for key stages in the providerŒclient relationship. In Part 1, readers will learn that: ŁNot all native cultures are the same. Similarities across native nations exist, but not all American Indian and Alaska Native people have the same beliefs or traditions.ŁThe use of diagnostic terminology in clinical work with American Indian and Alaska Native clients can be problematic, because the process of finamingfl can have signi˜cant spiritual meaning and may in˚uence individual and community beliefs about outcome.ŁFor hundreds of years and into the present, American Indians and Alaska Natives have endured traumatic events resulting from coloni – zation. They and their communities continue to experience repercussions (i.e., historical trauma) from these events. ŁAmerican Indian and Alaska Native clients experience grief for unique reasons, such as loss of their communities, freedom, land, life, self-determination, traditional cultural and religious practices, and native languages, as well as the removal of American Indian and Alaska Native children from their families. ŁAmong American Indians and Alaska Natives, historical loss is associated with greater risk for substance abuse and depressive symptoms. ŁGenes that increase risk of substance misuse and related factors (e.g., tolerance, craving) are no more common in American Indians and Alaska Natives than in White Americans.ŁAlcohol is the most misused substance among American Indians and Alaska Natives, as well as among the general population. Many American Indians and Alaska Natives do not drink at all, but binge drinking and alcohol use disorder occur among native populations at relatively high rates. ŁAmerican Indians and Alaska Natives start drinking and using other substances at a younger age than do members of other major racial or ethnic groups. Early use of substances has been linked with greater risk for developing substance use disorders. viii
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Executive Summary ŁHealth is viewed holistically. American Indian and Alaska Native cultures rarely make a distinc – tion among physical, mental, emotional, and spiritual health. One aspect of health is believed to affect the others. ŁIllness affects an American Indian or Alaska Native individual™s community as well as the individual. A health problem that affects one person will have effects on a family, community, tribe, and other individuals as well. This also means that healing the community can positively affect individual health. ŁAmerican Indian and Alaska Native clients™ ideas about behavioral health interventions will likely re˚ect traditional healing, mainstream treatment services, and mutual-help groups. ŁAmerican Indians and Alaska Natives use behavioral health services at a rate second only to White Americans; they may be even more likely to use addiction treatment services. Part 2: Implementation Guide for Behavioral Health Program Administrators Serving American Indians and Alaska Natives Part 2 is an implementation guide directed speci˜cally to administrators, program managers, and clinical and other supervisors. This part can also help providers who are interested in program development. Both chapters address programmatic features that can help foster culturally responsive treatment practices for American Indian and Alaska Native clients. Speci˜c topic areas include workforce development, culturally speci˜c consid- erations in program and professional development, and culturally responsive program policies and procedures. Part 2 consists of two chapters. Part 2, Chapter 1, content includes: ŁApproaches to fostering a culturally responsive organization and workforce, as well as program – matic policies and procedures that bene˜t American Indian and Alaska Native populations.ŁOverviews of administrative challenges and paths toward solutions. ŁMethods for staff training, along with supporting content on American Indian and Alaska Native history and culture. ŁSuggestions for supporting cross-cultural supervisorŒsupervisee relationships. ŁCriteria for evidence-based tribal behavioral health practices.ŁProvider competencies in attitudes, beliefs, knowledge, and skills related to working with American Indians and Alaska Natives.Part 2, Chapter 2, content includes organizational tools to help administrators and program managers better serve American Indian and Alaska Native clients. The chapter offers tools for: ŁDeveloping a culturally competent and responsive workforce. ŁDeveloping culturally adapted and evidence- based practices.ŁIntegrating care to include traditional practices in behavioral health services.ŁCreating sustainability. In Part 2, readers will learn that: ŁFacing serious health disparities has led to poorer behavioral health outcomes among American Indians and Alaska Natives compared with the general population.ŁWorking with American Indian and Alaska Native populations can pose challenges to implement- ing effective programs in remote communities where clients have dif˜culty accessing services because of a lack of service awareness, transpor -tation, phone or Internet services, child care, or insurance or healthcare ˜nancing. ŁEngaging and establishing a positive relationship with local native leaders and communities can help alleviate initial feelings of mistrust among American Indian and Alaska Native clients and can strengthen your program™s effectiveness. ŁRequesting programmatic input from tribal partners can help administrators identify potential obstacles early and develop culturally appropriate ways to overcome challenges. ŁEngaging with American Indian and Alaska Native communities as partners helps programs identify and make use of tribal resources and strengths, such as family ties, large community networks, physical resources, intergenerational knowledge and wisdom, and community resilience. ix
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