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Human Services

6-9-2015

Alcoholism: An Epidemic in the Native American Community Natalena Fantozzi

Follow this and additional works at: http://digitalcommons.goodwin.edu/hsr_stu_cap Part of the Medicine and Health Sciences Commons, Religion Commons, Social Welfare Commons, and the Social Work Commons Recommended Citation Fantozzi, Natalena, "Alcoholism: An Epidemic in the Native American Community" (2015). Human Services Capstones. Paper 2.

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Running head: ALCOHOL ABUSE: NATIVE AMERICANS

Alcoholism: An Epidemic in the Native American Community Natalena Fantozzi Goodwin College, Capstone 6/9/2015

Running head: ALCOHOL ABUSE: NATIVE AMERICANS

Alcoholism is an epidemic that is plaguing our nation, affecting some populations more than others. It is often difficult for the untrained eye to determine the early signs of dependence from social use to abuse. Some common signs and symptoms of alcohol abuse include: repeatedly neglecting one’s responsibilities at home, work, or school, using alcohol in situations where it’s physically dangerous, such as drinking and driving, operating machinery while intoxicated, and experiencing legal problems due to one’s drinking (American Psychiatric Association, 2000). It is not uncommon for social use to become abuse when an individual uses alcohol to self-soothe and relieve stress. Alcohol consumption can result in a state of euphoria that some people will utilize as an emotional crutch to negate or counteract physical or emotional discomfort. Not all individuals that abuse alcohol become alcohol dependent, but abuse correlates to higher rates of future dependence. Alcoholism can also develop suddenly in response to a stressful change in one’s life; such as an ending relationship, loss of a job, loss of housing, or any other loss. Other times, more of a gradual change develops as a person’s tolerance to alcohol increases. It has been shown that increases in quantity or frequency of alcohol consumption raise the risks of developing alcoholism.

The next and final stage, according to the (Diagnostic and Statistical Manual of Mental Disorders) DSM IV (2000), is alcohol dependence. Some signs and symptoms of this are the same as alcohol abuse with two major differences. The first being tolerance, when an individual has to drink more to obtain the desired effect. The second is physical dependence, when an individual must drink in order to not go through withdrawal. Some symptoms of withdrawal are shakiness, vomiting, sweating, nausea, insomnia, depression, and headache; prolonged instances of any of these symptoms could result in death. In severe cases, withdrawal from alcohol can also involve hallucinations, confusion, seizures, fever, and agitation; because of the high fatality

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rate associated with alcohol withdrawal, it is highly recommended that an individual does this in a medical setting. According to the DSM IV (2000), some other symptoms of alcohol dependence include: 

loss of control over drinking

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having multiple failed attempts at quitting or cutting down

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all of one’s time is consumed by either obtaining using or recovering from the alcohol use

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Finally the individual continues to drink regardless of the above (DSM IV, 2000)

Although alcoholism is a serious disease affecting many races and creeds, it has an inordinately higher frequency within those peoples belonging to the Native American population due to several mitigating factors. “Native Americans have a higher rate of alcohol use, frequency of use, and increased rates of fetal alcohol syndrome when compared to other ethnic groups.” (Szlemko, Thurman, & Wood, 2006). A special approach and understanding must be used when dealing with this population due their complicated history and the values and traditions that are unique to Native Americans. Alcohol use among this group also shares commonalities among other groups. However, Native Americans’ uniqueness in terms of their history, culture, and society as a whole has resulted in a specific set of circumstances that are unlike any other groups. Few if any cultural groups have been as psychologically, physically, and emotionally marginalized as the Native American peoples. Within the United States there are over 500 federally recognized tribes, each decimated into small interspersed diasporas with each having their own sense of culture, history, and traditions (Szlemko, Thurman, & Wood, 2006). Tribal diversity results in a

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widely varying range of alcohol usage amongst Native Americans within the U.S. According to Szlemko, Thurman, & Wood, (2006), these rates are determined by using the number of patients discharged from the Indian Health Service (IHS) hospitals, throughout the nation, with an alcohol-related diagnosis. In general, Northern reservations reported higher rates of these diagnoses than did Southern reservations. The author also found that alcohol-related diagnoses were made twice as often for male patients than for female patients. Upon first glance, these rates may not appear problematic. However, this is an incomplete picture because many individuals may not be accurately diagnosed and not all Native Americans use or have access to IHS hospitals due to demographic location or health insurance barriers. A study performed by Shalala, Trujillo, Nolan, & D' Angelo, (1996) shows that, among Native Americans, a much greater percentage of deaths are alcohol-related as compared with the general population (Szlemko, Thurman, & Wood, 2006). This study goes on to further show that the proportion of current drinkers among Native Americans does not appear to be overwhelmingly different from that among the general population. However, the increased percentage of alcohol-related deaths and age-adjusted alcoholism mortality among Native Americans suggests higher abuse rates. Such findings also indicate that when alcoholism grips a member of the Native American populace the prognosis for recovery tends to be poorer than that of other groups; this can be contributed to a lack of trust of the government, lack of services, and a non-adherence to treatment. Another alarming concern is that Native American people tend to share a general distrust of governmental studies due to historical abuses by the U.S. government. This distrust may result in a good portion of Native American alcohol abuse going unreported. Due to the untreated alcohol abuse, the Centers for Disease Control and Prevention (CDC) reports that Native Americans have the highest findings of alcohol and suicide across all of the ethnic groups

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Running head: ALCOHOL ABUSE: NATIVE AMERICANS

at 46%. This study also shows that in every other ethnic group, men have a higher suicide rate with alcohol being a factor, except within the Native American population. In this study men and woman are shown to have equal rates of suicide (www.CDC.gov). With this being said, it is clear that the abuse and dependence of alcohol is fatal. With strong evidence indicating that alcohol use and abuse is occurring at such alarming rates within the Native American population, it is crucial to look at the adolescent use of alcohol in this culture. One of the largest ongoing studies of alcohol use among Native American adolescents has involved annual school-based surveys carried out since 1975 (Beauvais, 1998). The project entails the administration of anonymous surveys of 7th-12th grade reservation school students by the Tri-Ethnic Center for Prevention Research at Colorado State University. Data from this research has consistently shown that Native American adolescents have a higher lifetime prevalence of alcohol use than non-Native adolescents (Szlemko, Thurman, & Wood, 2006). A study as far back as 1992 by Beauvis showed that lifetime prevalence rates for alcohol use over a 15-year period among Native Americans were consistently 5% to 15% higher than for non-Native Americans and that Native Americans appeared to begin alcohol use at an earlier age. Studies conducted by other groups have produced similar findings in more recent years. (Wallace et al., 2003 as cited by Szlemko, Thurman, & Wood, 2006). For example, other studies have shown that Native American adolescents not only drink larger amounts and experience more negative consequences of drinking than do other adolescents, but also that Native American adolescents who live on reservations, attend boarding schools, or drop out of school have been found to have higher levels of alcohol use than do other adolescents in general (Szlemko, Thurman, & Wood, 2006).

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Running head: ALCOHOL ABUSE: NATIVE AMERICANS

Perhaps if we look back even further we could find a link between Native American Fetal Alcohol Syndrome (FAS) and the overall prevalence of alcohol abuse later in life. Through the research it appears that, “despite the lack of direct measurement for FAS, which results from maternal alcohol abuse during pregnancy, [it] provides another way of comparing alcohol use among Native Americans with that of other groups”, according to Szlemko, Thurman, & Wood (2006). Rates of FAS appear to vary by socioeconomic status and race, although these are often confounded, making clear distinctions difficult. In the United States, the rates of reported FAS have been steadily increasing from 1 per 10,000 in 1979, to 6.7 per 10,000 in 1993 (Centers for Disease Control and Prevention, 1995). It is unclear if this is a real increase or the result of more accurate diagnoses. In a study of Southwestern Native American tribes, researchers found rates ranging from 39 to 333 per 10,000 (May, Hymbaugh, Aase, & Samet, 1983, as cited by Szlemko, Thurman, & Wood, 2006). This is evident that this is not only long lasting trend but one that demands attention as it begins prior to the child’s birth and continues through adulthood when they become parents, thus continuing the cycle. “It is plain to see that the adult use, adolescent use, and FAS rates all indicate greater prevalence of alcohol use among Native Americans than among the general U.S. population” (Szlemko, Thurman, & Wood, 2006 p.440). According to recent studies, many factors that are affected by alcohol use include: increased risk of hypertension, increased comorbidity with anxiety and depression disorders, increased victimization, and greater risk of sexually transmitted disease, including HIV. (Baldwin, Maxwell, Fenaughty, Trotter, & Stevens, 2000). It is shown that geographically, Native Americans are unique from any other ethnic group in the United States due to the fact that Native Americans are clustered within certain geographic areas which including reservations and urban cities (Szlemko, Thurman, & Wood, 2006). According

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Running head: ALCOHOL ABUSE: NATIVE AMERICANS

to Szlemko, et.al., (2006) one of the largest barriers to estimates of alcohol use is Native Americans untrusting nature of researchers, U.S. government, and the like. Some of the factors and events that have lead to this distrust are the environmental contamination, the unsolicited use of land, and centuries of government policies designed to move, eliminate, or assimilate Native Americans (Szlemko, Thurman, & Wood, 2006). Perhaps to fully understand the scope of this problem we must first look into the past. From very early in U.S. history, alcohol had played a prominent role in the sufferings of the Native Americans. This can be illustrated best by a quote by Benjamin Franklin: If it be the design of Providence to extirpate these savages in order to make room for the cultivators of the earth, it seems not improbable that rum may be the appointed means. It has already annihilated all the tribes who formally inhabited the seacoast. (Frankil, n.d. as cited by Szlemko, Thurman, Wood, 2006 p.5) This demonstrates only one of the many traumas’ that faced these people, and with this not only came death but also a loss of culture and self. Motions such as this ripped people from their ancestral lands and forced them to conform to the rule and values of the majority culture. “Throughout the 1950’s the US government has made attempts to further force Native Americans to conform to the European American mainstream culture” (Szlemko, Thurman, & Wood, 2006 p.450). The authors go on to explain that the relocation phase of the Termination and Relocation Act of 1954 further subsidized the immigration of Native Americans from their reservations to more urban areas. Finally, these traumas that continue include the present exploitation of Native American land. Much of the land that the Native American tribes were forced onto was found to contain mineral wealth and this has since been depleted by outsiders with minimal compensation to the tribe people of the area. (Colorado River Indian Tribes, 2005);

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Running head: ALCOHOL ABUSE: NATIVE AMERICANS

the author also argues that cumulative historical trauma may be one of the primary causes of alcoholism and that this area needs to be studied further. Szlemko, Thurman, and Wood, (2006) state that Native Americans tend to have higher rates of alcohol use due to the fact that as a population, they are generally exposed to more risk factors than other ethnic groups as a whole. Many of these risk factors fall under the category of demographics such as; low income, gender, and family history. It stands to reason that persons suffering from poverty are more likely to become depressed and attempt to self medicate with alcohol. It is also more likely for people who grow up in family units afflicted by alcoholism to emulate such negative behavior. It has been documented that family history plays a huge part in alcohol use, this is two prong in effect; one being inheritance and the other being learned behaviors (Lieb, R., Merikangas, K. R., Hofler, M., Pfister, H., Isensee, B., & WiLtchen, H. U.,2002). One of the largest risk factors for alcohol use and abuse among adolescents is cultural and peer attitudes toward the use of substances. Since peer influence stands as a major unavoidable risk factor, perhaps it can also have the potential to be a preventative factor. The authors go on further to state that another potential reason for increased use in this ethnic group may be a result of differences in peer groups due to the closeness of their extended family. The age of initial alcohol use is another factor that has been shown to affect later alcohol abuse (Warner & White, 2003 as cited by Szlemko, Thurman, & Wood, 2006). Often this first use is within the company of one’s peers, this typically making the first drink of alcohol come at an earlier age. This would be due to the child’s peer group consisting of their familial circle. Perhaps the explanation to the elders within the household of the dangers of alcohol use, particularly to the still developing mind and body, would decrease the use by the next generation, thus breaking a cycle of substance abuse.

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Running head: ALCOHOL ABUSE: NATIVE AMERICANS

Today alcoholism continues to be a major struggle for many Native Americans and their families. Native Americans suffer far more alcohol-related deaths than the national average (Duran & Duran, 1995 as cited by Szlemko, Thurman, & Wood, 2006). It is very important to tailor treatment options to the standing beliefs of the specific group one is working with. This is of the upmost importance because most treatment approaches have largely been developed with European American culture in mind (Duran & Duran, 1995 as cited by Szlemko, Thurman, & Wood, 2006). The authors state that many treatment and intervention options have been developed and attempted among this population, and all can be categorized as “native centered” or “nonnative-centered”. Unfortunately the majority is that of the later and proves to be ineffective. A more comprehensive and holistic approach may be key to ending this cycle. It is clear that when dealing with a Native American struggling with alcohol abuse or addiction it is essential to treat the individual as a whole due to their strong connection to mother earth. For example, perhaps treatment models for dealing with this population could include, dance, talking circles, and sweat lodges as part of the holistic approach; as these are part of their heritage, described by Szlemko, Thurman, and Wood (2006). One program that has been developed for Pacific Northwest tribes incorporated their traditional concept of a canoe journey. The only requirement for being part of the canoe family was that the participants were clean and sober throughout all activities. Marlatt and colleagues (2003) are currently evaluating an adaptation of this program and early results show positive outcomes. One tribe in British Columbia has achieved tremendous success in reducing alcoholism through an increase in the authority and autonomy of tribal leaders and an intentional revitalization of tradition culture. (Szlemko, Thurman, & Wood, 2006 p.447). It may also be beneficial to look at a treatment from an

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educational standpoint. For example, we must educate the parents of adolescents of the risks associated with consumption of alcohol at an early age. Education would also prove helpful in preparing an individual’s environment for their new found sobriety. One cannot be expected to change if their environment has not evolved to foster their rehabilitation. Although there has been a great deal of research which has lead to a deep understanding of alcoholism, there is still a need for deeper investigation as how this relates to cultures outside of the norm of the European American individuals that make up the majority of the U.S. After completing the research I have learned so much, not only about this issue but about a whole new way of thinking of substance abuse treatment as a whole. It is imperative that one not only think of the problem an individual is presenting with, but the whole person and underlying cause of the negative behavior. This should include their family, beliefs, living situation, culture, cultural history, cultural norms, and their soul. I believe that in any therapeutic relationship there must be a mutual respect between patient and therapist. After my research, I have concluded that this goes beyond client/professional respect but rather into a respect of a person’s cultural history and traditions. With regards to this specific population, it is noted that each of the tribes within the United States, have their own unique culture. For many Native Americans, spirituality is a way of life rather than just a small aspect of their life. According to Coyhis (2000), Native Americans differentiate themselves based on differences in spirituality and religion. The author states that because Christian missionaries have been working in Native Americans communities for many years, there is also a great deal of blended spiritual belief with religion. This mixing may enable counselors to pull from each of these resources to better serve the client. I believe that instead of looking at the difference in culture as a barrier, it can be viewed as an opportunity for more

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Running head: ALCOHOL ABUSE: NATIVE AMERICANS

treatment options. For example, the Native American tradition of sharing in ceremonies may allow for a greater success in a group counseling approach, perhaps pulling from the Mutual Aid concept of group counseling. There is increasing evidence that interracial and/or interethnic group therapy treating addictive disorders can be effective if the minority members satisfy themselves that the therapist is sensitive to their socio-cultural and personal situation (Jenkins, 1998). Perhaps this can most obviously be seen within the Alcoholics Anonymous (AA) movement within the United States. It is vital that therapists dealing with a different race or a culture other than their own to be educated and become familiar with the particular ways of the individuals culture that they will be working with in the future (Holmes, 1998).

Common sense dictates that mental health and substance abuse affects people in every city and neighborhood throughout the nation. It is important to always remember that it takes a great deal of courage to seek help for substance abuse especially when this very act may be going against everything one may have learned their entire life. Unfortunately there may be others do not feel safe or understood by behavioral health providers because of lack of cultural competence or diversity of treatment providers. Furthermore, culturally competent care is essential to ensure that every client that presents for treatment has the best possible outcome by the commencement of treatment. From my experience in the human service field; from within the walls of a children’s hospital to homeless and domestic violence shelters, I have learned that I must always be mindful of such things as: 

How behavioral health symptoms manifest (e.g. described as physical symptoms)

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Verbal and non-verbal communication

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Financial Status

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Running head: ALCOHOL ABUSE: NATIVE AMERICANS 

Legal History

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Living Situation

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History of trauma

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Reasons for seeking help, and ways of seeking help

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Perceptions of medical providers and healthcare, in general

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Stigma about substance use disorders

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Perceptions about substance use

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Family/ Community support (Mental Health and Diverse Populations, 2014) It is always important for counselors to gather knowledge of their client’s ethnic

background and cultures and sensitivity to their values, prior to the initial meeting. This will result in fostering of a therapeutic relationship, leading to a positive outcome. Therefore, different cultural, social and religious imperatives have to be assessed in their proper context (Holmes, 1998) and should not be overridden by a white, secular, Judeo-Christian middle class gold standard (Silverstein, 1999). As we have learned in Goodwin’s Drug and Alcohol Dependence class, it is not only important to treat the mind body and soul but to also foster a healthy environment for the individual to return to after treatment; thus encompassing the incorporation of the connection between body, mind, soul, and nature. In this specific community, it is a reality that traditional methods will not be accepted as useful until they incorporate all that this culture holds dear. Thus, it is imperative that the counselor meet the client where they are to ensure the best outcome. During my capstone placement with Community Health Center (CHC), my role was to pilot a role for a Medical Assistant for the Behavioral Health Prescribers. This was part of a bigger goal to fully integrate psychiatry with medical in a Patient Centered Medical Home. One

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of the key terms I heard over and over was “meeting the client”, this occurs when you physically place yourself where the need of a specific population. This speaks volumes and is a mindset that I will carry with me through-out my career. In order to provide comprehensive care to a population one must understand the culture as well as any barriers they may face. As with the Native Americans, I found that the population that CHC serve (homeless, undocumented, uninsured, underinsured, and individuals facing substance abuse and other mental illnesses) face many of the same barriers that are outlined in this research paper. These include distrust in the government for the wrongs that they have faced, stigma of substance abuse and mental illness, or HIV and a sense of not being understood by their caregivers if treatment is sought. I find it critical to treat each individual on a holistic level; this includes their mind, body, and soul. It is when this happens that I believe the desired outcomes will have the best chance of occurring.

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References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Baldwin, J. A., Maxwell, C. J. C, Fenaughty, A. M., Trotter, R. T., & Stevens, S. J. (2000).Alcohol as a risk factor for HIV transmission among American Indian and Alaska Native drug tisers. American Indian and Alaska Native Mental Health Research, 9, 116.Warner, L. A., & White, H. R. (2003). Longitudinal effects of age at onset and first drinking situations on problem drinking. Substance Use & Misuse, 38, 1983-2016s. Beauvais, F. (1998). American Indians and alcohol. American Health & Research World, 22,253-259 Centers for Disease Control and Prevention (CDC). Alcohol and Suicide among racial/ethnic Population: 17 states, 2005-2006. Morbidity and Mortality Weekly Report. 58 (23):637-641, 2009a. PMID: 19543198 Colorado River Indian Tribes. (2005, August 3). It's official-La Paz lands returned to CRIT.CRIT Online. Retrieved March 20, 2006, from http://critonline.com/crit_contents/news/080305.shtml Holmes, D. (1998). Race and transference in psychoanalysis and psychotherapy. International Journal of Psychoanalysis 73, 1, 1-11. Jenkins, A. (1998). Dynamics of the relationship in clinical work with AfricanAmerican clients. International Journal of Group Psychotherapy, 14, 1 36-43.

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Jernstorm, B.A., Larious, S., Lebron, D., Sorensen, J., Wright, S. (2011). EvidenceBased Practices, Attitudes, and Beliefs in Substance Abuse Treatment Programs Serving American Indians and Alaska Natives: A qualitative Study. Journal of Psychoactive Drugs, 43 (4), 355-259. Lieb, R., Merikangas, K. R., Hofler, M., Pfister, H., Isensee, B., & WiLtchen, H. U. (2002).Parental alcohol use disorders and alcohol use and disorders in offspring: A community study. Psychological Medicine, 52(1), 63-78. Marlatt, G. A., Larimer, M., Mail., P. D., Hawkins, E. H., Cummins, L. H., Blume, A. W., et al. (2003). Journeys of the circle: A culturally congruent life skills intervention for adolescent Indian drinking. Alcoholism: Clinical & Experimental Research, 27, 1327 1329. Shalala, D. E., Trujillo, M. H., Nolan, L. J., & D'Angelo, A. J. (1996). Regional differences In Indian Health. CDC/Indian Health Service Annual Report, Indian Health Service Office of Planning, Evaluation, and Legislation, Division of Program Statistics. Retrieved September 9, 2005, from http://www.ihs.gov/PublicInfo/Archives/Publications/Trends/Trends96/regions96.ap Silverstein, R. (1999). Bending the conventional rules when treating the ultra-orthodox in a group setting. International Journal of Group Psychotherapy, 45, 2, 237-249. Szlemko, W., Thurman, P., Wood, J. (2006). Native Americans and Alcohol: Past, Present, and Future. The Journal of General Psychology, 133, 4, 435-451.

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