Design of a behavioral health program for urban American Indian/Alaska native youths: a community informed approach.
Article Type: Report
Subject: Behavioral health care (Usage)
Behavioral health care (Health aspects)
Behavioral health care (Practice)
Psychiatric services (Access control)
Substance abuse (Care and treatment)
Substance abuse (Patient outcomes)
Mix of Mental Health & Substance Abuse Services
Programs for co-occurring mental and substance abuse disorders
Authors: Dickerson, Daniel L.
Johnson, Carrie L.
Pub Date: 10/01/2011
Publication: Name: Journal of Psychoactive Drugs Publisher: Taylor & Francis Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Taylor & Francis Ltd. ISSN: 0279-1072
Issue: Date: Oct-Dec, 2011 Source Volume: 43 Source Issue: 4
Topic: Event Code: 200 Management dynamics Canadian Subject Form: Behavioural medicine; Behavioural medicine; Behavioural medicine
Product: Product Code: 8000186 Mental Health Care; 9105250 Mental Health Programs; 8000143 Alcohol & Drug Abuse Programs NAICS Code: 62142 Outpatient Mental Health and Substance Abuse Centers; 92312 Administration of Public Health Programs SIC Code: 8093 Specialty outpatient clinics, not elsewhere classified
Accession Number: 278880922
Full Text: Abstract--American Indian/Alaska Native (AI/AN) urban youths experience significant mental health and substance use problems. However, culturally relevant treatment approaches that incorporate community perspectives within the urban setting are limited. This study analyzes community perspectives from AI/AN parents, AI/AN youths, and services providers within Los Angeles County. information gathered was utilized to develop a needs assessment for AI/AN youths with mental health and substance use problems and to design a community-informed treatment approach. Nine focus groups and key informant interviews were conducted. The Los Angeles County community strongly expressed the need for providing urban AI/AN youths with traditional healing services and cultural activities within their treatment program. However, various barriers to accessing mental health and substance abuse treatment services were identified. An integrated treatment approach was subsequently designed as a result of input derived from community perspectives. The community believed that providing urban AI/AN youths with an integrated treatment approach has the potential to decrease the risk of mental health and substance abuse problems in addition to enhancing their cultural identity and self esteem.

Keywords--Alaska Natives, American Indians, mental health, substance abuse, youth

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Approximately two-thirds of American Indians/ Alaska Natives (AI/ANs) reside within an urban setting (U.S. Bureau of the Census 2000). However, formalized community-based approaches addressing the treatment needs of urban AI/AN youths with mental health and substance abuse problems are limited. A collaborative partnership between AI/AN youths, parents, elders and AI/AN agency leaders has significant potential to assist in the development of a treatment program that could be more engaging, more accepted, and more culturally appropriate. Furthermore, urban AI/AN consumers and their families may possess knowledge with regard to unique stressors experienced by urban AI/AN youths which may place them at risk for mental health and substance use disorders. In addition, urban AI/AN families and youths may be familiar with traditional-based activities and healing methods that may contribute to improved mental health and substance abuse treatment outcomes. Also, obtaining community feedback with regard to treatment barriers experienced by urban AI/AN youths can increase our understanding of their behavioral health treatment needs.

Incorporating traditional healing within mental health and substance abuse treatment programs has the potential towards providing culturally relevant and culturally appropriate services for urban AI/AN youths. The Tribal Participatory Research (TPR) model highlights the need for culturally specific interventions that allow for the incorporation of traditional practices that create the potential for testing indigenous models of health and well-being (Fisher & Ball 2003). In addition, culturally tailoring mental health treatment approaches for AI/ANs has the potential to improve mental health treatment strategies for this population. For example, among individuals exposed to their cultural heritage and traditional activities, previous studies have found themes of renewed pride in their cultural heritage, and of having motivation to learn more about their cultural heritage (Prussing 2007).

Although research is limited with regard to mental health and substance use characteristics among AI/AN youths, data to date suggests that AI/AN youths are at high risk for these disorders. For example, compared to other racial/ethnic groups, AI/ANs between the ages of 15 and 24 have the highest suicide rates in the United States (CDC 2004). In addition, AI/AN youths have an earlier onset, experience significantly higher rates of alcohol and illicit drug use, and experience more severe consequences of drug use compared to any other ethnic/racial group in the United States (Dixon et al. 2007). Also, among AI adolescents and young adults, ages 15-24, deaths attributable to alcoholism were found to be more than 15 times those of the same age group of all races combined (Mitchell, Beals & Whitesell 2008).

A unique history exists as it relates to AI/ANs residing in urban areas in the U.S. The Indian Relocation Act of 1956 financed the relocation of individual AIs and their families to urban centers, providing them funding to establish job training centers (Jaimes 1992). However, this move has been implicated in having detrimental effects. For example, a variety of biopsychosocial problems for this population have been suggested due to this relocation (Evans-Campbell & Walters In press; Evans-Campbell et al. 2006; LaFromboise, Berman & Sohi 1994). Also, many AI/ANs who moved to urban areas found themselves homeless, unemployed, in poverty, without a strong cultural base or community, and not achieving economic stability. In addition, the relocation of AI/AN to urban areas appears to have contributed to an intergenerational effect whereby AI/ANs have experienced significant health-related disparities over successive generations. Also, acculturative stress directly and indirectly related to the historically related trauma experienced by AI/ANs have been shown to result in poor mental health outcomes (Duran & Duran 1995).

Being able to obtain information from a community perspective within the urban setting may lead to greater understanding of the unique needs of this population and aid in designing a culturally appropriate treatment approach. This report builds upon our prior descriptive analyses of AI/AN youths with mental health and substance use disorders (Dickerson & Johnson 2010) by providing an overview of how treatments are provided utilizing a community-informed process within a large urban treatment setting. By partnering with the AI/AN urban community and utilizing community-based knowledge regarding the treatment needs of urban AI/AN youths with mental health and substance abuse problems, there could be a higher likelihood of providing a culturally competent mental health and substance abuse program for this population.

To further these goals, a community needs assessment was conducted to identify the mental health and substance abuse needs of AI/AN youths in Los Angeles County. This information assisted with the development and implementation of a system of care that was culturally appropriate and informed by the community.

METHODS

Design

A county-wide community needs assessment was conducted by the second author and program staff between August, 2005 and July, 2006 based on two research methods: focus groups and key informant interviews. A total of nine focus groups, three each for parents, youths, and service providers were conducted. Additionally, the three focus groups for each participant group were divided between three separate geographic areas within Los Angeles County. The interviews were conducted at various locations within Los Angeles County to maximize participation, including mental health care offices, homes and public locations. This research study was reviewed and approved by the UCLA Institutional Review Board (IRB), #G02-07-019-03.

Both the focus group questions and the key informant questions were developed through a series of stages. Question formulation was first conducted with program staff; the questions were then reviewed and revised by the community advisory board, and then reviewed and revised at a community forum. Once the question schedule was completed for each participant group (parents, youths, and service providers), pilot testing was done for each of the three types of participant groups. Based on this feedback, the questions were finalized.

Outreach and recruitment for participants for the focus groups and key informant interviews were conducted by use of flyers. Flyers were distributed in local AI/AN agencies. Parent participants were required to be of AI/AN descent, reside in Los Angeles County and have AI/AN children. Youth participants were required to be AI/AN, reside in Los Angeles County, and be between ages of 14 and 17 years of age. Service providers were required to have provided services to AI/ANs within the past year within Los Angeles County and were not required to be AI/AN. Traditional healers (with whom three interviews were conducted) were required to be AI/AN and recognized as a traditional healer or spiritual advisor by multiple members of the community.

Participants

There were a total of nine separate focus groups conducted (n = 67). The three focus groups with parents (n = 25) had 18 females and seven males. The focus groups for youths (n = 25) had fourteen females and eleven males. The focus group for service providers (n = 17) had eleven females and six males. All participants in the youth and parent focus groups were AI/AN from various tribal backgrounds. With regard to education level, the parents had an average of some college, youth had some high school, and service providers had a college degree.

There were a total of 46 key interviews conducted. The key informants were chosen for their high involvement in the community and recognition by the community as key individuals. Several parents, youth, and service providers were identified and asked if they wanted to participate. Some were involved with First 5 California, a comprehensive system of education, health services, childcare, and other programs for parents, caregivers, and children up to age five (CCFC 2011). For the parents (n = 14), twelve were females and two were males and the average educational level was high school graduate or GED. For the youths (n = 13) ten were females and three were males with the majority in high school. The key informant interviews for the service providers (n = 16) consisted of nine females and six males, with an average educational level of a college degree. There were three traditional healer interviews conducted (one female and two males), who had either a high school degree or GED.

Data Collection

The three focus groups (parents, youths, and service providers) were held at three different geographic areas in Los Angeles, They were held in community centers, or AI/AN agencies. The key informant interviews were conducted at offices or homes of participants. For the focus groups a lead moderator and two assistant moderators facilitated each focus group. After the consent form was reviewed and questions were answered, participants who did not wish to participate were free to leave the group, although none chose to do so. This was followed by an introduction and overview of the topic, explanation of how the focus group would be conducted, and establishment of the ground rules. Each focus group lasted approximately two hours and participants were provided with a $20 gift card for their participation. The focus groups were audio recorded and later transcribed. The third facilitator took written notes during the discussions. For the key informant interviews, participants were asked to read and sign the consent form, then the interviewer explained the interview process. All interviews were audio recorded and later transcribed. The interview took approximately one and a half hours and participants were provided with a $20 gift card.

Data Analysis

Audiotapes from the nine focus groups and 46 interviews were transcribed verbatim. The transcripts were reviewed for completeness and accuracy. This process included the following stages: verbatim transcription of the tapes; proof listening and editing; manual axial coding for reoccurring themes; and internal reliability tests. The notes taken by the assistant moderators and post-focus group debriefings were also used in checking the reliability of the axial coding. The goal of the analysis was to identify keywords, phrases, and concepts, and then document their context, frequency, intensity, and specificity.

RESULTS

Findings from the focus groups and key informant questionnaires were used to implement a system of care that was culturally appropriate and informed by the community for AI/AN youths. There were eight community needs that emerged from the focus groups and key informant interviews. These included:

* Accessing services: "I come from a reservation where everything is paid for, you know, where you go to get your teeth done, you go, to get your prescription, you get a doctor, you know, everything is taken care of." (parent participant)

* Outreach and awareness of services: "I think we need to do a little more outreach as there are more than 100,000 Native American people in Los Angeles County. I'm sure we are not reaching those people nor are we letting them know that there are services available." (spiritual advisor participant)

* Youth services: "Kids could come together and identify with one another and learn about their culture, learn about what's going on in the Indian community for themselves." (service provider participant)

* Recreational services: "[We] need more American Indian programs, sports, and cultural gatherings and activities." (youth participant)

* Child and family support services: "A parent with a child 0-5 needs medical and educational services-not only for the child, but also for the parent." (First 5 California participant)

* Child and family behavioral health: "For my son fight now, he's got a mental health disorder, and he's been in a mental health facility for five years, and I had to go to the courts to go through the Department of Mental Health in LA and asking for a Native American Indian worker, and I couldn't even get one." (parent participant)

* Cultural activities: "I think there needs to be more cultural awareness and I think that needs to be supported through organizations that will promote the identity of the Native Americans." (parent participant)

* Culturally appropriate training: "I wish ideally that there could be Indian people providing Indian services." (service provider participant) "The number one reason our children are not succeeding in school is because they are objectified. There are still teachers who teach subjects on American Indian culture that were written 50 years ago by non-natives. (First 5 California participant)

General Suggestions

The AI/AN community in this study reported they often feel invisible living in the urban area. Also, participants reported that there were not enough cultural activities for AI/AN youths. The shortage of cultural activities was viewed as having a negative impact on their cultural identity, which then contributes to a higher risk of mental health and substance abuse problems. One youth participant stated: "Even though you have friends that are other races, you feel left out, because there's probably only one or two of you in the whole school."

Many participants reported that they or their family were a part of the relocation program in the 1950s. As a result, they reported not having support from their families or tribe to help with many stressors and difficulties they experienced. Participants reported that the stress of trying to live in an unfamiliar urban environment as a result of historically-based events led to many of them turning to drugs and alcohol to cope. A parent participant said: "I think it's different to live in the urban area because ... you miss your family. You know, you miss being around your own tribe. The language, the culture, the traditions and history ... we don't get that out here very often."

When asked: "How do people tell when youth are not emotionally healthy?" nearly all parent focus group respondents agreed that youth who were not emotionally healthy displayed multiple behavioral problems. For example, many parent participants said that youth became very rebellious, manipulative, and hostile towards others. Also, most participants from all groups agreed that AI/AN youth who are not emotionally healthy socially isolate themselves from others.

Across all, focus groups, drug and alcohol abuse was identified as the most serious issue among AI/AN youths. Gang activity and violence were the next most commonly identified serious issues for youth, followed by problems associated with racism and negative stereotypes. Domestic violence, high school dropout rates, gang activity, sexually transmitted diseases, and teen pregnancy were identified as moderately serious problems among AI/AN youths. Also, service providers identified serious issues associated with the loss of culture and identity in American Indian youth most frequently, followed by drug use and poverty. Parent participants also discussed physical, psychological, and sexual abuse as being serious issues.

Traditional Activities Suggestions

Participants frequently reported that their community lacks many traditional and cultural opportunities for AI/ANs. Most participants also agreed that there were few opportunities for AIANs to socialize with each other. Some participants suggested that this could be attributed to the lack awareness of the AI/AN community in the city. Among parent and service provider focus groups, the majority of participants expressed that traditional activities such as powwows, tribally specific ceremonies, and intertribal gatherings kept families connected to tribal identities. Many participants credited American Indian social service agencies with providing some of these opportunities. Another theme identified was that many families continue to travel to their respective reservations to participate in cultural events and practices. Some participants also discussed the fact that neither they nor their families practiced any traditional cultural practices. These statements were often followed by discussions about having never been taught about their tribal traditions by theft own parents or families who had moved here during relocation.

Overall, the general responses indicated that a large number of AI/AN youths are lacking traditional activity opportunities. Thus, participands believed that AI/AN youths may not have opportunities to connect to their AI/AN cultural identity within their urban environment. Other discussions among the youth participants indicated that AI/AN youth programs were of great benefit to keeping youth connected to traditional practices: "It helps me when I go over and I interact with other Native American people" (youth participant).

Participants specifically identified powwows, sweat lodges, and tribally specific ceremonies as important cultural or traditional strengths that benefit AIANs in Los Angeles. Participants often reported that there were not enough culturally appropriate services in their community and that services for AI/ANs need to integrate traditional and cultural practices with evidence-based treatments.

Developing a Culturally Appropriate System of Care Treatment Program

Using the information from the focus groups and key informant interviews, a system of care for AI/AN youths with behavior problems was developed and implemented. Cultural activities were a key component that all participants wanted to see incorporated into the program. The cultural activities included traditional craft workshops such as beading, basket making, drumming, dancing, and regalia making. These cultural activities were seen as important to restore the loss of cultural identity among urban youths. Other activities included attending pow-wows, participating in sweat lodge ceremonies and other traditional ceremonies, as well as having access to a traditional healer if needed. Youth and family activities were other key components. These were seen as allowing these youth and families to feel more connected to other AI/ANs.

Providing more community outreach and awareness of behavior services was recommended by participants. Many participants reported that they did not know about services for AIANs and often did not get notice of cultural activities that were taking place in the community. They also reported that it was difficult to get to services, so access was reported as a barrier to services.

The community informed program that was implemented allowed all clients who participated in the program to develop their own treatment plan. Evidence-based treatments were offered which included: Parent Child Interactive Therapy, Seeking Safety, and Trauma Focused Cognitive Behavior Therapy. Clients were also given the opportunity to participate in the many cultural workshops offered. These included beading classes, basket making classes, dancing, singing and drumming workshops as well as regalia making workshops. Outreach to the community was done through flyers, monthly calendars, and Facebook. A youth and parent committee was developed to inform the program on what activities youth and parents wanted to incorporate into their treatment. Some of these included family camping, picnics, storytelling events, and hiking. As the program was being developed, clients, youth and parents identified Equine Assisted Psychotherapy (EAP) as another requested treatment option that was implemented into the treatment program. Transportation was offered for all cultural and youth/family activities.

DISCUSSION

Results from this study have provided several suggestions and perspectives from urban AI/AN community parents, youths, and service providers as they relate to the mental health and substance abuse care needs of urban AI/AN youths. Community members strongly advocated for the integration of traditional healing practices within the treatment milieu. Specifically, community members advocated for the use of sweat lodges ceremonies, participation in pow-wows, bead-making, drumming activities, and jewelry making. Community members believed that participation in these traditional-based activities integrated with currently provided Evidence-based treatments can assist towards improving outcomes as mental health and substance abuse treatment outcomes among urban AI/AN youths. In addition, community members believed that providing these treatments can assist towards enhancing urban AI/AN youths' cultural identities and self esteem thereby assisting towards overcoming their mental health and substance abuse problems.

Participants reported various barriers to receiving behavior treatment for AI/AN youths. For example, many participants did not believe enough outreach activities were being employed to reach the urban AI/AN community. Participants also felt that if more AI/AN providers were employed, that more culturally appropriate services would be available for them which would help them to feel more comfortable in seeking and receiving treatment. However, a significant shortage of Ph.D.s, M.D.s/D.O.s, and Masters of Social Work (MSW) who are of AI/AN decent has been observed within the local AI/AN community. Thus, further educational opportunities and academic programs targeting AI/ANs interested in mental health and substance abuse career fields are recommended.

Providing an opportunity for urban AI/ANs to participate in traditional healing services and activities may have significant benefits. For example, urban AI/AN youths who participate in the program proposed by community members may increase their self esteem and their cultural identity. These potential effects could be especially beneficial for these youth within the complex, multicultural environment in Los Angeles County where the sense of cultural identity may be more complex. In addition, participation in traditional healing activities may ultimately result in improving mental health and substance abuse treatment outcomes in addition to decreasing their risk of these disorders. Also, providing traditional healing and cultural-based activities may assist towards decreasing the stigma that often exists among AI/ANs with mental health and substance abuse problems. For example, some AI/ANs with mental health and substance abuse issues may feel more comfortable first discussing these issues with an AI/AN traditional healer or cultural leader who may possess the cultural competence necessary to create a comfortable therapeutic relationship.

Momentum for an integrated approach of providing traditional-based healing and cultural activities for AI/AN youths and adults is also reflected in a sponsored project coordinated by the Los Angeles County Department of Mental Health (LACDMH) in partnership with the AI/AN community of Los Angeles County. This initiative, the Learning Collaborative, was comprised of a three-phase project to support a referral system for traditional healing services for AI/ANs in Los Angeles County. From 2007 to 2010, numerous meetings were held comprised of LACDMH administrators, AI/AN mental health professionals, AI/AN consumers, key stakeholders, and traditional healers. Also, additional community forums and focus groups were conducted to assist towards future planning of an integrated treatment approach. This initiative was propelled through the advice by AI/AN leaders who have expressed the need for providing culturally-relevant mental health treatments for AI/ANs in Los Angeles County The feedback obtained by community members in this article strongly mirrors the work led by the Learning Collaborative, thus, further suggesting the need for incorporating traditional healing and cultural-based activities for urban AI/AN youths with mental health and substance abuse problems.

Research evaluating the effectiveness of urban AI/AN youths receiving integrated traditional-based activities is limited. Research investigating the potential effectiveness of traditional healing-based treatments is needed in order to inform policy makers, insurance companies, and other county/state/federal entities involved in reimbursement of mental health and substance abuse issues for AI/ANs. Although traditional-based healing services and cultural activities are considered effective among AI/AN community members in this report, studies demonstrating their benefits are limited within the scientific literature. The authors of this article will be evaluating the treatment outcomes of the treatment approach described in this report in a subsequent study. This report will build on a previous descriptive study we conducted analyzing psychiatric and substance abuse characteristics among a sample of urban AI/ANs (Dickerson & Johnson 2010). In our previous study, urban AI/AN youths demonstrated various mental health symptoms including feeding withdrawn, aggressive problems, attention problems, and internalizing/externalizing problems. Furthermore, many urban AI/AN youth in this study witnessed domestic violence, lived with someone who had a substance abuse problem, lived with someone who was depressed, lived with someone who was convicted of a crime, and had histories of physical abuse.

This study is subject to limitations. It is restricted to one urban area within the United States and may not be representative of all community-based perceptions with regard to AI/AN youths who are receiving behavior services in the U.S. Nonetheless, this study provides valuable information with regard to community-based perspectives and recommendations as they relate to the mental health and substance abuse needs of urban AI/AN youths.

In conclusion, results from this study provide very valuable information as it relates to community-based perceptions of mental health and substance abuse treatment needs of urban AI/AN youths. It also provides specific community-based treatment recommendations for urban AI/AN youths with mental health and substance abuse problems. Further integration of traditional-based practices with westernized-based treatments, addressing accessibility to treatment, further outreach efforts, and research strategies aimed towards analyzing the potential benefits of traditional-based practices can all assist towards providing culturally-competent care for urban AI/AN youths with mental health and substance abuse problems.

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Daniel L. Dickerson, D.O., M.P.H. (a,b) & Carrie L. Johnson, Ph.D. (b)

(a) Addiction Psychiatrist, United American Indian Involvement, Inc., Los Angeles, CA, Assistant Research Psychiatrist, UCLA Integrated Substance Abuse Programs (ISAP), Los Angeles, CA.

(b) United American Indian Involvement, Inc, Los Angeles, CA.

Please address correspondence to Carrie L. Johnson, Ph.D., 1125 W. 6th Street, Suite 103, Los Angeles, CA 90017: phone: 213-202-3970; fax: 213-261-7130: email: drcjohnsn@aol.com

DOI: 10.1080/02791072.2011.629152
Gale Copyright: Copyright 2011 Gale, Cengage Learning. All rights reserved.