N t v r n n n l h l nd b t n bTr t ntr P t r n, l B r tz, rtn hl r rt, l r Br nd

Journal of Health Care for the Poor and Underserved, Volume 13, Number3, August 2002, pp. 360-378 (Article)

P bl h d b J hn H p n n v r t PrDOI: 10.1353/hpu.2010.0688

For additional information about this article

Access provided by your local institution (14 Oct 2015 18:39 GMT)

http://muse.jhu.edu/journals/hpu/summary/v013/13.3.peterson.html

360 Original paper

NATIVE AMERICAN WOMENINALCOHOLAND

SUBSTANCE ABUSE TREATMENT

SARA PETERSON, MPHInstitute for Health Policy Studies,

University of California, San FranciscoGALE BERKOWITZ, DrPH

Charles and Helen Schwab Foundation

COURTNEY UHLER CART, MPH, MSWCLAIRE BRINDIS, DrPH

Institute for Health Policy Studies,University of California, San Francisco

Abstract: Alcohol and other drug use is a serious problem amongAmerican Indian and Alaska Native women. However, information abouttheir needs for treatment is lacking. In response, a study was conducted todocument the life experiences and perceived recovery needs of AmericanIndian and Alaska Native women at nine treatment centers nationwide.The data show that most of these women have experienced various forms ofabuse and neglect from childhood into adulthood and have been exposed toalcohol and other drugs from an early point in their lives. Most of thesewomen have made multiple attempts to recover from their addictions,often for the sake of their children. The information derived from thisstudy can be used as the foundation for further research about the treat-ment needs of American Indian and Alaska Native women.

Key words: American Indian, Alaska Native, women, drugs, alcohol,substance abuse, health.

Alcohol and other drug (AOD) use among American Indian and AlaskaNative (ΑΙ/AN) women is a serious problem that has not received suffi-

cient attention. ΑΙ/AN women die from alcohol-induced morbidity at higherrates and at younger ages than ΑΙ/AN men and the general population.1,2Deaths among ΑΙ/AN women that are directly associated with alcohol use are

Received May U, 1997; revised April 12,1999 and December 17,2001; accepted December 19,2001.

Journal of Health Care for the Poor and Underserved · Vol. 13, No. 3 · 2002

Peterson et al. 361

estimated to reduce the life span of substance-using AI/AN women by asmany as 22 years. If such indirect causes as accidents were added to these esti-mates, the number of years of life lost would almost certainly be higher.1,3There is an increased risk of mortality from cirrhosis among American Indi-ans, compared with other ethnic groups, perhaps due to higher rates of alco-hol consumption.4

Recent studies have shown that alcohol-related problems among AI/ANwomen actually may be more similar to normative populations than previ-ously found. One study5 of American Indians, African Americans, and Euro-pean Americans seeking inpatient treatment found strong similarities acrosswomen from the different ethnic groups regarding the duration of their alco-hol abuse problem, number of previous treatment episodes, and conse-quences related to alcohol. Another study6 of Alaska Natives found that theage of onset of alcohol problems and the type and frequency of psychologicaland physical problems were similar to findings from research among non-Native inpatients.

However, for Native populations, AOD use may disproportionately con-tribute to—and be influenced by—mental health problems, cultural displace-ment, family separation, unemployment, and poverty.2 Further, some AODissues seem to be manifested at a cross-generational level. A significantlyhigher percentage of American Indians (70 percent) than European Ameri-cans (65 percent) or African Americans (60 percent) reported a family historyof alcoholism.6 Child abuse and domestic violence are also often related toalcohol and other substance use. One study reported that between 85 percentand 93 percent of all chUd neglect cases on an AI/AN reservation involvedalcohol abuse.7,8 Crime, suicide, homicide, and motor vehicle and other acci-dents are frequently associated with alcohol abuse, often in conjunction withacute episodes of binge drinking. In fact, most of the crime-related arrests forAmerican Indians and Alaska Natives are alcohol related.9

Fetal alcohol syndrome (FAS) may be the most evident outcome of alcoholuse among AI/AN women. Prenatal exposure to alcohol is one of the leadingpreventable causes of birth defects, mental retardation, and neuro-developmental disorders.10,11 Rates of FAS among those with low socioeco-nomic status (SES) and African American or Native American background areabout 10 times higher compared with those with a predominant middle/upper SES and Caucasian background.12

Despite the extent of the problem, substance abuse treatment services tai-lored to the needs of AI/AN women, as well as programs tailored to the needsof women in general, have only recently received much attention in this coun-try. Currently, women-centered, family-focused AOD treatment programs arerare in the United States. AI/AN men and women together are more thantwice as Ukely as members of other ethnic groups to need drug abuse treat-ment (7.8 percent versus 3.9 percent for non-Hispanic blacks and 3.7 percentfor Hispanics of Puerto Rican descent).13 The National Association of State

362 Native American Women in Treatment

Alcohol and Drug Abuse Directors has estimated that only 14 percent of allwomen and 12 percent of pregnant women who need treatment receive it.14

Historically, because of barriers such as unmet needs for child care, womenwith alcohol problems have been less likely than men to receive the treatmentthey need.15,16 The treatment programs that have been available to womenhave tended to tailor their services to the needs of males, primarily Caucasian.Research on AOD abuse treatment centers has shown that women's character-istics and daily circumstances must be addressed concurrently with addictionin substance abuse treatment programs.17 Traditional treatment programshave not taken into account the distinct needs of women. These may be practi-cal needs such as child care or transportation or underlying difficulties such asdepression, childhood sexual abuse, domestic violence, or eating disorders,all of which are more frequently found among women than men.16 Only 33percent of women-only treatment centers and 6 percent of other treatmentcenters in the United States provide child care for clients.17

Another barrier to treatment is that women who seek care are more likelythan men to lack support or face opposition from their family. The stigma andshame surrounding substance use, which is often greater for women thanmen, may discourage some women from seeking help. However, once in treat-ment, women may remain in the program out of concern for the health andwell-being of their children, to obtain basic resources, and to receive social andemotional support.18

Programs tailored specifically for these populations are beginning toemerge. For example, the Kakawis are a tribe in British Columbia who imple-mented a recovery process that involved women in the development of recov-ery activities and processes; there appear to have been very positive results forthe sobriety of the women in the tribe.19 A study of American Indians in drugtreatment programs20 revealed the importance of incorporating cultural andsocial needs of the clients. The study found that 81 percent of their clients com-pleted treatment, which is higher than most drug treatment programs. Theyattributed the high completion rate to the participation of the majority of theirclients in culturally sensitive residential programs and to the program forfemales that allowed children to accompany their mothers. Since disruptedfamily structures and poor family relationships seemed to be associated withsubstance use, these researchers stressed the need for community-based inter-vention programs.

In response to these issues, the Indian Health Service (IHS) targeted AODtreatment services for AI/AN women as a critical area that requires additionalresources. As a step toward assessing the treatment needs of AI/AN womenwho use alcohol and other substances, a descriptive study was undertaken toexamine the demographic, social, behavioral, health, and help-seeking char-acteristics of women receiving treatment services through a select number ofIHS-funded programs.

Peterson et al. 363

Method

A cluster sampling strategy was used to select the IHS-funded treatmentcenters for the study. The treatment center was used as the cluster unit, anddata were coUected from women participants and staff from the selected cen-ters. Nine treatment centers were selected using information provided by theIHS about the pool of AOD treatment centers that are fully or partially IHSfunded. To be selected, a center had to have been in operation and providingservices to women (and possibly also men) for at least one year, in this waymeriting designation as a provider of services for women. Other factors thatwere considered in selecting the sites were the following:

• A mix of high-, moderate-, and low-volume centers had to be selected,although a center had to have a minimum of six women participants.

• Urban, rural, and reservation-based centers had to be included, repre-senting the major regions of the United States.

• AU treatment modaUties (i.e., outpatient, intensive day, or residentialtreatment) had to be included in the sample.

• There had to be a maximization of study resources (e.g., if two treatmentcenters that serve women were located within the same geographic loca-tion, both were visited by the researchers, if possible).

AU treatment centers were located in the United States, representing the West,Southwest, Northern Plains, and Midwest regions and Alaska. AU programsprovided residential treatment for women; six also included an outpatienttreatment component. Five centers had been providing services for at least 20years, while the others had been in existence from 4 to 15 years. Four centershad been offering services to women from the year they were established,while the others began ervrolling female participants several years after open-ing. Three of the participating centers were women-only programs; the restwere cogender faculties. The number of treatment slots for female participantsranged from 4 to 30.

To ensure that the research would be both scientificaUy sound and cultur-ally appropriate, a Technical Advisory Committee (TAC) was convened; fourconsultants were also selected to help the university-based research team con-duct the study. The TAC and the consultants represented AI/AN substanceabuse treatment centers, women's treatment centers, research centers, and theIHS. Most of the TAC members were American Indian or Alaska Native andrepresented a variety of tribal affihations from urban and rural locations. TheTAC and consultants provided expertise and overall guidance to the researchprocess. The four consultants also participated in the study site visits wherethey f aciUtated the participant focus groups, conducted some of the staff inter-views, and helped review the records of the women in treatment.

364 Native American Women in Treatment

Both qualitative and quantitative data collection approaches were used toassemble a comprehensive profile of female AI/AN participants in treatmentat a sample of IHS-funded centers that provide services to women. The meth-ods included a review of participant treatment records on women who hadrecently exited treatment, focus groups of women currently in treatment,group interviews with treatment center staff to discuss the women in treat-ment, and individual interviews with treatment center administrators.

To develop the chart abstract form used to record this information, a feasi-bility assessment was conducted on a sample of charts at one IHS-fundedtreatment center to determine the quantity and quality of the data availablefrom participant treatment records. The forms used at each treatment center torecord participant data were examined to determine the type of informationeach center collected and the format used to record that information. Follow-ing this process, a core set of variables common to all the treatment centers wasisolated. In addition to this cross-site standardization process, all treatmentrecord forms at each participating treatment center were individuallyreviewed to derive a set of indicators that were unique to that center.

The chart review was used to collect information in several areas includingbasic demographic characteristics, history of AOD use, social and behavioralrisk factors, and duration of treatment. Investigator-developed chart abstractforms systematically retrieved information from the participant treatmentrecords. All records for women who had exited treatment within the preced-ing year were eligible to be reviewed, from which a random sample of up to 30charts was selected at each site. Members of the research team or the consul-tants abstracted all information from participant treatment records. Each chartreview took from 20 minutes to an hour to complete depending on the typeand amount of information that was available in the participant treatmentrecords. Although this varied widely across the nine selected centers, most ofthe data variables of interest to the research team were available from themajority of treatment records.

Participant focus groups at all nine sites were conducted to provide contex-tual data to supplement the largely quantitative data derived from the chartreview. The research team developed a focus group guide to elicit informationin several important areas. These included the history of AOD use; precursorsand consequences of the participant's AOD use; the role of family, friends, andcommunity in the participant's AOD use; the participant's experience anddegree of satisfaction with previous AOD treatment centers; benefits derivedfrom participation in the current treatment center; and plans for the future,including aftercare involvement.

In keeping with federal Office of Management and Budget regulations, upto nine women were permitted to participate in the focus groups at each cen-ter. At all of the treatment centers, nine or fewer women were currently in theactive phase of treatment, and thus no woman who wished to participate wasrefused. The focus group sessions lasted from 90 minutes to two hours and

Peterson et al. 365

were facilitated by an American Indian consultant with expertise in alcoholand substance abuse among AI/AN women. One member of the researchteam attended each group to record observations. The research team providedparticipants refreshments and a nonmonetary incentive such as a gift certifi-cate to a local store, a souvenir T-shirt, or bath accessories.

Treatment center administrators were asked to participate in an interviewcovering aspects of the centers they manage and their perceptions of the needsof the women participating in their AOD treatment program. In addition,group interviews with counselors and support staff were conducted at eachlocation. The purpose of these interviews was to gather essential contextualinformation about the treatment centers, as well as administrator and staffimpressions about the centers, observations of trends and significant issuesrelated to women's treatment needs, and the experiences and needs of womenseeking treatment. Staff members were interviewed in groups of three to ninepersons. The majority of staff members were American Indian or AlaskaNative. The amount of time that staff members had worked at their presentfaciUty ranged from less than one month to several years.

Data analysis included strategies for synthesizing both quantitative andquaUtative descriptive and comparative information to assemble a compre-hensive profile of women in treatment at IHS-funded centers. Findings fromone center were not compared with those from another center. Instead, resultswere aggregated across aU nine centers. Because almost aU of the centers servea multitribal clientele, it was not possible to examine intertribal differences.

Written transcripts were provided by the interviewers and analyzed manu-ally. Two persons recorded their detailed observations during the participantfocus groups and staff interviews. Each was provided a semistructuredrecording form to faciUtate note taking. Immediately after the focus groupsand interviews, the recorders met to discuss their observations, addressingeach question in turn. The observations of the recorders at each center wereaggregated so as to produce a single transcript for each center. For each ques-tion, observations were aggregated across all nine centers. The descriptive fac-tors that emerged from the transcripts were then prioritized according to thefrequency with which they appeared. AU members of the research teamreviewed the aggregated responses, and then a series of discussion meetingswas held to identify the similarities and differences across the nine centers.

The information from the review of the participant treatment records wasabstracted and recorded on a chart abstract form that was used across aU sites.The information was then precoded and entered into a computer database.Frequency distributions of all response categories for each relevant indicatorwere then computed. A second stage of analysis included cross tabulation byselected variables, including analyses of correlations and variations amongselected variables. For example, geographic characteristics (i.e., reservation,rural, or urban residence) were compared with participant AOD use charac-teristics. However, because of the smaU sample sizes within each center, most

366 Native American Women in Treatment

statistical analyses were invaUd. Thus, any inferences about associationsbetween variables (such as tribal affiliation) had to be drawn from quaUtativedata.

Triangulation, or the coordinated employment of multiple data collectionstrategies, enabled the researchers to better assess the reliabiUty and vaUdityof each indicator. For example, in the effort to describe women who use IHS-funded treatment centers rather than relying on one source of information(such as treatment records alone), the researchers asked the AOD treatmentstaff to describe their female clients. To gather information from another per-spective, the women who were in treatment were queried during focus groupsabout their views on the treatment center and invited to talk about their histo-ries and life experiences. The responses from these group staff interviews andparticipant focus groups were used to support or refute findings from othersources of information. In circumstances where inconsistencies arose, the dif-fering responses were compared, and further clarification was sought.

Results

The themes and variations that emerged from the various data collectionmethods employed in the study are summarized below according to the fol-lowing categories: the life conditions of the participants, their initiation intoand the progression of their AOD use, pathways into treatment, and percep-tions about AOD treatment centers. The research team reviewed 164 charts ofwomen who had exited treatment within the current year at the nine treat-ment centers that participated in the study. A total of 60 women participated inthe nine focus groups, which varied in size from three to nine women each. Atotal of 52 staff members were interviewed across the nine treatment centers.

The demographic characteristics of women whose charts were reviewedare shown in Table 1. The women in treatment at the nine centers ranged in agefrom 15 to 59, with a mean age of 31 years. At the time of treatment, nearly half(46 percent) were single, while 31 percent were divorced, separated, or wid-owed, and 24 percent were married and /or living with a partner. Most wereeither American Indian (67 percent), Alaska Native (24 percent), or of "mixed"heritage (American Indian and other) (7 percent). Nearly all (98 percent) indi-cated affiliation with an American Indian or Alaska Native tribe. The Uvingsituations of the women varied and included living with parents (22 percent);alone with children (21 percent); with other family members (17 percent); withpartner and children (16 percent); homeless, incarcerated, or institutionalized(15 percent); or alone (9 percent). Only 11 percent of the women in the IHS-funded programs did not have children, and 19 percent were pregnant at thetime of enrollment into treatment. Nearly half (45 percent) had not earnedtheir high school diploma, while 39 percent had a high school diploma, and 16percent had taken some coUege or professional courses. The majority of partic-ipants (77 percent) were not employed. The employed women were workingin a variety of fields, including clerical positions, health and social services,

Peterson et al. 367

and food services. The majority of the participants (80 percent) had beenarrested at least once at the time of entry into the program, and nearly three-quarters (72 percent) reported having been arrested for an AOD-related rea-son (Table 1).

AU of the women interviewed in the focus group discussions were at leastpart American Indian or Alaska Native; they represented a wide range oftribal affiliations. About half of the women were either pregnant or had chil-dren. Approximately half the women had previously been in treatment.

Comparison data are avaUable from a study of enrollment data on womenentering one of the National Institute on Drug Abuse's Perinatal 20 programsfor substance-using pregnant and parenting women and their children.21 Themean age of these women was 28, and 67.2 percent were not married. Themajority (89 percent) were African American, 9.5 percent were white, and 1.5percent were Hispanic. These women had a mean of 11.3 years of education,and 43 percent had some job or technical training. Nearly half (42 percent) hadbeen unemployed in the past three years, 86 percent had been employed atsome point, and 83 percent were receiving public assistance at the time ofentering treatment. Data from this study are presented below where relevant.

As shown in Table 2, the IHS-funded study participants whose charts werereviewed had experienced various types of abuse and neglect, beginning dur-ing childhood. The majority (81 percent) had been abused as children (definedas younger than age 18). As children, 39 percent were physically abused, 34percent were sexually abused, 23 percent were emotionaUy abused, and 7 per-cent experienced some sort of neglect. More than three-quarters of the partici-pants (78 percent) had experienced abuse as an adult. Sixty-one percent werephysically abused as adults: 12 percent were sexually abused, 9 percent wereemotionaUy abused, and 3 percent experienced some other kind of abuse asadults. Many women had been abandoned by one or both parents, raised byrelatives, sent to a boarding school, or had run away from home as a child. Inaddition, the women had endured other personal hardships, such as lack ofeducation and social supports and discrimination by race and gender. Asobserved by treatment staff, poverty, homelessness, and social isolation werecommon among the treatment participants from childhood through adult-hood. Death and/or separation from close family members and friends,accompanied by strong feelings of loss and grief, were common experiencesfor the participants.

As Table 3 shows, 44 percent of participants had records indicating somelevel of cultural or spiritual involvement; 36 percent were strongly involved intheir culture of choice, and 27 percent were somewhat involved with AI/ANpractices. Examples of traditional cultural practices included belief in a"higher power," fluency in their native tribal language, cooking and eatingtraditional foods, attending spiritual ceremonies, participating in sweatlodges and pow wows, and teaching their chüdren many of their tribal tradi-tions. Another 27 percent were actively involved with Christian religion withno AI/AN traditional involvement, and 10 percent had been raised Christian

368 Native American Women in Treatment

TABLE 1DEMOGRAPHIC PROFILE OF PARTICIPANTS

PERCENTAGE

Age at admission to treatment (min. 15, max. 59)M = 31SD = 8.5

Marital statusSingleDivorcedMarriedSeparatedCohabitationWidowedTotal

RaceAmerican IndianAlaska NativeMixed (American Indian/other)WhiteUnknownTotal

Living arrangementParentsAlone with childrenOther family membersPartner and childrenHomeless, incarcerated, or institutionalizedAloneTotal

Number of childrenNone1-23-45 or moreTotal

Education levelLess than high schoolHigh school diplomaSome college or professional coursesTotal

EmploymentUnemployedFull-timePart-timeOtherTotal

Number of arrests prior to treatmentNone1234More than 5Total

78312816116

170

115421221

172

2221171615

9100

18844820

170

736427

164

13124

77

169

253033174

15124

461817

974

100

6724

711

100

22211716159

100

11502812

100

453916

100

771544

100

20242714

312

100

Source: Participant chart review, 1995.Note: N = 164.

Peterson et al. 369

TABLE 2PARTICIPANTS' EXPERIENCE OF ABUSE AND NEGLECT

PERCENTAGE

Type of abuse as children"Any type

PhysicalSexualEmotionalNeglect /other

TotalType of abuse as adults3

Any typePhysicalSexualEmotional

Neglect/otherTotal

11750493310

144

1058216124

135

81353423

7100

80611293

100

Source: Participant chart review, 1995.a More than one type of abuse could be documented for each participant.

TABLE 3PARTICIPANTS' CULTURAL INVOLVEMENT

PRIOR TO TREATMENT

η PERCENTAGE

No cultural or spiritual involvementSome cultural or spiritual involvement

Strong American Indian and Alaska Native(AI/AN) involvement/beliefs

Somewhat involved with AI/AN practicesActively involved with Christian religion withno AI/AN traditional involvement

Raised Christian and also involved with AI/ANpractices and beliefs

Not statedTotal

4270

2519

19

747

159

2644

3627

27

1030

100

Source: Participant chart review, 1995.

and were also involved with AI/AN practices and beliefs. The women whowere less actively involved in their culture said that they were not as knowl-edgeable about their culture as they would like to be.

About 8 percent of the focus group participants identified themselves aspracticing Christians. Many reported that they had been raised in a stableChristian environment, currently attended church regularly, and were notinvolved with any AI/AN beliefs or activities. A small proportion of women(about 2 percent) indicated that their cultural background combined Christiantraditions and beliefs with an increasing interest and participation in AI/ANtraditional beliefs. Some of these women had been baptized and were raised

370 Native American Women in Treatment

TABLE 4ALCOHOL AND/OR OTHER SUBSTANCE

INITIATION CHARACTERISTICS

PERCENTAGE

Age at first useM 14SD 3.4

First substances usedAlcohol 98 79Inhalants 13 10Marijuana 9 7Other drugs 5 4Total 125 100

Source: Participant chart review, 1995.

by non-Native Christian families but were now beginning to learn more abouttheir AI/AN traditions. For example, one woman said that she had beenraised as a Mormon but nevertheless found meaning in attending traditionalIndian pow wows.

Table 4 shows the alcohol and other substance use characteristics of partici-pants whose charts were reviewed. Most participants had begun using alco-hol at a young age; over time their AOD use increased in frequency and quan-tity. The mean age at first AOD use was 14, with some participants reportingfirst use as young as age 6. Of the 58 charts from which this information wasavailable, 73 percent contained references to AOD use during a pregnancy atsome time prior to entry into the treatment program. In comparison, womenfrom the Perinatal 20 program reported days of substance use during preg-nancy as 73.5 for tobacco, 43.4 for cocaine, 16.9 for alcohol, and 5.3 formarijuana.

The substance most participants used was alcohol (79 percent), while theremainder started with inhalants (10 percent), marijuana (7 percent), or otherdrugs (4 percent). For the majority of women in the IHS-funded programs,alcohol was the primary substance of choice throughout their substance-usingperiods. At the same time, polysubstance use was predominant, with thewomen reporting their secondary substances of choice as inhalants first, fol-lowed by marijuana and amphetamines. Patterns of substance use appearedto become more complex with the passage of time. In comparison, women inthe Perinatal 20 program (mean age = 28) had used, on average, alcohol for 7.7years, cocaine for 6.2 years, and marijuana for 5.3 years.

The women in the focus groups consistently described a progression ofsubstance use. TypicaUy, while most continued to use alcohol and marijuana,they progressed to using inhalants, then amphetamines, and then cocaine.Injection substance use was uncommon among the sample. Participantsexpressed a variety of reasons for initiating AOD use. Some women indicatedthat they accepted alcohol when it was offered to them because they wanted to

Peterson et al. 371

please their parents. As one woman said, "I drank with my mother to get toknow her; she was cold to me when she was sober." Another said, "My dadwas a bootlegger and gave me my first drink when I was a girl." As children,many of these women drank with their siblings or cousins. One participantsaid, "When my parents went out fishing, I was left in the care of my older sib-lings, who drank."

Another way the women were commonly introduced to alcohol or drugswas through their peers. Most said they drank with friends at parties in highschool, at local bars, or with gang members. Many said that their boyfriendshad introduced them to alcohol and drugs or that they drank alcohol, smokedmarijuana, or inhaled substances (such as paint) to be accepted by their peersor "to be cool." One woman in her early 20s said that she drank because shewas too shy to be part of the crowd, and that when she was intoxicated she feltmore self-confident in a social gathering.

The women in the focus groups described a recurring cycle predicated onlong-standing emotional problems that had never been resolved. Low self-esteem seemed to preclude overcoming these problems or their addiction.Nearly all the women described using alcohol and/or drugs as attempts tosuppress such emotional difficulties as grief, self-pity, and loneliness. Amongthe women who began AOD use during their 20s, initiation into substance usewas often triggered by a tragedy or major life transition. Many said the deathof a close family member, a divorce, or the end of an important relationshipwas the impetus for their initiation into regular and heavy AOD use.

In most cases, the nine treatment centers evaluated for this study were theonly faculties in their respective geographic areas that offered AOD treatmentservices for AI/AN women. Where other programs did exist, they were notspecifically for American Indian/Native Alaskan women, did not aUow chil-dren to accompany their mothers to treatment, and /or did not offer residen-tial services.

As seen in Table 5, data derived from the chart review showed that morethan half the participants (56 percent) had been in drug and alcohol treatmentbefore attending the current treatment program (data were unavailable for 28participants). Nearly half these women (46 percent) had been in AOD treat-ment more than once. Approximately one-third (30 percent) who had previ-ously been in treatment indicated that they had sought services at an IHS-funded program. The length of time AI/AN women remained in treatmentvaried from as little as five days to as long as 10 months, with most staying intreatment for approximately one to two months. Comparable data from thePerinatal 20 program show that women had experienced an average of 2.4 pre-vious episodes of treatment, and 83 percent of participants reported at leastone episode of previous treatment.

Anecdotal information derived from the participant focus groups suggeststhat women left treatment for a variety of reasons, two of which appeared pre-dominant: either they were not ready for treatment or they did not feel the pro-gram was suitable for their immediate needs. Statements made by the focus

372 Native American Women in Treatment

TABLE 5PATHWAYS TO ALCOHOL AND OTHER DRUG (AOD) TREATMENT

PERCENTAGE

Previous AOD treatment episodesAny prior treatment experience 81 56More than one treatment experience 37 46

Reasons for seeking treatmentChildren/parenting issues 44 28To change lifestyle 39 25To stop using AOD 34 22Court ordered 27 17Need/want help 13 8Family/friends pressure 7 4Other 6 4Total 158 100

Treatment referral sourceCourt order 57 40Treatment or health professionals 28 20Self-referral 20 14Family or friends 13 9Other 24 17Total 142 100

Source: Participant chart review, 1995.a More than one reason could be documented.

group participants about previous AOD treatment experiences tended tofocus on overall program structure. In particular, the women appeared to dis-like the strict regimens of these programs. For example, participants com-plained about programs that did not allow them sufficient freedoms, such asphone privileges. One woman commented that she had "had more freedom injail than in that program." (Note: When later asked what they did not likeabout their current treatment program, similar complaints emerged about"strict rules," such as lack of visitation privileges, mandatory dress codes, andnot being able to watch R-rated movies.) Another complaint about previoustreatment programs concerned the confrontational approach used by staff.One woman said that the previous staff members were mean and unfriendly;another said that the staff's aim had been to "cure you or break you."

When asked about the overall approach of their current IHS-funded treat-ment program compared with previous AOD treatment experiences, mostparticipants expressed appreciation for the IHS program's supportive atmo-sphere. The women often indicated that they felt more at home, or more "partof a big family," compared with previous programs. Overall, the womenagreed that AI/AN-focused treatment programs were more effective atencouraging individual discipline and self-exploration, thus helping partici-pants to "find answers for themselves" while still providing a structuredgroup environment with strongly enforced rules.

Both the chart review and the focus groups revealed that the strongest treat-ment motivation was the participant's desire to maintain or to regain custody

Peterson et al. 373

of her children. More than one-fourth (28 percent) of the women for whomdata were available in the charts indicated that they had sought treatment forthe sake of their chüdren or to improve their parenting capacities (Table 5),while 40 percent were referred to treatment by a court order. Those who weremandated tended to enter treatment as an alternative to incarceration becauseof repeated criminal offenses, such as driving while intoxicated, or other AODuse-related charges or as a condition of family reunification or family mainte-nance. The treatment charts showed that, in addition to court mandates, othermajor categories of referrals included treatment centers/medical profession-als (20 percent), self-referrals (14 percent), and family or friends (9 percent).

According to focus group participants, another important factor was thewomen's personal motivation to be "clean and sober" and to change their life-style. Prevention of relapse and pregnancy were the other documented rea-sons for enrolling in treatment. Some women reported that encouragementand/or pressure from family members or friends was an important source ofreferral to treatment. Other women were self-referred to treatment, having"hit bottom" in many aspects of their lives.

The staff described a number of barriers that prevent women from enteringtreatment. The leading obstacle for mothers is the lack of child care for theirchildren while in treatment. Transportation is also a major barrier for manywomen who live in rural, isolated areas far from a treatment center and forwomen who live in cities with inadequate pubUc transportation systems.Another problem is that many of the women face resistance from partnerswho do not want them to enter treatment. Many women are also hesitant toseek out treatment services because of confidentiality concerns.

As recorded in participant charts, the average length of treatment participa-tion was about three months (86 days), the minimum stay was 2 days, and themaximum stay was just more than two years. Ninety-three percent of thewomen were in treatment six months or less. Completion criteria varied fromcenter to center and were sometimes based on individual client needs. Theminimum duration of treatment required to complete the program was 21days, the maximum was six months, and the median length of program dura-tion was 60 days. Of the 160 participants for whom discharge data were avail-able, 80 percent completed the treatment program.

One of the most common reasons given during the focus groups for earlytermination was that the client did not comply with program rules that for-bade smoking or drinking alcohol at the faciUty. Others were terminatedbecause they started romantic relationships (in centers that discouraged suchrelationships between participants) or demonstrated negative attitudestoward other clients. Some participants left the program before completionbecause of medical or legal problems.

Generally, the staff at the IHS-funded centers beUeved that women com-plete treatment in large part because they want to prove their worth to them-selves, to their peers, and to their famiUes and /or to achieve family reunifica-tion with children who are in out-of-home placements. Staff felt that the most

374 Native American Women in Treatment

common obstacles to recovery were involvement with a nonsupportive part-ner and having to return to communities where substance abuse was wide-spread. According to staff, once enrolled in treatment, the women remain fordiverse reasons, with success depending on their ability to accept their addic-tion and their willingness to make the changes needed to sustain recovery.Staff also pointed out that many stayed in treatment to avoid less palatablealternatives, such as incarceration. These findings are consistent with otherstudies of treatment programs for women.

Based on chart review, most participants (78 percent) planned on partici-pating in aftercare activities upon graduation from the treatment program.Only 12 percent of the participants did not have any aftercare plans (data onaftercare plans were unavailable from 30 [17 percent] of the charts reviewed).

Most of the IHS-funded treatment centers participating in this study adopteda holistic approach to AOD treatment that incorporates mental, emotional,physical, social, and cultural components in the treatment process. Clearly, theemphasis that the centers place on American Indian and Alaska Native cul-ture and traditions was important to the participants. In fact, the women in thefocus groups tended to select their current AOD treatment program over alter-natives because of its focus on AI/AN tradition and culture. The facets of thetreatment centers that were most frequently mentioned as beneficial weretheir AI/AN focus and their supportive environments. Moreover, the womenderived support from other Native American women, and this supportencouraged their efforts to stay sober.

The treatment programs have adopted a variety of strategies to make theirservices culturaUy appropriate. The programs made special efforts to recruitand hire AI/AN staff members, particularly AI/AN applicants who areknowledgeable about their culture and history. Incorporating traditionalactivities and beliefs was an integral part of all the treatment programs. Thetreatment centers employed a variety of cultural and spiritual activitiesincluding participation in talking circles, pow wows, peyote meetings, andsweat lodges. They played tribal music, taught participants native crafts (suchas beadwork), cooked and ate traditional foods, and discussed a their cultureand history. The programs also focused on personal spirituality and inte-grated traditional elements such as the medicine wheel, feathers, sage, anddrums into the AOD treatment curriculum. Spiritual leaders, such as medi-cine people and tribal elders, were often invited to meet with the participantsduring the recovery process.

The women and staff also gave credit to the benefits of the family-like envi-ronment that the treatment centers promoted. Family members of partici-pants were encouraged to visit the center regularly and to attend family coun-seling and special family events. Participants were also encouraged to think ofother participants and staff as sources of support. Staff characteristics such asprofessional quaUfications, dedication to recovery, strong interpersonal skills,and ability to work together as a recovery team were highlighted by both staffand clients as conducive to achieving a therapeutic environment. It also

Peterson et al. 375

appeared important to the perceived success of the program that a high pro-portion of staff members was in recovery from substance use problems.

However, the participants also criticized their treatment programs forshortcomings, of which the most frequently mentioned concerned the rulesgoverning residents and the barriers women with children encountered intheir attempt to enter or continue treatment.

Discussion

It should be noted that the while efforts were made to ensure that the treat-ment centers included in the study would be as representative as possible ofthe complete range of IHS-funded treatment centers, information derivedfrom this study may not be generalizable to aU IHS-funded treatment centers.Moreover, the findings presented here are based on a small sample of womenand thus may not be representative of all AI/AN women. Historical and socialvariations exist within the AI/AN population in language, settlement pat-terns, tribal values, and such individual-mediated influences as reservationversus nonreservation residence, level of acculturation, and access to AODtreatment and other health services. Substance use patterns, statistics, andoutcomes vary widely from tribe to tribe; between urban areas, federal reser-vations, and isolated northern vUlages; and between men and women.22

Another limitation of this study is that although some of the nine IHS-funded treatment centers used the same standardized forms to record data,the use of these treatment record forms was not consistent across the treatmentcenters. In addition, the research team found inconsistencies in the completionof standard forms within each treatment center. Consequently, this valuabledata source is less valid and reliable than it could have been.

The findings of the present study describe the Ufe experiences, recoverypatterns, and treatment needs of diverse group of AI/AN women. The studydemonstrates that for many AI/AN women, recovery needs to be understoodnot only as recovery from AOD use itself but from poverty, abusive relation-ships, low self-esteem, and negative patterns that have become entrenchedover generations.23

Most of the women in treatment at the nine IHS-funded treatment centersthat participated in this study were first exposed to AODs at an early age.Many have experienced varying levels of abuse, neglect, and hardship fromchildhood into their adult lives. As adults, these women repeated many of thesame patterns with their own children, including single parenthood, unem-ployment, poverty, abusive relationships, child abuse, and continued AODuse. For many, these problems were further exacerbated by Uving in an envi-ronment where alcohol and drugs are readily available and where substanceuse is acceptable or even encouraged by family members and friends. AODuse is perceived by many of these women as a means of coping with a varietyof painful life experiences and circumstances.

376 Native American Women in Treatment

Despite a host of countervailing influences, most of these women mademultiple attempts to recover from their addictions. For the most part, thewomen in treatment were motivated to seek a better life for themselves andtheir children and exhibited an intense desire to lead substance-free lives. Thetreatment programs in which these women enrolled attempted to meet theircomplex needs through conventional treatment approaches as well as tradi-tional cultural practices.

A common theme that emerged from this study is the relationship betweenculture and substance use. For the women who participated in this study, thecultural basis for the programs had a positive resonance. Participantsexpressed particular appreciation for the AI/AN staff and felt that they could"get more from their own kind" than they could from a program that was notAI/AN focused. Programs need to make available a comprehensive, cultur-ally appropriate array of services that can help to engage a woman initially,provide multidimensional support during the course of her treatment, andfacilitate her reentry to the community.

It is also very important to pay attention to the voices of these women indeveloping treatment and service policies for AI/AN women. Some contendthat to engage women successfully in AOD treatment programs, programsmust understand the perspective of clients, acknowledge their value, andassist in the resolution of needs and issues voiced by clients. As is attested bythe data from the participant focus groups, the chart reviews, and the inter-views with staff and administrators, the experiences and needs of thesewomen are best articulated by the women themselves. Because women tendto be socialized to cater to others, they may not possess the self-confidencerequired by the recovery process. As a result, women need to be empoweredas part of the treatment process. When AI/AN women seek and receive helpfor alcohol problems, there is a direct positive impact on their lives. The posi-tive consequences of treatment include a decrease in isolation, blame, andstigma and less resistance to outside help.

Families and communities can play an extremely important role in awoman's recovery. Children in particular often strongly motivate mothers toseek treatment and recovery; the extended family can either facilitate or hin-der this process. It is therefore important for treatment programs to assess theinfluence of family and community in the lives of women seeking treatmentand use these potential support systems in the recovery process as effectivelyas possible. Given the prevalence of traumatic life events among the womenrepresented in this study, treatment programs should also not only assess theiroccurrence but also be able to respond to potential repercussions that mayarise during and after the therapeutic process.

Further qualitative and quantitative research is needed to better under-stand the precursors to and consequences of substance abuse among all AI/AN people. Moreover, because of the great diversity among AI/AN tribes,such studies need to include a wide range of tribal representation, geographic

Peterson et al. 377

diversity, and cultural diversity. AI/AN women should be categorized as agroup in large epidemiological studies rather than being subsumed into an"other" racial/ethnic category. This would allow direct comparisons withother racial/ethnic groups of women.

When additional research on AI/AN people is undertaken, it is importantthat such investigative endeavors be sensitive to local conditions. Researchersneed to establish positive working relationships with the tribal communitiesin which the investigation is to be conducted, the staff and participants withinthe treatment centers themselves, and the IHS. By establishing such rapport,the research design, data-gathering approaches, and information derivedfrom the research will have greater legitimacy and validity, nationally andwithin the communities where it is conducted. Operating principles shouldinclude being respectful of local practices in the scheduling and conduct ofresearch activities, being responsive and adaptable to the needs of the commu-nity, and employing culturally appropriate measures whenever possible.Finally, although they are frequently asked to participate in research activity,treatment centers rarely receive the reports from the research and are thusunlikely to benefit from the findings. This must be rectified.

Toward the goal of promoting the health and weU-being of AI/AN women,their famiUes, and their communities, a critical first step is to adequatelyunderstand the life conditions of the women who are currently receiving treat-ment through IHS-funded centers. The information derived from this studycan be used as the foundation for further research about the experiences of AI /AN women to improve models of recovery that are designed to serve them.

AcknowledgmentsThis study was funded by the Office of the Assistant Secretary of Health, U.S. Department of

Health and Human Services, in collaboration with the Indian Health Service. We would like toacknowledge the contributions, expertise, and dedication of our delivery order officers, WendyPerry and Winnie Mitchell; our technical adviser, Eva Marie Smith; Leo Nolan, from the Office ofPlanning, Evaluation, and Legislation; IHS representatives Timothy Taylor, Johanna Klevenger,Tim Whitehorse, Charlene Hamilton, and Irene Johnson; and our consultants, Betty Cooper,Bonnie Duran, Christine Lowery, and Candace Shelton. We extend special thanks to the staff andwomen participants at the participating IHS-funded treatment centers for their time, honesty, andinspiration. The opinions expressed in this paper are those of the authors and do not necessarilyreflect the views of the Indian Health Service.

REFERENCES

1. Hisnanick JJ, Erickson PM. Hospital resource utilization by American Indians/Alaska nativesfor alcoholism and alcohol abuse. Am J Drug Alcohol Abuse 1993;19(3):387-96.

2. May PA. The epidemiology of alcohol abuse among American Indians: The mythical and realproperties. Am Indian Culture Res J 1994 Apr-Jun;18(2):121-43.

3. Christian CM, Dufour M, Bertolucci D. Differential alcohol-related mortality among AmericanIndian tribes in Oklahoma, 1968-1978. Soc Sei Med 1989;28(3):275-84.

378 Native American Women in Treatment

4. Singh GK, Hoyert DL. Social epidemiology of chronic liver disease and cirrhosis mortality inthe United States, 1935-1997: Trends and differentials by ethnicity, socioeconomic status, andalcohol consumption. Hum Biol 2000 Oct;72(5):801-20.

5. Nixon SJ, Phillips M, Tivis R. Characteristics of American-Indian clients seeking inpatienttreatment for substance abuse. J Stud Alcohol 2000 Jul;61(4):541-47.

6. Hesselbrock MN, Hesselbrock VM. Gender, alcoholism, and psychiatric co-morbidity. In:Wilsnack RW, Wilsnack SC, eds. Gender and alcohol: Individual and social perspectives. NewBrunswick, NJ: Rutgers Center of Alcohol Studies, 1997.

7. DeBruyn LM, Lujan CC, May PA. A comparative study of abused and neglected AmericanIndians. Soc Sei Med 1992 Aug;35(3):305-15.

8. Horejsi C, Craig BH, Pablo J. Reactions by Native American parents to child protection agen-cies: Cultural and community factors. Child Welfare 1992 Jul-Aug;71(4):329-42.

9. Anonymous. Alcohol-related hospitalizations—Indian Health Service and tribal hospitals,United States, May 1992. MMWR Morb Mortal WkIy Rep 1992 Oct 16;41(41):757-60.

10. American Academy of Pediatrics, Committee on Substance Abuse and Committee onChildren With Disabilities. Fetal alcohol syndrome and alcohol-related neurodevelopmentaldisorders. Pediatrics 2000 Aug;106(2 Pt 1):358-61.

11. Faden VB, Graubard BI. Maternal substance use during pregnancy and developmental out-come at age three. J Subst Abuse 2000;12(4):329-40.

12. Abel EL. An update on incidence of FAS: FAS is not an equal opportunity birth defect.Neurotoxicol Teratol 1995 Jul-Aug;17(4):437-43.

13. Overview of the National Drug and Alcoholism Treatment Survey (NDATUS), 1992 and 1980-1992. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse andMental Health Services Administration, 1995. (DHHS Pub. No. (SAMHSA) 9.)

14. Reid J. Substance abuse and the American woman. New York: Columbia University, NationalCenter on Addiction and Substance Abuse, 1996.

15. Grella CE. Services for perinatal women with substance abuse and mental health disorders:The unmet need. J Psychoactive Drugs 1997 Jan-Mar;29(l):67-78.

16. Colletti SD. Service providers and treatment access issues. In: Wetherington CL, Roman AB,eds. Drug addiction research and the health of women. Rockville, MD: National Institute onDrug Abuse, 1998. (NIH Pub. No. 98-4290.)

17. Brindis C, Clayson Z, Berkowitz G. Options for recovery: Promoting perinatal drug and alco-hol recovery, child health, and family stability. J Drug Iss 1997 Jul-Sep;27(3):607-24.

18. Clayson Z, Brindis C, Berkowitz G. Themes and variations among seven comprehensiveperinatal drug and alcohol abuse treatment models. Health Care Soc Work 1995Aug;20(3):234-38.

19. Anderson EN. A healing place: Ethnographic notes on a treatment center. Alcoholism Treat-ment Q1992 Jul-Dec;9(3/4):1-21.

20. Gutierres SE, Russo NF, Urbanski, L. Sociocultural and psychological factors in AmericanIndian drug use: Implication for treatment. Int J Addict 1994 Dec;29(14):1761-86.

21. Comfort M, Kaltenbach, KA. The psychosocial history: An interview for pregnant andparenting women in substance abuse treatment and research. In: Rahdert ER, ed. Treatmentfor drug exposed women and their children: Advances in research methodology. NIDAResearch Monograph No. 165. Rockville, MD: U.S. Department of Health and Human Ser-vices, National Institute on Drug Abuse, 1996.

22. Liepman MR, Goldman RE, Monroe AD. Substance abuse by special populations of women.In: Gromberg EL, Nirenberg T, eds. Women and substance abuse. Norwood, NJ: Ablex, 1993.

23. Burman S. The disease concept of alcoholism: Its impact on women's treatment. J Subst AbuseTreat 1994 Mar-Apr;ll(2):121-26.

MS. PETERSON is project director, MS. CART is senior research associate, and DR. BRINDIS is professorat the Institute for Health Policy Studies, University of California, San Francisco. DR. BERKOWITZ isevaluation officer at the Charles and Helen Schwab Foundation in Kensington, California.