Cover Story

For decades, substance use and suicide have plagued many American Indian and Alaska Native communities. According to the Centers for Disease Control and Prevention, the suicide rate among American Indians ages 18 to 24 is nearly double the national rate. And significantly more American Indians and Alaska Natives needed treatment for alcohol or illicit drug use in the prior year than people from other ethnic groups, according to a report by the Substance Abuse and Mental Health Services Administration (National Survey on Drug Use and Health, November 2012).

In the past, many psychologists attempted to tackle these problems by introducing Western evidence-based strategies that failed to recognize indigenous values—such as spirituality, the wisdom of elders and family relationships. And indigenous people were rarely invited to participate in designing solutions. Researchers also focused on people who were using substances rather than on the strengths found in those who were staying sober. Over time, it became clear these Western practices did not work.

Over the last few decades, psychologists have started working closely with indigenous communities to incorporate American Indian traditions into interventions. "We realized that the therapeutic tools of the day were very limited in their application to the challenges of life in Native America," says Spero M. Manson, PhD, director of the Centers for American Indian and Alaska Native Health at the Colorado School of Public Health. "Our awareness of the importance of culturally relevant care has grown, and evidence to this effect has accumulated," says Manson, who is Pembina Chippewa.

Today's work in indigenous communities is informed by these lessons from the past, and cultural heritage is proving to be a powerful force in combating these public health crises. "Many of the struggles native communities face are caused by broken connections with their heritage," says psychology professor Art Blume, PhD, of Washington State University Vancouver, who is Cherokee and Choctaw. "Progress has been made over the last few years because we are combining the best indigenous cultural practices for healing with empirically supported interventions, plus we have enhanced the trust of the communities by working with them."

Here we explore four of these innovative programs, which are showing promise in preventing suicide and addiction in indigenous communities.

A Yup’ik man stands next to a fish trap on the Kuskokwim River in Akiak, Alaska. While tepees are mostly used for ceremonial purposes today, they remain a strong cultural symbol among many tribes. New interventions work to nurture tribes’ customs, languages and beliefs.

Yup'ik Alaska Native

A toolbox for survival

Knowing how to read the ice is a critical survival skill for members of Yup'ik Alaska Native communities, who live along Alaska's Bering Sea coast. Traveling across frozen rivers is a necessity in this roadless region, so locals must understand the color and texture of ice to assess its risk of giving way.

For millennia, the elders in these communities passed this and other cultural knowledge along to younger generations. But with the advent of Western influence, connections between younger and older generations have frayed. Western schools teach children English, often at the expense of the Central Yup'ik language spoken by the elders, and traditional ways of instruction and ancestral learning have often been disrupted.

When Yup'ik community members shared this cultural disconnect and their concerns for their youth with psychologist Gerald Mohatt, PhD, they concluded that a return to these practices would nurture strengths that would promote protection from alcohol and suicide risk. Over the last two decades, Yup'ik leadership and community members have collaborated with a team of University of Alaska Fairbanks researchers, including Mohatt's colleague James Allen, PhD, now a professor of family medicine and biobehavioral health at the University of Minnesota Medical School, Duluth, and anthropologist Stacy Rasmus, PhD, who is a member of the Lummi Tribe. Together they developed an intervention called Qungasvik (kung-as-vik), or "toolbox" in Yup'ik, which includes activities and teachings about Yup'ik cultural values that reconnect youth with ancestral traditions. The strength of the program lies in qasgiq (kawz-gick), a process of communities coming together in a circle to accomplish important tasks, says Billy Charles, a Yup'ik member from Emmonak, Alaska, and a leader in using Qungasvik. 

The toolbox engages youth in shared activities and lessons with elders and other cultural experts. One such lesson involves outdoor training on ice and assists young people in crafting their own ayaruk (aw-yaq-ruk)—a traditional tool used to test the ice. The ayaruk acts as a powerful symbol for youth: Its pointed end allows you to test the ice for safety on your path, helping you always to be aware of what is underfoot. If you do fall through, you can latch the other hook-shaped end onto the ice edge and pull yourself to safety. "It shows that we all need something to lean on and protect our path," Charles says. "Even though we think we're alone, we all have a guide or higher power."

The ayaruk also represents ellangneq (eshl-law-ng'-nek)—a form of Yup'ik cultural awareness—as a tool that helps youth to be present and aware of their surroundings in a world in which people, the land and spirit are interconnected. This traditional perspective can be applied to a variety of challenging life situations, including reflecting deeply on the consequences of alcohol misuse in an interconnected world.

So far, more than 600 youths in six communities have participated in Qungasvik, and the results are encouraging. The researchers compared preliminary data from a lower-intensity version of the program with a higher-intensity implementation that included more exposure to the intervention. After participating for more than one year, young people in the higher-intensity condition experienced significantly more protection from suicide. Specifically, youth reported higher levels of beliefs and experiences that make life enjoyable, worthwhile and provide meaning, such as strong cultural and spiritual beliefs and a sense of family responsibility, among other factors (Allen, J., et al., Prevention Science, 2017).

While Allen and his collaborators continue to provide consultation, the community leaders manage and sustain the interventions on their own. The team's research collaboration is currently conducting a large-scale prevention trial of Qungasvik. The goal is to make the intervention an evidence-based practice so Yup'ik communities will be eligible for funding from foundations and federal agencies, such as the Substance Abuse and Mental Health Services Administration, and will be able to run the project as a community-directed program. 

White Mountain Apache

Connecting spirituality to mental health

In Arizona's White Mountain Apache Tribe, more than 128 of every 100,000 youths ages 15 to 24 completed suicide each year from 2001 to 2006. That's 13 times the U.S. all-races rate and seven times the American Indian and Alaska Native rate (American Journal of Public Health, Vol. 99, No. 10, 2009). 

Eager to address this problem, the tribe sought help from researchers at Johns Hopkins University in 2006. Psychologist Mary Cwik, PhD, from the university's Center for American Indian Health, collaborated with the tribe to incorporate their beliefs and practices into a prevention program that would serve a population of 17,000 people on the reservation.

"When we were discussing the cognitive-behavioral therapy model, the tribal representatives felt like something was missing," Cwik says. "They felt that spirituality should be a part of treatment."

The tribe's worldview is cyclical, so instead of using the triangular CBT model (thinking, feeling, doing), the academic and community partners adopted a model with four quadrants in the shape of a circle: thoughts, feelings, behaviors and spirituality. Data from the community showed that the vast majority of people were high or drunk at the time of a suicide death or attempt, and that arguments with parents, relatives or significant others were the most common causes of the behavior (American Journal of Public Health, Vol. 106, No. 12, 2016). As part of the intervention, tribal members who have suicidal thoughts or harm themselves can meet one on one with community mental health specialists who incorporate spiritual prayers, songs and stories into recovery efforts and explain how these traditions could be sources of strength during difficult times.

The program also extends to three elementary schools and two middle schools on the reservation. The elders talk with children about tribal values, such as respect for life and the land, as well as for the individual and the family, and take students on field trips to sacred sites.

Data from the same 2016 study suggest that the intervention is making a difference. The incidence of suicide deaths within the White Mountain Apache Tribe dropped 38 percent from 2006 to 2012 compared with the previous six-year period. The rate among those ages 15 to 24 dropped 23 percent during the same time frame.

Cwik and her Apache collaborators have been approached by more than 10 tribes that are interested in replicating the intervention in their communities.

Cheyenne, Arapaho and other tribes

Success with integrated care

With a stigma against mental health care among many patients and physicians, the Indian Health Service's Clinton Indian Health Center in Clinton, Oklahoma, seemed an unlikely candidate for success with an integrated-care model. But in 2016, the center's medical director hired American Indian psychologist Lahoma Schultz, PhD, to take on the daunting task of implementing a program that would address the community's behavioral and physical health needs.

Under the model, nurses screened patients for depression, alcohol misuse, tobacco use, opioid addiction and domestic violence. If the screens revealed any concerns, Schultz or one of the clinic's two social workers, who were also of Native American descent, would see the patients the same day.

Within weeks of launching the program, physicians saw patients improving after their visits with the behavioral health team, says Schultz, who belongs to the Muscogee (Creek) Nation and is part Oklahoma Seminole. Patients discovered that they enjoyed talking to the center's mental health professionals—particularly because these providers understood their traditions and heritage.

"Sometimes, patients come in and start sharing about something that happened in a sweat lodge or a meeting with a medicine man, and they appreciate that I know exactly what they're talking about," says Schultz.

Sharing cultural knowledge allowed Schultz to quickly build trust with clients. And as patients started to feel better, they spread the word to others in their tight-knit communities about their positive experiences with behavioral care, Schultz says. After one year, the mental health specialists at the clinic now see more than 100 patients each month, exceeding the Indian Health Service's expectations. In July, Schultz and her staff received the Indian Health Service's National Director's Award for their work to improve quality and access to care for patients. Now there are plans to integrate behavioral health into primary care at additional Indian Health Service sites in Oklahoma.

Great Plains Indians

Finding strength in the buffalo

Older American Indians in the Great Plains region still remember the signs that read "No dogs or Indians allowed"—remnants of a time when some businesses refused to serve indigenous people.

The signs are now gone, but the emotional scars are not. "When Native Americans think about all that they have lost, from land to culture to language to religion and traditions, it increases sadness, anxiety and anger—all things that contribute to relapse," says Monica Skewes, PhD, an assistant psychology professor at Montana State University. She partnered with Blume to identify stressors that could be causing addiction and relapse on a reservation of Great Plains Indians. Now they are part of a group designing a new intervention that capitalizes on indigenous traditions. "American Indian, Alaska Native and Native Hawaiians are very communal in their approach to life, so they could benefit from group meetings that allow them to share about discrimination and experience healing together," Blume says.

Community members also felt that the intervention should address the family of the individual who is struggling with relapse, which differs from many Western models that typically focus on the individual.

"Our participants have gone to rehab or treatment and have been told, ‘You have to do this for yourself, and you have to quit drinking for you,'" Skewes says. "But the indigenous people who are successful have told us they didn't do it for themselves. They did it for their parents, their kids, their people."

In their original study, the researchers found that community members who stopped drinking and avoided relapse were more engaged in cultural activities, such as speaking the traditional language, attending ceremonies or participating in sewing and beading classes. One goal of the new program is to work with the community to make cultural activities more accessible for people struggling with substance misuse. 

The connection to the buffalo is also particularly important for the Great Plains tribes, who view the animals as ancestors, Skewes says. Millions of wild buffalo roamed across the Great Plains until the late 1800s, when European settlers hunted them to near extinction. Now a decades-long national effort—involving the U.S. government, Indian tribes and nongovernmental organizations—has returned the animals to several reservations, offering an opportunity to integrate visits to a buffalo ranch into the intervention.

"The animals are a powerful metaphor for recovery," Skewes says. "Members of the tribe tell us that the buffalo are the only animals that don't hide from a storm, but instead turn and walk directly into the oncoming storm."

Additional reading

Healing of the Canoe: Preliminary Results of a Culturally Tailored Intervention to Prevent Substance Abuse and Promote Tribal Identity for Native Youth in Two Pacific Northwest Tribes
Donovan, D.M., et al.
American Indian and Alaska Native Mental Health Research, 2015

Association of the Firewater Myth with Drinking Behavior Among American Indian and Alaska Native College Students
Gonzalez, V.M., & Skewes, M.C. Psychology of Addictive Behaviors, 2016

Exploration of Pathways to Binge Drinking Among American Indian Adolescents
Cwik, M.F., et al. Prevention Science, 2017