Clinician's corner: A call for ground-up and trauma-informed approaches in the development of alcohol interventions for North American Indigenous Peoples
Nicole H. Weiss, PhD & Nichea S. Spillane, PhD
December 13, 2023
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Alcohol is a primary determinant of health disparities facing North American Indigenous (NAI) peoples of the United States and Canada, including American Indian, Alaska Native, Native Hawaiian and other Native Pacific Islander peoples in the United States, and First Nations, Métis, Inuit and other Aboriginal peoples in Canada, among others. Rates of alcohol use among NAI peoples—while lower than or comparable to other racial and ethnic groups (Center for Behavioral Health Statistics and Quality, 2021)—are distinguished by more severe alcohol-related consequences. Indeed, NAI peoples have the highest rates of alcohol abstinence of all racial and ethnic groups yet exhibit the highest rates of binge and heavy drinking (Substance Abuse and Mental Health Services Administration, 2015), and lifetime (43.4%) and 12-month (19.2%) rates of alcohol use disorder are substantially higher for NAI peoples than for other racial and ethnic groups (Vaeth et al., 2017). Thus, reducing harm from alcohol use among NAI peoples is critical to addressing health disparities in this population.
Historical trauma has been identified as a key factor in the development, maintenance, and exacerbation of alcohol use among NAI peoples (for a review, see Spillane et al., in press). Historical trauma describes emotional and psychological wounding over the lifespan and across generations stemming from genocide, colonization and forced assimilation (Brave Heart, 1998). The mass traumas that NAI peoples have been subjected to have resulted in disruption and devastation of economic systems, sustenance practices, spiritual customs, kinship networks and family ties, causing historical losses of people, land, family and culture (Brave Heart, 1998; Brave Heart et al., 2011; Brave Heart & DeBruyn, 1998). The distinguishing characteristics of historical trauma—its widespread quality among NAI peoples, perpetration by outsiders with purposeful and destructive intent, and resultant collective distress in modern communities—makes historical trauma particularly devastating (Evans-Campbell, 2008). The historical trauma response (Brave Heart et al., 2011) is a constellation of physical, psychological and social problems related to this accumulated historical trauma (Walters et al., 2011), and includes responses at the individual (e.g., mental health), familial (e.g., parental stress) and community (e.g., breakdown of culture) levels (Evans-Campbell, 2008). These responses are transmitted intergenerationally as NAI peoples continue to identify with ancestral suffering (Sotero, 2006).
In terms of the relationship between historical trauma and alcohol use, prior to colonial contact, with the exception of specific ceremonies, alcohol was not used by NAI peoples (Brave Heart, 2003). However, acts of oppression stemming from colonization, such as the banning of traditional ways of healing, left NAI peoples without mechanisms for coping with emotional distress (Brave Heart, 1998). This, coupled with the emotional after-effects of mass cumulative trauma (e.g., sadness, shame), made NAI peoples vulnerable to developing maladaptive ways of coping. NAI peoples began using alcohol as a way of self-medicating to cope with trauma memories and related emotional pain (Brave Heart, 2003). This existing evidence points to the potential utility of targeting historical trauma in alcohol interventions for NAI peoples.
Consistent with recommendations in the literature for the concurrent treatment of trauma and alcohol use (Flanagan et al., 2016; Roberts et al., 2015), addressing historical trauma in alcohol interventions for NAI peoples may result in clinically meaningful reductions in alcohol-related harms. However, the research on interventions that target co-occurring trauma and alcohol use among NAI peoples is limited, and that which exists has relied on adaptations of empirically-validated interventions originally designed for non-NAI populations (e.g., adaptation of Seeking Safety to treat co-occurring posttraumatic stress and substance use) (Marsh, Cote-Meek, et al., 2016; Marsh, Young, et al., 2016). Approaches used to guide the development of culturally adapted interventions for co-occurring trauma and alcohol use are based on Western and individualistic paradigms (Kagawa-Singer et al., 2015; Walsh, 2014), and thus overlook the epistemological foundation that embodies NAI knowledge, protocols and practices (Walters et al., 2020). For instance, current adaptations often use decontextualized cultural add-ons such as replacing English words with tribal language (Walters et al., 2020). Moreover, few have been adequately adapted by and for NAI communities, and thus are not sufficiently culturally validated (Lucero, 2011). Adaptations that merely add NAI practices to Western structures of knowledge unknowingly diminish the power and valuing of NAI knowledge (West et al., 2012) and reflect a lack of appreciation and respect for efforts that communities may have developed using NAI ways of knowing to address historical trauma and alcohol use (Gone, 2013).
An alternative approach to intervention development is one that is culturally grounded and utilizes strengths that NAI peoples possess. Culturally grounded interventions move beyond adapting interventions drawn from Western-based theories by rooting intervention processes in Indigenous knowing, doing and being in the world (Martin & Mirraboopa, 2003), and reflect commitments toward the decolonization of the therapeutic endeavor (Gone, 2021). These approaches involve close collaboration among NAI communities and researchers in the design of intervention efforts rooted in NAI knowledge, protocols and practices from the “ground up.” Such interventions draw from cultural strengths, using NAI history, language, values and healing traditions as a way for NAI peoples to reclaim their cultural beliefs, practices and aspirations that promote health and well-being (Belone et al., 2017; Belone et al., 2016; Dutta, 2007). At their core, culturally grounded interventions aim to restore order to daily living in accordance with traditional cultural values (Castellano, 2014).
NAI communities have long advocated for health interventions designed for NAI peoples to be culturally grounded (Bassett et al., 2012) and strengths-based (Kana ‘iaupuni, 2005). This Clinician’s Corner column serves as a call to action for traumatic stress researchers, clinicians and policymakers to acknowledge and respond to these requests by amplifying NAI voices in the development, implementation and evaluation of health interventions for NAI peoples. We advocate for building authentic, collaborative and equitable partnerships with NAI communities to define intervention targets and identify intervention approaches and methods of delivery; to undercover unique experiential understanding and underlying values; and to build upon community strengths, resiliency and resources. By centering NAI knowledges and ways of being, we believe that culturally grounded interventions for co-occurring trauma and alcohol use have the potential to substantially improve the health and well-being of NAI peoples.
This research was supported by National Institute on Alcohol Abuse and Alcoholism Grant R34 AA028587, awarded to Nicole H. Weiss and Nichea S. Spillane.
About the Authors
Dr. Nicole Weiss is an Associate Professor in the Department of Psychology at the University of Rhode Island. Her program of research focuses on the co-occurrence of posttraumatic stress disorder (PTSD) and substance use disorder (SUD), including development, implementation and evaluation of culturally responsive and trauma-informed approaches for SUD.
Dr. Nichea Spillane is an Associate Professor in the Department of Psychology at the University of Rhode Island. Her research interests focus on risk and protective factors for alcohol and other drugs and using this to inform interventions in North American Indigenous peoples.
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