Behavioral Health Services for 

American Indians and Alaska Natives 

For Behavioral Health Service Providers, Administrators, and Supervisors 

TREATMENT IMPROVEMENT PROTOCOL 

TIP 61 
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BEHAVIORAL HEALTH SERVICES FOR TIP 61 AMERICAN INDIANS AND ALASKA NATIVES

Executive Summary 

For Behavioral Health Service Providers, Program Administrators, Clinical 

Supervisors, and Researchers 

The Executive Summary of this Treatment Improvement Protocol summarizes substance use and 

mental illness among American Indians and Alaska Natives and discusses the importance of delivering 

culturally responsive, evidence-based services to address these behavioral health challenges. 

TIP Navigation 

Executive Summary 

For behavioral health service providers, program administrators, clinical supervisors, and researchers 

Part 1: Practical Guide to the Provision of Behavioral Health Services for American Indians and 

Alaska Natives 

For behavioral health service providers 

Part 2: Implementation Guide for Behavioral Health Program Administrators Serving American 

Indians and Alaska Natives 

For behavioral health service providers, program administrators, and clinical supervisors 

Appendix and Index 

Part 3: Literature Review 

For behavioral health service providers, program administrators, clinical supervisors, and researchers 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Contents 

EXECUTIVE SUMMARY 

Foreword .................................................................. iii 

Introduction .................................................................v 

Overall Key Messages......................................................... vi 

Content Overview .......................................................... viii 

Terminology .................................................................x 

TIP Development Participants................................................. xiii 

Publication Information...................................................... xvi 

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Executive Summary TIP 61

Foreword 

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the U.S. Department of Health 

and Human Services agency that leads public health efforts to advance the behavioral health of the nation. 

SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities. 

The Treatment Improvement Protocol (TIP) series fulflls SAMHSA’s mission by providing science-based 

best-practice guidance to the behavioral health feld. TIPs refect careful consideration of all relevant clinical 

and health service research, demonstrated experience, and implementation requirements. Select nonfederal 

clinical researchers, service providers, program administrators, and client advocates comprising each TIP’s 

consensus panel discuss these factors, offering input on the TIP’s specifc topic in their areas of expertise to 

reach consensus on best practices. Field reviewers then assess draft content. 

The talent, dedication, and hard work that TIP panelists and reviewers bring to this highly participatory 

process have helped bridge the gap between the promise of research and the needs of practicing clinicians 

and administrators to serve, in the most scientifcally sound and effective ways, people in need of behavioral 

health services. We are grateful to all who have joined with us to contribute to advances in the behavioral 

health feld. 

Elinore F. McCance-Katz, M.D., Ph.D. 

Assistant Secretary for Mental Health and Substance Use 

SAMHSA 

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BEHAVIORAL HEALTH SERVICES FOR TIP 61 AMERICAN INDIANS AND ALASKA NATIVES

Executive Summary 

This Treatment Improvement Protocol (TIP) serves as a primer for working with individuals 

who identify with American Indian and Alaska Native cultures. It aims to help behavioral 

health service providers improve their cultural competence and provide culturally responsive, 

engaging, holistic, trauma-informed services to American Indian and Alaska Native clients. 

The TIP presents culturally adapted approaches for the prevention and treatment of 

addiction and mental illness, as well as counselor competencies for providing behavioral 

health services to American Indians and Alaska Natives. 

Introduction 

American Indians and Alaska Natives have 

consistently experienced disparities in access to 

healthcare services, funding, and resources; quality 

and quantity of services; treatment outcomes; 

and health education and prevention services. 

Availability, accessibility, and acceptability of 

behavioral health services are major barriers to 

recovery for American Indians and Alaska Natives. 

Common factors that infuence engagement and 

participation in services include availability of 

transportation and child care, treatment infrastructure, level of social support, perceived provider 

effectiveness, cultural responsiveness of services, 

treatment settings, geographic locations, and tribal 

affliations. 

In response to existing behavioral health disparities, 

this TIP illustrates strategies for facilitating American 

Indian and Alaska Native individuals’ access to 

and engagement in behavioral health services. 

It outlines promising practices for providers to 

apply in working with American Indians and Alaska 

Natives, and it includes tools and strategies that 

will help program administrators facilitate implementation of these practices. 

Through this TIP, behavioral health workers will 

learn to identify how and to what extent a client’s 

cultural background affects his or her behavioral 

health needs and concerns. It offers practical 

ideas and methods for addressing the realities of 

service delivery to American Indian and Alaska 

Native clients and communities, and it provides 

programmatic guidance for working with their 

communities to implement culturally responsive 

services. Throughout, the TIP emphasizes the 

importance of inclusivity, collaboration, and incorporation of traditional and alternative approaches 

to treatment and recovery support when working 

with American Indian and Alaska Native clients. 

This TIP was developed through a consensus-based 

process that refected intensive collaboration with 

American Indian and Alaska Native professionals. 

These professionals, who represented diverse 

tribes and native cultures, carefully considered 

all relevant clinical and research fndings, traditional and culturally adapted best practices, and 

implementation strategies. American Indian and 

Alaska Native contributors shared their behavioral 

health-related experiences and stories throughout the process, thereby greatly enriching this 

important resource. 

Audience 

This TIP can serve as a resource to both native and 

non-native behavioral health professionals who 

wish to provide culturally appropriate and responsive services. This TIP is for: 

• Addiction treatment/prevention professionals.

• Mental health service providers.

• Peer support specialists.

• Behavioral health program managers and

administrators.

• Clinical supervisors.

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TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

• Traditional healers.

• Tribal leaders of governance.

• Other behavioral health professionals (e.g.,

social workers, psychologists).

• Researchers and policymakers.

Objectives 

Addiction and mental health professionals will 

improve their understanding of: 

• American Indian and Alaska Native demographics, history, and behavioral health.

• The importance of cultural awareness, cultural

identity, and culture-specifc knowledge when

working with clients from diverse American

Indian and Alaska Native communities.

• The role of native culture in health beliefs,

help-seeking behavior, and healing practices.

• Prevention and treatment interventions based

on culturally adapted, evidence-based best

practices.

• Methods for achieving program-level cultural

responsiveness, such as incorporating American

Indian and Alaska Native beliefs and heritage

in program design, environment, and staff

development.

Overall Key Messages 

Importance of historical trauma. Providers should 

learn about, acknowledge, and address the effects 

of historical trauma when working with American 

Indian and Alaska Native clients. Most American 

Indians and Alaska Natives believe that historical 

trauma, including the loss of culture, lies at the 

heart of substance use and mental illness within 

their communities. 

Acceptance of a holistic view of behavioral 

health. Among many American Indian and Alaska 

Native cultures, substance use and mental illness 

are not defned as diseases, diagnoses, or moral 

maladies, nor are they viewed as physical or 

character faws. Instead, they are seen as symptoms 

of imbalance in the individual’s relationship with 

the world. Thus, healing and treatment approaches 

must be inclusive of all aspects of life—spiritual, 

emotional, physical, social, behavioral, and 

cognitive. 

Role of culture and cultural identity. Providers 

need to understand how clients perceive their 

own cultural identity and how they view the role of 

traditional practices in treatment. Not all American 

Indian and Alaska Native clients recognize the 

importance of culture or perceive a need for 

traditional practices in their recovery. Nonetheless, 

providers and administrators must be ready to 

address their clients’ cultural identity and related 

needs. Helping clients maintain ties to their native 

cultures can help prevent and treat substance use 

and mental disorders. Through reconnection to 

American Indian and Alaska Native communities 

and traditional healing practices, an individual 

may reclaim the strengths inherent in traditional 

teachings, practices, and beliefs and begin to walk 

in balance and harmony. 

Recognition of sovereignty. Tribal governments 

are sovereign nations. Each nation adopts its own 

tribal codes and has a unique history with the 

U.S. federal government. Providers in native and 

non-native programs need to understand the role 

of tribal sovereignty and governance systems in 

treatment referrals, planning, cooperative agreements, and program development. 

Signifcance of community. American Indian and 

Alaska Native clients and their communities must 

be given opportunities to offer input on the types 

of services they need and how they receive them. 

Such input helps match services to clients, increase 

community use of services, and use agency and 

tribal fnancial resources effciently. Providers must 

involve themselves in native community events 

and encourage native community involvement in 

treatment services. 

Value of cultural awareness. If providers are 

aware of their own cultural backgrounds, they 

will be more likely to acknowledge and explore 

how culture affects their interactions, particularly 

their relationships with clients of all backgrounds. 

Without cultural awareness, providers may discount 

the infuence of their own cultural contexts— 

including beliefs, values, and attitudes—on their 

initial and diagnostic impressions of clients and 

selection of healing interventions. 

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Executive Summary TIP 61

Culturally Specifc and 

Responsive Skills and Practices 

(North) 

Cultural 

Perspective Cultural 

on Behavioral Knowledge 

Health (East) 

(West) 

Cultural Awareness 

and Competence 

(South) 

Part 1: 

Providers 

Part 2: 

Administrators 

Part 3: 

Researchers 

Commitment to culturally responsive services. 

Organizations have an obligation to deliver 

high-quality, culturally responsive care across the 

behavioral health service continuum at all levels— 

individual, programmatic, and organizational. Not 

all American Indian or Alaska Native clients identify 

or want to connect with their cultures, but culturally 

responsive services offer those who do a chance 

to explore the impact of culture, history (including 

historical trauma), acculturation, discrimination, and 

bias on their behavioral health. 

Signifcance of the environment. An environment 

that refects American Indian and Alaska Native 

culture is more engaging for, and shows respect to, 

clients who identify with this culture. Programs can 

create a more culturally responsive ethos through 

adapted business practices, such as using native 

community vendors, hiring a workforce that refects 

local diversity, and offering professional development activities (e.g., supervision, training) that 

highlight culturally specifc American Indian and 

Alaska Native client and community needs. 

Respect for many paths. There is no one right 

way. Providing direction on how something should 

be done is not a comfortable or customary practice 

for American Indians and Alaska Natives. For them, 

healing is often intuitive; it is interconnected with 

others and comes from within, from ancestry, from 

stories, and from the environment. There are many 

paths to healing. 

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TIP 61

 

Behavioral Health Services for American Indians and Alaska Natives 

Content Overview 

Through this TIP, providers can explore how they 

interact with American Indian and Alaska Native 

clients and how they can incorporate culturally 

responsive ways of healing into their work. First, 

the TIP explores the basic elements of American 

Indian and Alaska Native cultures. Second, it emphasizes the importance of becoming aware of and 

identifying cultural differences between providers 

and clients. Third, it highlights native cultural 

beliefs about illness, help seeking, and health. 

Fourth, it offers culturally adapted, practice-based 

approaches and activities informed by science and 

the restorative power of native traditions, healers, 

and recovery groups. 

Part 1: Practical Guide to the Provision of 

Behavioral Health Services for American 

Indians and Alaska Natives 

Part 1 is for behavioral health service providers 

who work with American Indian and Alaska Native 

clients and communities to support their mental 

health and drug and alcohol recovery. 

Part 1 consists of two chapters. Part 1, Chapter 1, 

explains the background and context for Chapter 

2, so it is strongly recommended that readers 

examine it frst. Part 1, Chapter 1, includes: 

• A summary of American Indian and Alaska

Native history, historical trauma, and critical

cultural perspectives on such key topics as

health beliefs and help-seeking behaviors.

• An overview of American Indian and Alaska

Native demographics, social challenges, and

behavioral health issues.

• Strategies to expand providers’ cultural

awareness/competence and culture-specifc

knowledge.

• Specifc treatment interventions, including

traditional American Indian and Alaska Native

interventions and cultural adaptations of

standard treatment/prevention strategies.

Part 1, Chapter 2, content provides: 

• Several case histories in the form of story-based

vignettes that demonstrate specifc knowledge

and clinical skills necessary for providing effective

counseling to American Indians and Alaska

Natives across behavioral health settings.

• For each vignette, an outline of the client’s

presenting concerns and treatment needs,

provider–client dialog, and master provider

notes.

• Practical suggestions and guidance for key

stages in the provider–client relationship.

In Part 1, readers will learn that: 

• Not all native cultures are the same. Similarities

across native nations exist, but not all American

Indian and Alaska Native people have the same

beliefs or traditions.

• The use of diagnostic terminology in clinical

work with American Indian and Alaska Native

clients can be problematic, because the process

of “naming” can have signifcant spiritual

meaning and may infuence individual and

community beliefs about outcome.

• For hundreds of years and into the present,

American Indians and Alaska Natives have

endured traumatic events resulting from colonization. They and their communities continue to

experience repercussions (i.e., historical trauma)

from these events.

• American Indian and Alaska Native clients

experience grief for unique reasons, such as

loss of their communities, freedom, land, life,

self-determination, traditional cultural and

religious practices, and native languages, as well

as the removal of American Indian and Alaska

Native children from their families.

• Among American Indians and Alaska Natives,

historical loss is associated with greater risk for

substance abuse and depressive symptoms.

• Genes that increase risk of substance misuse

and related factors (e.g., tolerance, craving)

are no more common in American Indians and

Alaska Natives than in White Americans.

• Alcohol is the most misused substance among

American Indians and Alaska Natives, as well as

among the general population. Many American

Indians and Alaska Natives do not drink at all,

but binge drinking and alcohol use disorder occur

among native populations at relatively high rates.

• American Indians and Alaska Natives start

drinking and using other substances at a

younger age than do members of other major

racial or ethnic groups. Early use of substances

has been linked with greater risk for developing

substance use disorders.

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Executive Summary TIP 61

• Health is viewed holistically. American Indian

and Alaska Native cultures rarely make a distinction among physical, mental, emotional, and

spiritual health. One aspect of health is believed

to affect the others.

• Illness affects an American Indian or Alaska

Native individual’s community as well as the

individual. A health problem that affects one

person will have effects on a family, community,

tribe, and other individuals as well. This also

means that healing the community can positively

affect individual health.

• American Indian and Alaska Native clients’ ideas

about behavioral health interventions will likely

refect traditional healing, mainstream treatment

services, and mutual-help groups.

• American Indians and Alaska Natives use

behavioral health services at a rate second only

to White Americans; they may be even more

likely to use addiction treatment services.

Part 2: Implementation Guide for 

Behavioral Health Program Administrators 

Serving American Indians and Alaska 

Natives 

Part 2 is an implementation guide directed 

specifcally to administrators, program managers, 

and clinical and other supervisors. This part can 

also help providers who are interested in program 

development. Both chapters address programmatic 

features that can help foster culturally responsive 

treatment practices for American Indian and 

Alaska Native clients. Specifc topic areas include 

workforce development, culturally specifc considerations in program and professional development, 

and culturally responsive program policies and 

procedures. 

Part 2 consists of two chapters. Part 2, Chapter 1, 

content includes: 

• Approaches to fostering a culturally responsive

organization and workforce, as well as programmatic policies and procedures that beneft

American Indian and Alaska Native populations.

• Overviews of administrative challenges and

paths toward solutions.

• Methods for staff training, along with supporting

content on American Indian and Alaska Native

history and culture.

• Suggestions for supporting cross-cultural

supervisor–supervisee relationships.

• Criteria for evidence-based tribal behavioral

health practices.

• Provider competencies in attitudes, beliefs,

knowledge, and skills related to working with

American Indians and Alaska Natives.

Part 2, Chapter 2, content includes organizational 

tools to help administrators and program managers 

better serve American Indian and Alaska Native 

clients. The chapter offers tools for: 

• Developing a culturally competent and responsive

workforce.

• Developing culturally adapted and evidencebased practices.

• Integrating care to include traditional practices

in behavioral health services.

• Creating sustainability.

In Part 2, readers will learn that: 

• Facing serious health disparities has led to

poorer behavioral health outcomes among

American Indians and Alaska Natives compared

with the general population.

• Working with American Indian and Alaska Native

populations can pose challenges to implementing effective programs in remote communities

where clients have diffculty accessing services

because of a lack of service awareness, transportation, phone or Internet services, child care, or

insurance or healthcare fnancing.

• Engaging and establishing a positive relationship

with local native leaders and communities can

help alleviate initial feelings of mistrust among

American Indian and Alaska Native clients and

can strengthen your program’s effectiveness.

• Requesting programmatic input from tribal

partners can help administrators identify

potential obstacles early and develop culturally

appropriate ways to overcome challenges.

• Engaging with American Indian and Alaska

Native communities as partners helps programs

identify and make use of tribal resources and

strengths, such as family ties, large community

networks, physical resources, intergenerational

knowledge and wisdom, and community

resilience.

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TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

• Incorporating cultural adaptations into effective 

evidence-based practices is essential to avoid 

the perception among American Indians and 

Alaska Natives that these practices are mainstream, thus ignoring or failing to honor native 

practices, knowledge, and culture. 

• Training efforts should be specifc to the tribe(s) 

a program serves and should function within the 

constraints of the geographic region in which 

the program operates. 

• Fostering culturally informed professional 

development creates ripple effects. Staff 

members see such education as benefcial; 

training improves organizational functioning; 

clients have better treatment experiences 

and outcomes; acceptance of and respect for 

programs increase among native communities; 

thus, more American Indian and Alaska Natives 

seek services from such programs. 

• Providing cultural training and developing 

cultural competence form a main pathway in 

reducing health inequalities. We know that 

understanding tribal history and culture results 

in better healthcare communications with 

American Indian and Alaska Native clients 

and communities and improves outcomes. 

Part 3: Literature Review 

Part 3 content includes: 

• A literature review, intended for use by clinical 

supervisors, researchers, and interested 

providers and program administrators. It 

provides an indepth review of the literature 

relevant to behavioral health services for 

American Indians and Alaska Natives. 

• Links to selected abstracts, along with 

annotated bibliographic entries for resources 

that had no existing abstract available. 

• A general bibliography. 

Parts 1 and 2 are available in print and online in 

both PDF and HTML formats. Part 3 is available 

only online in PDF and HTML formats; you can 

access digital versions at https://store.samhsa.gov. 

USE OF DIAGNOSES WITH 

AMERICAN INDIAN AND 

ALASKA NATIVE CLIENTS 

Some providers working with American Indian 

and Alaska Native clients fnd diagnostic 

terminology in clinical work to be problematic 

because the process of “naming” can have 

spiritual signifcance and may have negative 

consequences for the individual, family, and 

community. For those reasons, providers should 

be careful when using such terminology with 

clients, although the use of such terminology 

may be essential in other clinical contexts. 

Terminology 

Before you read Part 1, Chapter 1, you will want 

to be familiar with the terms this TIP uses, along 

with explanations for why they are used. Of course, 

different people have different preferences; some 

people will prefer different terms. The intent and 

usage of these key terms are explained below. 

Clinical diagnostic terms (e.g., “substance use 

disorder,” “social anxiety disorder,” “major 

depressive disorder”) are used in accordance 

with defnitions in the Diagnostic and Statistical 

Manual of Mental Disorders, Fifth Edition (DSM-5; 

American Psychiatric Association [APA], 2013). 

American Indians and Alaska Natives. This 

TIP uses the term “American Indians and Alaska 

Natives” to refer to the indigenous peoples from 

the regions of North America now encompassed by 

the continental United States and Alaska. The term 

includes a large number of distinct tribes, pueblos, 

villages, and communities, as well as a number of 

diverse ethnic groups. On occasion, “native” or 

“Native American” is used for the sake of brevity, 

and this usage is not meant to demean the distinct 

heterogeneity of American Indian and Alaska 

Native people. The Native American peoples of the 

continental United States are known as American 

Indians, and those from Alaska are known as Alaska 

Natives. American Indians and Alaska Natives 

are considered distinct racial groups. In the U.S. 

Census, for example, the federal government 

considers American Indian and Alaska Native to be 

racial categories. However, this TIP is concerned 

with the cultural identity of American Indian 

and Alaska Native people. A person may have 

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Executive Summary TIP 61

American Indian and Alaska Native ancestry but 

very little cultural identifcation with it, or he or 

she may have a large percentage of non-native 

American ancestors but still identify as a member 

of his or her native culture. A number of other 

terms used to describe American Indian and Alaska 

Native people are not used in this TIP, including 

“Amerindians,” “Amerinds,” “Indian,” “Indigenous 

People,”“Aboriginal People,” and “First Nations” 

(the last two are commonly used in Canada). This 

TIP sometimes refers to people from other racial or 

ethnic groups as “non-native” for brevity’s sake. 

Behavioral health. The term “behavioral health” is 

used throughout this TIP. Behavioral health refers 

to a state of mental/emotional being and choices 

and actions that affect wellness. Behavioral health 

problems include substance use disorders, serious 

psychological distress, suicide, and mental illness. 

Such problems range from unhealthy stress to diagnosable and treatable diseases like serious mental 

illness and substance use disorders, which are 

often chronic in nature but from which people can 

and do recover. The term is also used in this TIP 

to describe the service systems encompassing the 

promotion of emotional health; the prevention of 

mental and substance use disorders, substance use 

and related problems; treatments and services for 

mental and substance use disorders; and recovery 

support. Because behavioral health conditions, 

taken together, are the leading causes of disability 

burden in the United States, efforts to improve 

their prevention and treatment will beneft society 

as a whole. Efforts to reduce the impact of mental 

and substance use disorders on America’s communities, such as those described in this TIP, will help 

achieve nationwide improvements in health. 

Cultural competence. This TIP uses the term 

“cultural competence” to describe the process in 

which services are delivered that are sensitive and 

responsive to the needs of the cultural group being 

served. Cultural competence is an ongoing process 

that involves developing an awareness of culture, 

cultural differences, and the role that culture 

plays in many different aspects of life, including 

behavioral health. TIP 59, Improving Cultural 

Competence (SAMHSA, 2014a), contains more 

information on cultural competence in a general 

sense, whereas this TIP discusses how to provide 

culturally responsive treatment to American Indians 

and Alaska Natives specifcally. It is worth noting 

that there is no single Native American culture, but 

rather many hundreds of diverse cultures with their 

own languages, traditions, beliefs, and practices, 

and providers must try to understand the cultures 

of all the clients they serve. 

Culture. The term “culture” is defned in this TIP as 

the product of a shared history and includes shared 

values, beliefs, customs, traditions, institutions, 

patterns of relationships, styles of communication, 

and similar factors (Castro, 1998). An individual 

may belong to more than one culture or cultural 

subgroup and may not accept all the values and 

beliefs of his or her primary culture, but culture will 

play a role in defning the individual’s basic values 

and beliefs. TIP 59 (SAMHSA, 2014a) has more 

information on how cultures work and their importance in behavioral health services. 

Indian Country. The term “Indian Country” is often 

narrowly defned in legal terms. In this context, the 

term includes reservations, native communities, 

Indian allotments located inside or outside reservations, towns incorporated by non-native people if 

they fall within the boundaries of an Indian reservation, and trust lands. This includes lands held 

by federal, state, or local (nontribal) governments, 

such as wildlife refuges, as well as sacred sites that 

are not on tribal lands. Many American Indians 

and Alaska Natives use the term more broadly to 

include any native community, independent of land 

designation, this TIP uses the term in that sense. 

Medicine versus healing practices. Traditional 

healers may be referred to as “medicine men” and 

“medicine women,” but to avoid confusion among 

different meanings of “medicine,” this TIP refers 

to American Indian and Alaska Native healing 

practices rather than to medicine. 

Provider and client. The TIP refers to someone 

who provides behavioral health services as a 

“provider” and someone who receives them as 

a “client.” These terms are not intended to be 

pejorative in any way or to reduce the relationship 

between the two to a purely business relationship; 

they are merely intended to highlight the fact 

that a client is someone seeking a service from a 

provider and that the provider has a responsibility 

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TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

to provide the service that the client requests. The 

consensus panel invested considerable energy in 

selecting the most appropriate terminology when 

referring to providers and clients. Members gave 

voice to traditions and beliefs surrounding healing, 

as well as some traditions established within behavioral health programs. Different programs may 

use different terms, and different terms may be 

used for providers with different roles (e.g., “psychiatrist,” “counselor,” “prevention specialist”). 

Certain programs refer to individuals as “relative,” 

“family,” or “cousin,” regardless of whether 

they are the provider or client. Some American 

Indian and Alaska Native programs use the term 

“participant” rather than “client” and “counselor” 

rather than “provider.” This TIP generally uses the 

term “provider” rather than “counselor,” except 

in specifc examples where “counselor” is appropriate. As you read the document, recognize that 

there are certain phrases in the English language 

that would or could be perceived as paternalistic. 

For example, the term “your client” occurs a 

few times. This phrase is not meant to denote 

ownership or to reinforce paternalistic attitudes, 

but rather to reference the specifc clients that the 

provider is working with in the healing process. 

Substance abuse. The term “substance abuse” 

is used to refer to both substance abuse and 

substance dependence. This term was chosen 

partly because it is commonly used by substance 

abuse treatment professionals to describe any 

excessive use of addictive substances. In this TIP, 

the term refers to use of alcohol as well as other 

substances of abuse. Readers should note the 

context in which the term occurs to determine its 

meanings. In most cases, however, the term will 

refer to all varieties of substance use disorders 

described by DSM-5 (APA, 2013). The term 

“addictive disorders” is used to describe other 

mental disorders that are now classifed under 

the category “Substance-Related and Addictive 

Disorders” in DSM-5 (APA, 2013), including 

tobacco use disorder and gambling disorder. 

Traditional versus mainstream. When referring 

to American Indian and Alaska Native cultures, 

this TIP uses the adjective “traditional,” which is 

widely used by native people to refer to their own 

cultures. The term is not intended to imply that 

such cultures are static or out of date, but merely 

that American Indian and Alaska Native traditions 

reside in those cultures. This TIP uses the term 

“mainstream” to refer to the American culture 

that is endorsed by the majority of Americans. 

American society is pluralistic, and many diverse 

cultures contribute to that mainstream culture 

(including American Indian and Alaska Native 

cultures); for this reason, the TIP avoids terms 

like “European culture.” The term “mainstream” 

also avoids the hierarchy implied by terms such as 

“dominant culture.” 

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Executive Summary TIP 61

TIP Development Participants 

Consensus Panel 

Each Treatment Improvement Protocol’s (TIP’s) consensus panel is a group of primarily nonfederal behavioral 

health-focused clinical, research, administrative, and recovery support experts with deep knowledge of the 

TIP’s topic. With the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Knowledge 

Application Program (KAP) team, they develop each TIP via a consensus-driven, collaborative process that 

blends evidence-based, best, and promising practices with the panel’s expertise and combined wealth of 

experience. 

Consensus Panel Chair 

Pamela Jumper Thurman, Ph.D. 

Western Cherokee 

Senior Research Scientist/Director 

Commitment to Action for 7th Generation 

Awareness and Education 

National Center for Community Readiness 

Colorado State University 

Fort Collins, CO 

Part 1 Consensus Panelists 

Raymond Daw, M.A. 

Navajo 

Gamerco, NM 

Elaine Mzhickteno Barr, LMSW, CADC 

Prairie Band Potawatomi 

Alcohol and Drug Counselor 

Prairie Band Potawatomi Nation Health Clinic 

Mayetta, KS 

Shannon Sommer 

Koyukon Athabascan 

Director, Recovery Services 

Cook Inlet Tribal Council 

Anchorage, AK 

Sandra Stroud 

Choctaw Nation of Oklahoma 

Assistant Director 

Chi Hullo Li Treatment Center 

Talihina, OK 

Kamilah L. Venner, Ph.D. 

Athabascan 

Assistant Professor 

Department of Psychology 

Research Assistant Professor 

Center on Alcoholism, Substance Abuse and 

Addictions 

University of New Mexico 

Albuquerque, NM 

Raymond Watson 

Yup’ik Eskimo 

Director of Adult Rehabilitative Services 

Yukon Kuskokwim Health Corporation 

Bethel, AK 

Don Wetzel, Jr., M.A. 

Blackfeet 

Director 

Planting Seeds of HOPE/IT 

Montana–Wyoming Tribal Leaders Council 

Billings, MT 

Part 2 Consensus Panelists 

Mary Helen Deer, RN 

Kiowa Tribe of Oklahoma and Muscogee Creek 

Nation 

Health Consultant 

Oklahoma City, OK 

Victor Joseph 

Tanana Chiefs Conference (TCC) 

TCC Health Services Director 

Fairbanks, AK 

Duane H. Mackey, Ed.D. 

Santee Sioux Tribe of Nebraska 

Assistant Professor and PATTC-SD Coordinator 

University of South Dakota 

Vermillion, SD 

Eva L. Petoskey, M.S. 

Grand Traverse Band of Ottawa and 

Chippewa Indians 

Director 

Anishnaabek Access to Recovery 

Inter-Tribal Council of Michigan 

Sault St. Marie, MI 

xiii 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Stakeholders Meeting Participants 

Stakeholders represent a cross-section of key audiences with a deep interest in a TIP’s subject matter. 

Stakeholders review and comment on the draft outline and supporting materials for the TIP to ensure that 

its focus is clear, its stated purpose meets an urgent need in the feld, and it will not duplicate existing 

resources produced by the federal government or other entities. 

Chair 

Pamela Jumper Thurman, Ph.D. 

Western Cherokee 

Senior Research Scientist/Director 

Commitment to Action for 7th Generation 

Awareness and Education 

National Center for Community Readiness 

Colorado State University 

Fort Collins, CO 

Stakeholders Meeting Participants 

Christina Currier 

Government Project Offcer 

Knowledge Application Program 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, MD 

Dorothy A. Dupree 

Director of Tribal Affairs 

Offce of External Affairs 

Centers for Medicare and Medicaid Services 

Baltimore, MD 

Ginny Gorman-Gipp 

Senior Advisor for Tribal Affairs 

Offce of the Administrator 

Substance Abuse and Mental Health Services 

Administration 

Rockville, MD 

Jaime Hale 

Assistant for Legislation and Policy 

National Indian Health Board 

Washington, DC 

Richard Kopanda, M.A. 

Deputy Director 

Substance Abuse and Mental Health Services 

Administration 

Rockville, MD 

Jack Stein, Ph.D., M.S.W. 

Director 

Offce of Science Policy and Communications 

National Institute on Drug Abuse 

Rockville, MD 

Wilbur Woodis 

Management Analyst 

Indian Health Service 

Rockville, MD 

Brenda Woods-Francis 

Public Health Analyst 

Health Resources and Services Administration 

HIV/AIDS Bureau 

Division of Training and Technical Assistance 

Rockville, MD 

Michael Yesenko 

Public Health Advisor 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, MD 

xiv 
Executive Summary TIP 61

Field Reviewers 

Field reviewers represent each TIP’s intended target audiences. They work in addiction, mental health, 

primary care, and adjacent felds. Their direct front-line experience related to the TIP’s topic allows them 

to provide valuable input on a TIP’s relevance, utility, accuracy, and accessibility. 

Sean Bear, CADC 

Meskwaki Tribal Nation 

Senior Behavioral Health and Training Coordinator 

National American Indian and Alaska Native 

Addiction Technology Transfer Center 

University of Iowa 

Iowa City, IA 

Elaine Mzhickteno Barr, LMSW, CADC 

Prairie Band Potawatomi 

Alcohol and Drug Counselor 

Prairie Band Potawatomi Nation Health Clinic 

Mayetta, KS 

Raymond Daw, M.A. 

Navajo 

Behavioral Health Administrator 

Yukon-Kuskokwim Healthcare Corporation 

Bethel, AK 

Teresa Evans-Campbell, Ph.D., M.S.W. 

Snohomish Tribe of Indians Associate 

Associate Professor, School of Social Work 

Indigenous Wellness Research Institute 

University of Washington 

Seattle, WA 

Delores Ann Jimerson, M.S.W., LCSW 

Seneca, Bear Clan 

Integrated Care Mental Health Counselor 

Yellowhawk Circles of Hope Suicide Prevention 

Project 

Pendleton, OR 

Billie Jo Kipp, Ph.D. 

Blackfeet 

President 

Blackfeet Community College 

Browning, MT 

CAPT Cheryl A. LaPointe, M.A., M.P.H. (Ret.) 

Rosebud Sioux Tribe 

Lead Evaluator 

Tiwahe Glu Kini Pi ‘Bringing the Family Back to Life’ 

System of Care Project 

Sinte Gleska University 

Mission, SD 

Laura Fenster Rothschild, Psy.D. 

Director, Education and Training 

Rutgers University, Center of Alcohol Studies 

New Brunswick, NJ 

Anne Helene Skinstad, Ph.D. 

Program Director 

National American Indian and Alaska Native 

Addiction Technology Transfer Center 

University of Iowa, College of Public Health 

Iowa City, IA 

Sharon Tomah, LCSW 

Passamaquoddy: A Wabanaki Tribe of Eastern 

Maine 

Executive Director 

Wabanaki Health Wellness, NPC 

Bangor, ME 

Kamilla Venner, Ph.D. 

Athabascan 

Assistant Professor of Psychology 

University of New Mexico 

Albuquerque, NM 

Keja Nokomis Whiteman 

Turtle Mountain Band of Chippewa Indians 

Executive Director 

Alaska Native Village Corporation Association 

Anchorage, AK 

xv 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives

Publication Information 

Acknowledgments 

This publication was prepared under contract numbers 270-04-7049, 270-09-0307, and 270-14-0445 by the 

Knowledge Application Program (KAP) for the Center for Substance Abuse Treatment, Substance Abuse and 

Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). 

Christina Currier and Suzanne Wise served as the Contracting Offcer’s Representatives, and Candi Byrne 

served as KAP Project Coordinator. 

Special thanks go to Pamela Jumper Thurman (Western Cherokee), TIP Chair and content contributor; Betty 

Poitra (Turtle Mountain Band of Chippewa) and Stephanie Autumn (Hopi Tribe), content contributors; Kauffman 

and Associates, content contributors; and the many consensus panelists and other American Indian and Alaska 

Native people from various tribes who contributed stories, ideas, and feedback during the development of this TIP. 

Disclaimer 

The views, opinions, and content expressed herein are the views of the consensus panel members and do not 

necessarily refect the offcial position of SAMHSA or HHS. No offcial support of or endorsement by SAMHSA 

or HHS for these opinions or for the instruments or resources described is intended or should be inferred. The 

guidelines presented should not be considered substitutes for individualized client care and treatment decisions. 

Public Domain Notice 

All materials appearing in this volume except those taken directly from copyrighted sources are in the public 

domain and may be reproduced or copied without permission from SAMHSA or the authors. Citation of the 

source is appreciated. However, this publication may not be reproduced or distributed for a fee without the 

specifc, written authorization of the Offce of Communications, SAMHSA, HHS. 

Electronic Access and Copies of Publication 

This publication may be ordered or downloaded from SAMHSA’s Publications Ordering webpage at https:// 

store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español). 

Recommended Citation 

Substance Abuse and Mental Health Services Administration. Behavioral Health Services for American 

Indians and Alaska Natives. Treatment Improvement Protocol (TIP) Series 61. HHS Publication No. (SMA) 18-

5070EXSUMM. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2018. 

Originating Ofce 

Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center for 

Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, 

Rockville, MD 20857. 

Nondiscrimination Notice 

SAMHSA complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, 

national origin, age, disability, or sex. SAMHSA cumple con las leyes federales de derechos civiles aplicables y no 

discrimina por motivos de raza, color, nacionalidad, edad, discapacidad, o sexo. 

SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities. 

1-877-SAMHSA-7 (1-877-726-4727) • 1-800-487-4889 (TDD) • www.samhsa.gov
TIP 61 BEHAVIORAL HEALTH SERVICES FOR 

AMERICAN INDIANS AND ALASKA NATIVES

Part 1: Practical Guide to the Provision of Behavioral Health Services 

for American Indians and Alaska Natives 

For Behavioral Health Service Providers 

Part 1 of this Treatment Improvement Protocol addresses historical trauma among American Indians 

and Alaska Natives. It describes native perspectives on help-seeking behaviors. It also presents 

culturally adapted strategies for the prevention and treatment of addiction and mental illness. 

TIP Navigation 

Executive Summary 

For behavioral health service providers, program administrators, clinical supervisors, and researchers 

Part 1: Practical Guide to the Provision of Behavioral Health Services for American Indians and 

Alaska Natives 

For behavioral health service providers 

Part 2: Implementation Guide for Behavioral Health Program Administrators Serving American 

Indians and Alaska Natives 

For behavioral health service providers, program administrators, and clinical supervisors 

Appendix and Index 

Part 3: Literature Review 

For behavioral health service providers, program administrators, clinical supervisors, and researchers 
TIP 61

 

 

 

: GUIDE FOR PROVIDERS SERVING AMERICAN INDIANS AND 

ALASKA NATIVES 

PART 1

Behavioral Health Services for American Indians and Alaska Natives 

Contents 

Part 1, Chapter 1 5 

Introduction 5 

Choosing a Path for Your Learning Journey 11 

Beginning in the East: The Direction of Cultural Knowledge 13 

Moving to the South: The Direction of Cultural Awareness and Competence 34 

Continuing West: Cultural Perspective on Behavioral Health 42 

Arriving in the North: The Direction of Culturally Specifc and Responsive 

Skills and Practices 49 

Part 1, Chapter 2 69 

Introduction 69 

Vignette 1—Vicki: Establishing Relationships, Acknowledging the Past, 

and Choosing Treatment 74 

Vignette 2—Joe: Addressing Methamphetamine Dependence, Reconnecting 

With Family, and Recovering on the Reservation 86 

Vignette 3—Marlene: Facilitating Support, Creating Family Connections, 

Honoring Traditional Ways, and Recovering in Remote Alaska Villages 96 

Vignette 4—Philip: Making Connections Between Losses and Alcohol Use, 

Using One-Stop Outreach and Case Management Services for Homelessness 

and Treatment Service Needs, and Building Relationships Using Traditional 

Practices in Recovery 110 

Exhibits 

Exhibit 1 1-1 Timeline of Signifcant Events in Native American History 17 

Exhibit 1 1-2 Cycle of Historical Trauma 21 

Exhibit 1 1-3 Cycle of Assimilation and Reconnection 30 

Exhibit 1 1-4 Traditional American Indian and Alaska Native Values and Beliefs 37 

Exhibit 1 1-5 Examples of Culturally Adapted Treatment Approaches 61 

Exhibit 1 2-1 Vignette Summary Table 71 

Exhibit 1 2-2 The Stages of Change Model 93 

2 
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Part 1, Chapter 1 

TIP 61 BEHAVIORAL HEALTH SERVICES FOR 

AMERICAN INDIANS AND ALASKA NATIVES

Introduction 

This Treatment Improvement Protocol (TIP) is 

designed to assist you, the provider or program 

administrator, in working with and providing culturally responsive services to American Indian and 

Alaska Native clients in behavioral health service 

settings. This manual is addressed to all kinds of 

behavioral health service providers—counselors, 

outreach workers, prevention specialists, healthcare 

professionals, psychologists, program managers, 

and administrators—whose work is directly or 

indirectly concerned with supporting American 

Indian and Alaska Native clients and communities in 

recovery from mental illness and substance abuse. 

This manual, using guidance from consensus 

panels, weaves together practice-based experience with available published resources and 

research relevant to behavioral health in American 

Indians and Alaska Natives. A group of respected 

American Indian and Alaska Native behavioral 

health service providers, clinical directors, researchers, and administrators from across Indian Country 

formed the clinical- and administrative-focused 

consensus panels; their contributions shaped the 

development and content of this TIP. 

This TIP begins with a demographic, historical, and 

cultural overview of American Indians and Alaska 

Natives, laying the necessary groundwork that 

supports the dialog, suggestions, and resources 

that follow. This TIP can serve as a resource to 

both native and non-native providers in providing 

culturally appropriate and responsive services. By 

emphasizing the strengths of native cultures and 

reinforcing the importance of a holistic perspective 

in the etiology and treatment of substance use and 

mental disorders, it will help dispel the myths and 

stereotypes about American Indians and Alaska 

Natives. 

This TIP Is for You, the Behavioral Health 

Services Provider 

If you want to refect on your work and enhance 

your cultural competence in relationships with your 

American Indian and Alaska Native clients, this TIP 

is for you. If you are new to working with American 

Indian and Alaska Native clients, or if you fnd that 

your usual approaches to providing treatment 

services just do not seem to work as well with these 

clients, you are also the person for whom this TIP 

has been developed. 

You know your work, and you are likely good at 

it. You may assume that your clients see you as 

credible because you have earned your position; 

you have credentials that speak to your skill in 

helping people recover from mental and substance 

use disorders and maintain that recovery. Much of 

the time, this is suffcient for your clients to trust 

you enough to beneft from the help you offer 

them. 

Yet, somehow, you may sense that this is not 

enough for many of your American Indian and 

Alaska Native clients. Your credentials seem less 

important to them than their assessment of you 

and of your ability to help them. The fact that you 

have opened this TIP says that you care about their 

perceptions. You want to help your clients, and if 

there are things you can learn that will help you 

earn the trust of your clients, you want to learn 

them. 

Providing behavioral health services to members of 

a culture that is different from your own is not easy 

to do well. Grasping the nuances of another culture 

requires cultural self-awareness and the patience 

to learn, understand, and respect the expressions 

of the culture that you see and hear. Your curiosity 

about what you could do differently to be more 

effective with American Indian and Alaska Native 

5 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

clients in a way that works for them is a genuine 

asset. What is different about these clients that 

you need to better understand? How can developing your understanding help you provide more 

effective support, counseling, and treatment? 

This TIP will explore several responses to these 

questions. 

Why a TIP on Working With American 

Indian and Alaska Native Clients in 

Behavioral Health? 

American Indians and Alaska Natives have persistently experienced serious health disparities in 

access to care, funding, and resources for health 

services. They face disparities in the quality and 

quantity of services, treatment outcomes, and 

health education and prevention services. The 

availability, accessibility, and acceptability of 

services are all major barriers to substance abuse 

and mental health services for American Indian and 

Alaska Native people. Rural and remote areas often 

lack treatment infrastructure, and American Indian 

or Alaska Native individuals will sometimes delay 

seeking available care in part because they do not 

trust organizations. Other factors that infuence 

participation include transportation, level of social 

support, perceived provider effectiveness, type of 

treatment setting, geographic location, and tribal 

affliation. 

In response to existing behavioral healthcare 

disparities, this TIP illustrates strategies for facilitating access to and engagement in treatment 

and describes promising practices for working 

with American Indians and Alaska Natives. It also 

provides tools and strategies for administrators 

to facilitate implementation of these practices. 

This TIP helps behavioral health service providers 

identify how and to what extent an individual’s 

cultural background can affect his or her needs 

and concerns. It gives providers and administrators 

practical ideas and methods to deal with the 

realities of service delivery to American Indian and 

Alaska Native clients and communities. 

Culturally responsive treatment 

requires establishing a standard of 

respect, focusing on strengths, and 

addressing underlying personal and 

historical trauma issues as appropriate 

(see defnition on pages 20–21). 

Traditional interventions (both client 

centered and community centered) 

and care that are integrated with 

mainstream treatment methods are 

recognized as best practices for native 

communities. 

Did You Know? 

• Practicing many cultural traditions was illegal 

for American Indians and Alaska Natives from 

1878 until 1978, often resulting in imprisonment 

and fnes for those who broke the law. Today, 

many tribes are working to restore important 

and protective cultural practices in their communities. These cultural practices are a pathway to 

prevention and healing. 

• Although some professionals have suspected 

that genetic factors play a part in the high rates 

of substance abuse among American Indians 

and Alaska Natives who use alcohol or drugs, 

this is incorrect. There are no genetic factors 

unique to Native Americans that are associated 

with high rates of substance use. 

• Suicide and suicide attempts are a signifcant 

problem in many American Indian and Alaska 

Native communities, especially among young 

men ages 15–24, who account for nearly 40 

percent of all suicide deaths among natives. 

Native youth have a much higher suicide rate 

than youth or adults of other races. Suicide rates 

for Alaska Natives are more than double those 

for the U.S. population as a whole. 

• American Indians and Alaska Natives are less 

likely to drink than White Americans; however, 

those who do drink are more likely to binge 

drink and to have a higher rate of past-year 

alcohol use disorder than other racial and ethnic 

groups. 

6 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

• American Indians and Alaska Natives are more 

likely than White Americans or Latinos to abstain 

from alcohol and drugs. Among people who 

have been drinkers, American Indians and 

Alaska Natives are about three times more likely 

to have become abstainers than are former 

drinkers in the general population. 

• American Indians and Alaska Natives experience some mental disorders at a higher rate 

than other Americans (e.g., anxiety disorders). 

Although results vary, some research has found 

that Native Americans are less likely to have 

other disorders (e.g., major depression). 

• American Indians and Alaska Natives seek 

mental health services at a rate second only to 

that of White Americans and may be even more 

likely than White Americans to seek help, if one 

takes into account that many consult traditional 

healers for such problems. American Indians and 

Alaska Natives appear to be more likely than 

all other major racial and ethnic groups to seek 

substance abuse treatment services. 

• Likely reasons for today’s high rates of substance 

use, suicide, violence, and domestic abuse 

among American Indians and Alaska Natives lie 

in the fact that their communities are exposed 

to a greater degree to the same risk factors that 

are predictors of problems for everyone, such as 

poverty, unemployment, and trauma (including 

historical trauma), as well as loss of cultural 

traditions. 

• Many American Indians and Alaska Natives 

report experiencing at least one traumatic event 

in their lifetimes, and all Native Americans have 

been affected by historical trauma across generations (sometimes referred to as “intergenerational trauma”). 

• American Indian and Alaska Native women 

report higher rates of victimization than women 

from any other racial or ethnic group in the 

United States. For example, American Indian 

and Alaska Native women are nearly twice as 

likely to be raped or sexually assaulted than 

are White or African American women. Nearly 

80 percent of sexual assaults against Native 

American women are committed by non-native men (see Amnesty International, 2007; 

Bachman, Zaykowski, Kallmyer, Poteyeva, & 

Lanier, 2008; Tjaden & Thoennes, 2006). 

• Although more than 70 percent of American 

Indians live in urban areas, many maintain strong 

ties to their home reservations, making frequent 

visits and moving back and forth from cities to 

tribal lands. 

Native American individuals have 

historical cause to wonder whether 

behavioral health service providers 

will recognize them for who they are, 

respect them, and offer assistance 

in walking their life path. History has 

taught tribes that it is dangerous 

to trust outsiders. Their people’s 

lives—the lives of their parents and 

grandparents—have been taken or 

forever altered by outsiders. 

Before You Begin 

This TIP addresses the more common treatment 

needs of American Indians and Alaska Natives with 

behavioral health issues. However, the treatment 

concerns and pathways to healing presented in 

this manual will not—and cannot—equally and 

effectively represent all American Indian or Alaska 

Native individuals, communities, and tribes. There 

is simply much more diversity among American 

Indian and Alaska Native people than can be 

fairly represented here. Instead, the material can 

serve as a starting place, and you can adapt it 

to meet the unique attributes of each client and 

each client’s cultural identity, treatment setting, 

community, and culture. 

There are many distinct Native American cultures, 

and recognizing the diversity among tribes is 

important. Although clear similarities across native 

nations exist, especially when compared with 

mainstream American culture, not all American 

Indians and Alaska Natives hold the same beliefs 

or practice the same traditions. This also holds 

true for views on substance use and mental health, 

attitudes toward and beliefs about help-seeking, 

and treatment for mental and substance use 

disorders. Therefore, you as a provider must frst 

Chapter 1 7 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

invest in learning about and understanding the 

population and culture that you serve prior to 

selecting and adapting the material presented in 

this manual. 

Some providers working with American Indian and 

Alaska Native clients fnd the use of diagnostic terminology in clinical work problematic, because the 

process of “naming” can have spiritual signifcance 

and may infuence what is thus named. Providers 

should be careful when using such terminology 

with clients, although it may be essential in other 

clinical contexts. 

The consensus panels expressed concern about 

the possible misuse of sacred ceremonies and 

traditional practices; therefore, to preserve and 

respect native ceremonies and heritage, no 

specifc ceremonies are cited in detail. Without 

forethought, non-native providers may exploit 

native healing modalities by practicing traditional 

healing methods with clients. To avoid misuse of 

native healing modalities, native and non-native 

providers should rely on the community and native 

tribal council (governance) to guide the selection 

of traditional practitioners and the integration of 

traditional healing practices across the continuum 

of care. The consensus panels also agreed that 

identifying tribal affliations for specifc client case 

studies or examples could increase the risk of 

mistaken identifcation of individuals from a smaller 

tribe or a misrepresentation of tribal values and 

ways. 

A thorough online literature review in Part 3 

supports the manual. Parts 1 and 2 of this TIP 

use minimal citations to produce a user-friendly 

document, yet we recommend that you read 

the literature review. If you are interested in 

references associated with the presenting topics, 

please consult the literature review at https:// 

store.samhsa.gov. To complement the materials 

presented in this TIP, the consensus panel suggests 

that providers, including counselors, other clinical 

staff members, program directors, and administrators, read TIP 59, Improving Cultural Competence 

(Substance Abuse and Mental Health Services 

Administration [SAMHSA], 2014a). 

Consensus Panel Perspectives 

Throughout the consensus process, several themes 

emerged from many conversations, as well as 

shared experiences and stories among panel 

members. As you read and refect on the material 

presented in this manual, keep these core concepts 

at the center of your attention and let them guide 

your practice. 

Importance of historical trauma. As a provider, 

you should recognize, acknowledge, and address 

the effects of historical trauma in the treatment 

process (see the section in Part 1, Chapter 1, titled 

“The Importance of History for American Indian 

and Alaska Native Behavioral Health”). Although 

native people across North America share similar 

experiences of loss and trauma, each tribe has 

its own story of contact with Europeans. Most 

American Indians and Alaska Natives believe that 

historical trauma, including the loss of culture, lies 

at the heart of substance use and mental disorders 

within their communities. Typically, providers 

consider it important to obtain clients’ psychosocial history prior to any medical or psychological 

treatment and place less emphasis on addressing 

the history and role of trauma. However, in 

treatment for American Indians and Alaska Natives, 

it is critical to incorporate the role of historical 

trauma in assessments, in developing treatment 

plans, and in implementing healing strategies. 

Acceptance of a holistic view of behavioral 

health. The view of substance use and mental 

disorders—their defnition and nature—among 

American Indian and Alaska Native people is 

markedly different from mainstream beliefs. 

Among many Native Americans, substance use 

and mental disorders are not defned as diseases, 

diagnoses, or moral maladies; they are not physical 

or character faws. Instead, substance abuse is 

seen as a symptom, refecting an imbalance in the 

individual’s relationship with the world. Keeping 

with this holistic worldview, healing and treatment 

approaches need to be inclusive of all aspects of 

life—both seen and unseen—incorporating the 

spiritual, emotional, physical, social, behavioral, 

and cognitive. No one aspect is separate from the 

others, and all provide a path to recovery, with 

room to embrace traditional healing and mainstream treatment practices along the way. 

8 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

Role of culture and cultural identity. Mental and 

substance use disorders are frequently seen as 

the consequences of culture loss among American 

Indian and Alaska Native communities. Maintaining 

ties to one’s culture can help to prevent and treat 

substance use and mental disorders; thus, healing 

can come from reconnecting. Through reconnection to native communities and traditional healing 

practices, an individual may reclaim the strengths 

inherent in traditional teachings, practices, and 

beliefs and begin to walk in balance and harmony. 

In translating this belief into practice, initial 

interviews and assessments need to be culturally 

responsive (e.g., inquiring about the client’s involvement in traditional and healing practices). 

Providers need to understand how clients perceive 

their own cultural identity and how they view 

the role of traditional practices in treatment. 

Providers need to adapt treatment planning to 

match clients’ needs and treatment preferences. 

Not all American Indian and Alaska Native clients 

recognize the importance of culture or perceive 

a need for traditional practices in their recovery. 

Nonetheless, providers and treatment programs 

must be fexible to match their clients’ needs, 

rather than expecting the client to adapt to match 

the treatment program, regardless of whether it is 

native or non-native. 

Recognition of sovereignty. Tribal governments 

are sovereign nations. Each nation adopts its 

own tribal codes and has a unique history with 

the federal government. Providers in native and 

non-native programs need to understand the role 

of tribal sovereignty and governance systems in 

treatment referrals, planning, cooperative agreements, and program development. 

Signifcance of community. Creating culturally 

responsive services requires the participation of 

the native community, including leaders (formal 

and informal), councils, clients, potential clients, 

and client families. Even though it may appear less 

time consuming, complex, and expensive to avoid 

community participation, doing so represents an 

example of paternalism, in which the administrators 

or providers assume that they inherently know 

what is best for the program, client, staff, and 

community. 

Instead, clients and the community should have 

an opportunity to provide input on the type 

of services needed and how those services are 

rendered. Without this information, services may 

be poorly matched to clients and underused by the 

community, and may further drain the agency’s and 

tribe’s fnancial resources. For example, providers 

may overlook that the program location offers 

minimal privacy for clients seeking help, especially 

in rural and reservation settings. Unbeknownst to 

providers, clients may be reluctant to drive and 

park at the building for fear of being seen. With 

community involvement, providers are more likely 

to learn of potential obstacles and plan accordingly. 

Additionally, American Indian and Alaska Native 

beliefs revolve around the value of connectedness 

and the importance of relationships. If providers do 

not build relationships or demonstrate interests in 

the community, the native community may be less 

accepting of the services offered. Providers need 

to take time to be involved in community events 

and to create ways to encourage community 

involvement in treatment services. 

Value of cultural awareness. Providers who have a 

general understanding of how culture affects their 

own worldview (as well as that of their clients) will 

be able to work more effectively and be better 

equipped to respect clients who have diverse belief 

systems. If providers are cognizant of their own 

cultural backgrounds, they will be more likely to 

acknowledge and explore how culture affects their 

interactions, particularly their relationships with 

clients. 

Without cultural awareness, providers may offer 

counseling that ignores or does not address issues 

that relate specifcally to race, ethnic heritage, 

and culture. This lack of awareness can also lead 

to discounting the importance of how their own 

cultural backgrounds—including beliefs, values, 

and attitudes—infuence their initial and diagnostic 

impressions of clients. Providers may unwittingly 

use their own cultural experiences as a template 

to prejudge and assess clients’ experiences and 

clinical presentations. They might struggle to 

see the cultural uniqueness of clients, assuming 

that they understand clients’ life experiences and 

backgrounds better than they really do. With 

Chapter 1 9 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

cultural awareness, providers examine how their 

own beliefs, experiences, and biases infuence 

their defnitions of normal and abnormal behavior, 

illness, and healing. 

Commitment to culturally responsive services. 

Organizations have an obligation to ensure 

high-quality care and the cultural competence of 

all personnel. The frst aim is to protect the welfare 

of clients. Cultural competence is important at all 

levels of operation in behavioral health services: 

individual, programmatic, and organizational. It is 

also important in all activities and at every treatment 

phase—outreach, initial contact, screening, assessment, placement, treatment, continuing care, 

and recovery services—as well as with research, 

prevention, and education. Culturally responsive 

practice recognizes the fundamental importance 

of language and the right to language accessibility, 

including translation and interpreter services. 

Culturally responsive services will likely provide 

clients with a greater sense of safety, supporting 

the belief that culture is essential to healing. 

Although not all clients identify or want to connect 

with their cultures, culturally responsive services 

offer clients a chance to explore the impact of 

culture, history (including historical trauma), acculturation, discrimination, and bias and how these 

relate to their behavioral health. 

Signifcance of the environment. An environment 

that refects American Indian and Alaska Native 

culture will be more engaging to clients and set a 

tone that indicates respect. The program should 

take specifc steps to make the facility more accessible and culturally appropriate. In addition, the 

organization should work to create a more culturally refective environment—not only within the 

facility, but also through business practices, such as 

using local and community vendors when possible. 

Respect for many paths. There is no one right 

way. Providing direction on how something should 

be done is not a comfortable or customary practice 

for American Indians and Alaska Natives; the 

consensus panel expressed this sentiment while 

discussing treatment approaches. Most data on 

evidence-based practices (EBPs) are not based on 

native participation. Evidence- or science-based 

practices are practices that have emerged from 

mainstream culture. Although EBPs have value, 

practice-based approaches and traditional healing 

practices play a signifcant role in Indian Country. 

Inherently, introducing the necessity of using EBPs 

suggests that there is one right way of doing 

things. This approach can be seen as an attempt by 

mainstream treatment providers to impose specifc 

treatment methods on native communities while 

devaluing traditional healing practices and beliefs. 

To American Indians and Alaska Natives, healing is 

intuitive; is interconnected with others; and comes 

from within, from ancestry, from stories, and from 

the environment. Instead of one right way, there 

are many paths to healing. 

You Can Do This! 

You are likely aware that people who grow up in 

cultures different from your own may think differently than you do about many things. They have 

had different experiences than you might have 

had and generally have attitudes and beliefs about 

many things that are at least slightly different—if 

not very different—from yours. You may know 

this instinctively when you visit a foreign country, 

an Alaskan Native village, or an American Indian 

reservation. Things are different, and these differences go far beyond the diffculty of reading 

signs in another language or fnding familiar food 

on a menu. You observe that people have created 

a way of life that is grounded in their land and 

language and expressed in their beliefs, customs, 

communication styles, and relationships—their 

lives have a different rhythm or pace from yours. As 

you proceed in your work, remember you are the 

visitor, the guest, the “different” one. Take time to 

observe, learn, and participate. 

You already have plenty of knowledge and skills 

in your feld of practice. You know about mental 

health and substance abuse and how to carry out 

your own role in the continuum of prevention, 

assessment, intervention, treatment, and recovery. 

You have developed interpersonal, clinical, and 

psychoeducational skills that work well in connecting you to many of your clients. You are likely 

caring as well as competent. You are also interested in improving your ability to help your clients—in 

this case, your American Indian and Alaska Native 

clients. Pursuing this learning is as much personal 

as it is professional. You may learn new things 

about your own perspectives on life as you come to 

understand those of others. It can be a rich journey. 

10 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

Choosing a Path for Your Learning 

Journey 

In this publication, you will explore how you 

interact with your clients and adapt culturally 

responsive ways of healing. To this end, the TIP 

emphasizes four main content areas. First, it 

explores the basic elements of American Indian 

and Alaska Native cultures; more knowledge 

prepares you to listen in a new way, tuning in more 

carefully to your American Indian and Alaska Native 

clients. Second, the manual emphasizes the importance of becoming aware of and identifying cultural 

differences between you and your clients, whether 

you are a native or non-native provider. By avoiding 

assumptions of similarity and taking the time to 

understand your clients’ unique cultural identities 

and perspectives, these attitudes and actions can 

lead to a stronger and more trusting relationship. 

Third, the TIP highlights cultural beliefs about 

illness, help-seeking, and health. Fourth, it offers 

practice-based approaches and activities informed 

by science and the healing power available through 

native traditions, healers, and recovery groups. 

A circle is the best image to organize the information that you will need to work competently 

with American Indian and Alaska Native clients. 

The circle is a widely shared symbol among native 

cultures; all of life, seen and unseen, moves in 

circles and cycles. The circle symbolizes a key 

philosophy for understanding the relationship of 

people to everything in their environment and 

represents many things to American Indians and 

Alaska Natives. It represents the circle of life, the 

seasons, unity and harmony among all creation, 

and the importance of striving for balance and 

harmony. One lesson that the circle teaches is 

that there is no right or wrong within the circle, 

merely different viewpoints and pathways that are 

infuenced by life experience, family, community, and 

environment (Cruickshank-Penkin & Davidson, 1998). 

The circle graphic on the next page models the 

key elements for providing culturally responsive 

care for American Indians and Alaska Natives in 

behavioral health services. The concentric circles 

highlight the primary audience for each part of the 

TIP: providers, administrators, and researchers. The 

outermost shaded band symbolizes the importance 

of cultural, environmental, and historical factors 

that infuence the effectiveness of services across 

the continuum of care. Each quadrant of the circle 

represents an essential ingredient in supporting 

culturally responsive services for American Indians 

and Alaska Natives. Adapting Sue and Sue’s (2013) 

multidimensional model of cultural competence, 

the four ingredients (beginning in the East) are 

cultural knowledge, cultural awareness and competence, cultural perspective on behavioral health, 

and culturally specifc and responsive skills and 

practices. 

To your American Indian and Alaska Native clients, 

you are the embodiment of your message; they 

expect that you are an expert at what you do. 

What will they encounter when they are with you? 

Will you see them? Will you understand who they 

are? Will you respect their ways of seeing things 

and their goals, although they may be different 

from your own viewpoints and your own goals for 

them? American Indian and Alaska Native clients 

often do not care what you know until they know 

that you care. How can you demonstrate caring? 

Everything the power of the world does is done in a circle. The sky is round, and I 

have heard that the earth is round like a ball and so are all the stars. The wind, in 

its greatest power, whirls. Birds make their nests in circles, for theirs is the same 

religion as ours. The sun comes forth and goes down again in a circle. The moon 

does the same and both are round. Even the seasons form a great circle in their 

changing and always come back again to where they were.” 

—Black Elk, Oglala Sioux (as interpreted by J. G. Neihardt) 

Source: Black Elk & Neihardt, 1932, p. 121. 

Chapter 1 11 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Culturally Specifc and 

Responsive Skills and Practices 

(North) 

Cultural 

Perspective Cultural 

on Behavioral Knowledge 

Health (East) 

(West) 

Cultural Awareness 

and Competence 

(South) 

Part 1: 

Providers 

Part 2: 

Administrators 

Part 3: 

Researchers 

Your journey around the circle begins in the East, 

where the day dawns. East is the direction of 

awakening, newness, and beginnings. The East is 

about learning and understanding American Indian 

and Alaska Native cultures as much as you are able. 

The East explores historical roots, historical trauma, 

current native experiences, cultural worldview, 

beliefs, and values. What is the importance of 

these to your clients today? What do you need to 

know to work with your clients? 

In the South, you should look at the importance of 

your culture in your work and consider the roots of 

your own views, assumptions, values, and practices. 

In the South, you see similarities and differences 

and open yourself to learn. This quadrant is about 

becoming culturally aware and competent. Here, 

you focus on the roles of culture and cultural 

identity in the provider–client relationship. 

Continuing to the West, you will learn how your 

clients might view their own needs for healing 

and change and their ideas about help-seeking, 

treatment, healing, recovery, and prevention. What 

are your clients’ beliefs about illness? This quadrant 

focuses on the holistic view of behavioral health. 

The North is where you will learn to wisely 

implement the clinical skills that ensure the use 

of culturally responsive interventions, including 

12 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

traditional and best practices. This quadrant 

highlights practice-based approaches and activities 

informed by science and by the healing traditions 

of native healers, medicine, and recovery groups. 

The North also signifes a time of transition— 

changing things to make them better as you 

continue your path. 

Beginning in the East: The 

Direction of Cultural Knowledge 

In the circle, East is the direction of preparation, 

beginnings, and grounding. This section will help 

you to better understand the American Indian and 

Alaska Native experience of life, both historically 

and currently. This section begins with a discussion 

of Native American history, followed by a discussion of how that history continues to affect contemporary American Indians and Alaska Natives. It then 

presents some information about American Indians 

and Alaska Natives today and some challenges that 

many Native Americans face. 

Part 1: 

Providers 

Part 2: 

Administrators 

Part 3: 

Researchers 

Cultural 

Knowledge 

(East) 

American Indian and Alaska Native 

History: Efects of Colonization 

A grasp of events in their people’s past is essential 

for understanding American Indian and Alaska 

Native clients today. The American history you 

learned in school most likely began in the 17th 

century and was about European settlers and 

their descendants. This does not refect the 

experiences of American Indians and Alaska 

Natives. This summary of American Indian and 

Alaska Native history does not do justice to the 

richness of their past, but it can give you a sense 

of the centuries-long evolution of their cultures 

and how the lives of Native Americans have been 

disrupted by contact with other peoples. Ever 

since the Europeans’ arrival and colonization of 

North America, the history of American Indians 

and Alaska Natives has been tied intimately to the 

infuence of European settlers and to U.S. government policies. The lives of American Indians and 

Alaska Natives today are, to some extent, the result 

of their mistreatment at the hands of European 

(including Russian) settlers. Early colonists would 

not have survived without the assistance of Native 

Americans, yet within a relatively brief span of years, 

those colonists were killing their native hosts to 

claim land, degrading their environment, exposing 

them to infectious diseases from which their natural 

immunity could not protect them, and even 

enslaving them. 

Many native communities have 

origin stories. Passed down from 

one generation to the next, these 

symbolic and traditional narratives 

explain creation—the beginning of life, 

of place, and of the world—and are 

shaped by the individual community’s 

culture, region, and language. Many 

origin stories and legends have 

been passed through oral tradition, 

but some have been recorded for 

preservation. Origin stories prescribe 

how people should be in the world 

and their responsibilities to the Earth 

and to each other. These stories have 

great relevance in providing care 

and in healing. (For a review of oral 

narrative themes and an annotated list 

of resources across regions, see Bastian 

and Mitchell, 2004.) 

Chapter 1 13 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

In early colonial times, European settlers and 

American Indians established some mutually proftable trading networks on the East Coast. However, 

the Spanish used American Indian forced labor in 

mines and on ranches in the Southwest, the British 

forcibly took land for agriculture, and the Russians 

captured Alaska Natives for work in the fur trade. 

American Indians and Alaska Natives increasingly 

resisted European attempts at dominance but 

found themselves repeatedly defeated in local 

wars. As a result, they lost population, land, and 

power. 

Shortly after the U.S. government was created, 

the Northwest Ordinance laid out policies that 

allowed confscation of native lands in exchange 

for the payment of goods and monetary annuities. 

A department was established to keep track of 

the treaties signed and the funds disbursed and 

was later upgraded to a bureau. The Indian Offce 

became part of the War Department in 1824 and 

moved to the Department of the Interior in 1849. 

Unfortunately, the treaties were often broken, 

ignored, or forgotten. 

In 1830, as American settlers pushed westward, 

Congress passed the Indian Removal Act to 

force American Indians to relocate west of the 

Mississippi River. It was believed that American 

Indians could be more readily assimilated into 

mainstream culture if they were concentrated in 

one area; they could be “civilized,” and their native 

cultures would disappear. Whether voluntarily or 

by force after a military defeat, brutal marches of 

American Indians ensued, and the loss of life was 

tremendous. In the southeastern United States, 

an estimated 100,000 Cherokee, Choctaw, Creek, 

Chickasaw, and Seminole people were relocated in 

wintertime, during which thousands died of disease 

and starvation; this is known as the Trail of Tears. 

Within 10 years, the resettlements to what are now 

Nebraska, Kansas, and Oklahoma were completed, 

but intertribal conficts surfaced. The American 

Indians who now had to share their land resented 

the new arrivals. American settlers moved into 

new areas, the Indian Offce became more corrupt, 

and pressures on hunting grounds and reservation 

lands increased. More tribes were sent to live on 

reservations of marginal land where they had little 

chance of prospering. The Plains tribes suffered the 

extermination of buffalo herds, depletion of water 

resources, economic depredation, and loss of 

human lives (Hirschfelder & de Montaño, 1993). 

The Indian boarding school movement began 

about 1875 as a part of an effort to assimilate 

American Indian and Alaska Native children into 

mainstream culture. The government removed 

children from their families and communities, 

often by force, and placed them in schools often 

hundreds and even thousands of miles away from 

their homes. In some areas, generations of families 

attended boarding schools. By 1899, there were 26 

off-reservation schools scattered across 15 states. 

The number of boarding schools grew, and by the 

1930s, nearly half of all American Indian and Alaska 

Native children were enrolled in a boarding or 

industrial school. Some schools were still operating 

as recently as the 1970s. The emphasis within the 

Indian educational system later shifted to reservation schools and public schools, but boarding 

schools continued to have a major impact for many 

years thereafter because they were perceived to be 

an effective means of assimilating American Indians 

into mainstream culture. The boarding school 

experience also prevented the transmission of 

tribal culture, language, traditional parenting skills, 

and naturally occurring patterns of family socialization. Recently, the extent of child physical and 

sexual abuse that occurred at the boarding schools 

has come to light. A 1990 report, published by the 

National Resource Center on Child Sexual Abuse, 

found widespread abuse occurring over years, 

particularly at missionary schools. 

President Grover Cleveland signed the General 

Allotment Act (also known as the Dawes Severalty 

Act) in 1887. This law broke up reservation land 

into portions allotted to Indian families and individuals. The government then sold the leftover reservation land at bargain prices. This Act, intended 

to encourage American Indians to farm the land 

and otherwise integrate them into U.S. society, 

had disastrous consequences. In addition to losing 

surplus tribal lands, many natives lost their allotted 

lands in future sales and had little left for survival 

(Hirschfelder & de Montaño, 1993). 

The Bureau of Indian Affairs (BIA) intruded further 

into Native American life in the early 20th century. 

Community celebrations were prohibited, and 

14 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

BIA workers assumed management of reservation 

health care, education, public safety, and road 

maintenance. The Meriam Report (known by the 

surname of its author, Lewis Meriam, but offcially 

titled The Problem of Indian Administration), 

published in 1928, exposed problems that had 

worsened under this system and marked a policy 

change that resulted in passage of the Indian 

Reorganization Act in 1934. 

Indian policy shifted again near the end of World 

War II. Congress began to withdraw federal 

support and to abdicate responsibility for Native 

American affairs. Over the following two decades, 

under a policy known as “termination,” many 

federal services were withdrawn, and federal trust 

protection was removed from tribal lands and 

given to the states. At the same time, the Indian 

Relocation Act encouraged Native Americans to 

move to urban areas where they were more likely 

to fnd jobs. This further weakened tribal ties and 

sense of community (Hirschfelder & de Montaño, 

1993). Many families never returned to their 

reservations. 

Self-determination became the new watchword 

of policy toward American Indians and Alaska 

Natives in the late 1960s and 1970s. The Indian 

Self-Determination and Education Assistance Act 

of 1975 codifed the policy, which repudiated 

termination policies and permitted tribes to 

enter into contracts to manage aspects of tribal 

governance, such as education. The Indian Child 

Welfare Act of 1978 put an end to the practice of 

adopting out American Indian and Alaska Native 

children into non-native homes. In keeping with 

self-determination, the American Indian Religious 

Freedom Act of 1978 ended the ban on traditional 

spiritual practices. Despite the prohibitions and 

Christianizing efforts by various churches, indigenous culture and spirituality have survived and 

are widely practiced. Even in areas where many 

American Indians and Alaska Natives practice 

Christianity, traditional cultural views still heavily 

infuence the way in which Native Americans 

understand life, health, illness, and healing (Kalt et 

al., 2008). 

An important class action suit, known as Cobell 

v. Salazar, was fled on behalf of a large group 

of American Indians against the Departments 

of Treasury and the Interior in 1996. It asserted 

that the government had failed to account for 

monies held in trust since tribal lands had been 

allotted to individuals beginning in 1887; that 

other assets held in trust had been mismanaged; 

and that royalties were owed to individuals for 

leases of their lands for grazing, oil, gas, and other 

resources. The issues in the suit were enormously 

complex, and it was not settled until 2010. The 

government agreed to set aside $3.4 billion, of 

which $1.5 billion would compensate approximately 500,000 individuals, and $1.9 billion would buy 

back land to beneft tribes (Campbell, 2013). 

AMERICAN INDIANS AND ALASKA NATIVES IN MILITARY SERVICE 

Approximately 12,000 American Indians and Alaska Natives volunteered for military service in World 

War I—an estimated 25 percent of the total male American Indian population at the time (Britten, 1997). 

During World War II, more than 44,000 Native American men and women served in the military. This 

is about 13 percent of the 350,000 individuals that made up the American Indian and Alaska Native 

population at the time (Armed Forces History Museum, 2013). 

In World War I, the U.S. military began using American Indians and Alaska Natives as code talkers. Initiated 

by Choctaws in World War I, American Indians and Alaska Natives used their language in a code for 

transmitting messages on the battlefeld. The code was never broken. During World War II, the armed 

forces began to recruit Kiowa, Cherokee, Navajo, Tlingit, Comanche, Seminole, and at least 25 other tribes 

and nations to transmit coded messages. Beginning in 2000, 29 code talkers were awarded special 

Congressional Gold Medals for their service (National Museum of the American Indian, 2007). 

Five American Indians received the Congressional Medal of Honor for their service during World War II, and 

three received it for their service in the Korean War (Center for Military History, United States Army, 2011). 

Chapter 1 15 
TIP 61

 

Behavioral Health Services for American Indians and Alaska Natives 

The experience of Alaska Natives with foreign 

cultures was, in some ways, similar to that of 

American Indians, but the basic state history is 

quite different, owing in part to its climate and 

geography. The Aleuts were the culture most 

affected by contact with Russian explorers and fur 

traders after their arrival in the early 1700s. Few 

Russians actually settled in Alaska, but they were 

able to coerce the Aleuts into doing their marine 

hunting for them, using Alaskan seaworthy vessels 

and weapons that were well suited to this pursuit. 

Other inhabitants of coastal areas, such as the 

Yup’ik, Chugach, and Tlingit, who relied on fshing 

and hunting, were also affected (Korsmo, 1994). 

No land was set aside for Alaska Natives to use. 

They simply lived where they chose and inhabited 

much of the land, particularly where game, fsh, 

and other foods were plentiful. Yet, as among 

American Indians, missionaries undertook the 

assimilation of the native population by forbidding 

the use of traditional languages and customs and 

sending the children to boarding schools where 

they would become more “American.” Physical, 

emotional, and sexual abuse by adults and other 

students at these schools added to the losses of 

family relationships and cultural traditions (LaBelle, 

2005). 

With the purchase of Alaska in 1867 and the 

discovery of gold near Juneau in 1880 and in the 

Yukon in 1896, the area became a valuable asset to 

the United States. According to the Mining Act of 

1872, however, Alaska Natives were not permitted 

to stake mining claims, and they were often paid 

less than Whites for the same work (Ongtooguk, 

n.d.). Schools for Alaska Natives were operating 

under federal supervision within 20 years. Alaska 

became a U.S. territory in 1912. Generally, Alaska 

Natives’ land claims were respected in accordance with the 1884 Organic Act, but there were 

some problems. For example, the Alaska Native 

Allotment Act, passed in 1906, provided reservation land only for hospitals, schools, and reindeer 

(Korsmo, 1994). 

Alaska Natives were reorganized by law in 1936. 

Few groups chose to create reservations. Many 

Alaska Natives were opposed to reorganization, 

as was the territorial governor, who feared that 

the Alaska Native groups would stagnate and that 

reservations would become subsistence enclaves. 

Commercial fshing and canning industries 

opposed reservations, as they wanted to ensure 

access to water (Korsmo, 1994). 

Alaskan statehood, granted in 1959, became the 

catalyst for clarifcation of natives’ land claims. If 

their claims were to be respected as required by 

the 1884 treaty, mining, oil, and other industries 

could not confscate Alaska Native territory. 

These land issues mobilized Alaska Natives to 

form the Alaska Federation of Natives in 1966. 

Representatives of 17 native organizations met to 

present a united voice for a fair settlement. 

Five years later, the Alaska Native Claims 

Settlement Act resolved land issues by law. Alaska 

Natives would receive the title to 40 million acres 

of land that they already occupied. To compensate 

them for the loss of their claims to other lands, 

they would also receive nearly $1 billion over 11 

years; Alaska Natives would be organized into 12 

corporations that would administer the land and 

funds (R. S. Jones, 1981). 

Although it appears that governmental agencies 

have become more aware of past injustices toward 

American Indians and Alaska Natives, it is diffcult— 

if not impossible—to make amends for centuries 

of disrespect and hostility. American Indians and 

Alaska Natives have demonstrated their resilience 

and have responded to the self-determination 

mandate by taking control of tribal government; by 

fostering economic development of reservations; 

and by making their voices heard on environmental, 

healthcare, and other issues that affect them. 

Exhibit 1.1-1 provides information on major events 

in American Indian and Alaska Native history. 

Not all events are included in both the previous 

narrative and the timeline, so you may beneft from 

reading both. 

16 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

EXHIBIT 1.1-1. Timeline of Signifcant Events in Native American History 

TIME PERIOD EVENT 

c. 28,000–12,000 B.C. Groups migrated from Asia into North America, perhaps across a land bridge 

connecting the two continents. 

c. 11,000 B.C. Archaeological evidence indicates that people inhabited a region near Clovis, 

NM, meaning that the original groups had migrated substantial distances. 

c. 10,000 B.C. Other groups continued their migration to populate the woodlands in what is 

now the Northeast. 

c. 6,000 B.C.–1 A.D. During the Archaic period, big game moved eastward, and native groups 

moved from what is now California to the Southwest. They planted maize. 

1 A.D.–1000 A.D. In the Formative period, native groups living in the Southwest diversifed from 

those living in the Southeast (Dutton, 1983). Anasazi, Mogollon, Hohokam, and 

Hakataya civilizations fourished. Agricultural techniques evolved, and pottery 

was in use. In the Northeast, Adena, Hopewell, and Mississippian cultures 

prospered. They are noted for their fne art, agriculture, and metalwork. 

1000–1600 The Great Plains were repopulated by native groups, drawn in part by the 

reappearance of big game. 

1607–1630 British and Dutch settlers made contact with American Indians in Virginia, 

Massachusetts, and New York. 

1720–1750 Russian explorers arrived in the Aleutian Islands and established fur trading. 

1787 The Northwest Ordinance established fair policies toward natives living in the 

area claimed by the United States. 

1820–1840 Russian settlers had initial contact with Alaska Natives, exposing them to fatal 

diseases such as smallpox and syphilis. Alaska Native populations decreased by 

20–50 percent in the groups most affected. 

1830 The Indian Removal Act passed, marking the beginning of an assimilationist 

policy for Native Americans. They were required to move west of the Mississippi 

River. 

1832 Liquor was prohibited in Indian Country; 2 years later, penalties were set for 

violating the ban. It was fnally repealed in 1953. 

1834 What became the BIA was established to administer and manage lands held in 

trust for American Indian tribes and Alaska Natives by the U.S. government. 

1867 The United States purchased Alaska from Russia. The Treaty of Cession 

recognized three groups of residents: Russian subjects who could return to 

Russia within 3 years, Russian subjects who chose to remain in Alaska and 

become Americans, and uncivilized tribes (those who had virtually no contact 

with Russians). Missionary boarding schools similar to those in the lower 48 

states were soon established. 

Continued on next page 

Chapter 1 17 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

EXHIBIT 1.1-1. Timeline of Signifcant Events in Native American History 

(continued) 

TIME PERIOD EVENT 

1879 The Carlisle Indian School (in operation until 1918) and other boarding schools 

opened with the goal of separating Native American children totally from their 

cultures and turning them into members of the mainstream society. Children 

were forced to cut their hair and wear mainstream clothing; they were taught 

English and forbidden to speak their original languages. Their names were 

changed, Christianity replaced their traditional spiritual practices, and they 

were taught that their native cultures were inferior. The guiding philosophy 

was, “kill the Indian, save the man.” 

1887 The General Allotment Act (also known as the Dawes Severalty Act) became 

law. It allotted land to individuals and provided for the land’s use in agriculture 

and its sale in the future. Allotted lands would be held by the U.S. government 

in trust for 25 years. Designed to continue assimilation policies, it resulted in 

further losses of Native American lands. 

1924 The Indian Citizenship Act, also known as the Snyder Act, was signed into law 

on June 2, 1924. The Act created national citizenship for indigenous people in 

the United States, but the qualifcations for state citizenship were determined 

by each individual state. The fnal state to grant full citizenship to American 

Indians was New Mexico in 1962. Overall, the Indian Citizenship Act was more 

inclusive than previous policies pertaining to citizenship, but it was not until the 

Nationality Act of 1940 that all people who were born on United States soil were 

automatically considered citizens. 

1934 The Indian Reorganization Act was signed into law. Its purpose was to develop 

Native American economic resources and restore tribal self-government. The 

allotment system was ended. 

1936 Alaska Native cultures were included in reorganization. The law recognized 

tribes, permitted establishment of tribal lands, and allowed self-government. 

1945–1961 Congress adopted policies to terminate federal obligations to tribes, known 

as the “termination era.” Three primary policies and strategies were used. 

First, the relocation program was designed to relocate American Indians and 

Alaska Natives away from reservations and Alaska Native villages into cities to 

force assimilation. Second, a resolution was passed to end the special federal 

relationship with many tribes and terminate their status as tribes. Tribes were 

given the choice of being paid for their lands or having their lands held in trust 

by a Native American corporation. Finally, Congress extended state jurisdiction 

into Indian Country, which shifted the responsibility to the states. 

1955 The Indian Health Service (IHS) was created within the Department of Health 

and Human Services (HHS) to provide health care to Alaska Natives and 

American Indians who are members of federally recognized tribes. 

1956 The Indian Relocation Act, touted as employment assistance, encouraged 

Native Americans to move to urban locations where jobs were more plentiful. 

By the 1990 Census, 51 percent of Native Americans lived in urban areas. 

Continued on next page 

18 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

EXHIBIT 1.1-1. Timeline of Signifcant Events in Native American History 

(continued) 

TIME PERIOD EVENT 

1958–1967 The Indian Adoption Project removed Native American children from their 

families and placed them in boarding schools or with non-native families. 

Public child welfare services removed many more children in the 50s and 60s. 

In states with the largest native populations, an estimated 25 to 35 percent of 

American Indian and Alaska Native children were removed; of these, 85 percent 

entered foster care or were adopted by non-native families. The Indian Child 

Welfare Act ended this practice in 1978. 

1959 Alaska became a state. 

1960s In response to public outcry, the federal termination policy was ended and 

replaced by a policy that encouraged self-determination. Recognition was 

extended to some tribes that had previously been terminated, and additional 

tribes were recognized. The Indian Civil Rights Act of 1968 allowed the federal 

government to intervene in intratribal disputes, while extending, in part, 

constitutional rights to American Indians and Alaska Natives. 

1971 Pressed by the Alaska Federation of Natives, the Alaska Native Claims 

Settlement Act became law, granting 40 million acres of land and nearly 

$1 billion in compensation for land lost to 12 native corporations. 

1988 The Indian Gaming Regulatory Act established a commission to regulate 

gambling casinos on tribal lands. 

1989 The oil tanker Exxon Valdez spilled an estimated 260,000–760,000 barrels of 

crude oil in Prince Edward Sound, AK. The environmental damage was severe. 

Populations of sea birds and mammals, as well as other marine species, were 

signifcantly reduced, radically altering the lives of Alaska Natives whose 

economy depended on them. Even 25 years after the spill, a great deal of oil 

remained on nearby shores. The Chugach Corporation declared bankruptcy as 

a result of the spill but has since recovered. 

1995 Alyeska, which owns the Trans-Alaska Pipeline System, created the Alaska 

Native Program to meet legal obligations to employ, promote, train, and help 

educate Alaska Natives. The agreement was renewed in 2007. 

2010 The class action lawsuit Cobell v. Salazar was settled for $3.4 billion in favor of 

the Native American plaintiffs. Funds are to compensate individuals for their 

interest in lands leased by the federal government while it was trustee for the 

lands and to buy back land so that tribes can consolidate their holdings. 

2013 The Violence Against Women Reauthorization Act granted federally recognized 

tribes jurisdiction over protective order violations, domestic violence, and 

dating violence that occur on tribal lands. Previously, non-native perpetrators 

of these crimes were not often prosecuted, as federal, state, and tribal law 

enforcement all lacked the authority to act. 

Sources: Campbell, 2013; Dutton, 1983; Hirschfelder & de Montaño, 1993; Martin, 2003; Pritzker, 1998. 

Chapter 1 19 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

The Importance of History for American 

Indian and Alaska Native Behavioral 

Health 

The overview of historical events presented above 

shows that for more than 500 years, American 

Indians and Alaska Natives have endured multiple 

traumatic events as a result of colonization. As a 

behavioral health service provider, you need to be 

aware that your American Indian and Alaska Native 

clients continue to experience repercussions from 

these events. It may be diffcult for you to read 

and think about these events, in part because you 

know that they have had such damaging effects 

on American Indians’ and Alaska Natives’ lives 

(discussed in the next section), but an understanding of how trauma affects clients is vital to your 

effectiveness as a provider. 

Clinicians and researchers call the process through 

which past traumatic events affect one’s presentday functioning historical trauma. Historical trauma 

has been defned as the “cumulative emotional 

and psychological wounding across generations, 

including the lifespan, which emanates from 

massive group trauma” (Brave Heart, Chase, 

Elkins, & Altschul, 2011, p. 283). 

Another author has described historical trauma as 

“collective complex trauma inficted on a group 

of people who share a specifc group identity 

or affliation—ethnicity, nationality, and spiritual 

affliation. It is the legacy of numerous traumatic 

events a community experiences over generations 

and encompasses the psychological and social 

responses to such events” (Evans-Campbell, 2008, 

p. 320). It is collective in that it affects an entire 

people, rather than an individual, and complex 

in that it does not have a single traumatic cause. 

Historical trauma has also been referred to as a 

“soul wound” that affected and continues to affect 

the physical, social, cultural, and psychological 

health of American Indians and Alaska Natives (B. 

Duran, Duran, & Brave Heart, 1998). 

Dr. Maria Yellow Horse Brave Heart applied the 

concept of historical trauma to American Indians 

and Alaska Natives when she noted parallels 

between Holocaust survivors and their children 

and American Indians and Alaska Natives whose 

ancestors had suffered massive trauma. She 

TRADITIONAL CULTURES AND 

HISTORICAL TRAUMA 

A stronger connection to traditional cultures 

may help reduce the effects of historical trauma 

on American Indians and Alaska Natives, as the 

loss of traditional cultural practices may have 

exacerbated the effects of historical trauma. 

Brave Heart (2003) gives an example of this 

drawn from Lakota history. The Lakota culture 

had specifc rituals and practices for grieving 

that allowed for a year of publicly expressed 

mourning, followed by a ceremony to heal that 

grief. U.S. policies outlawing native ceremonies 

interrupted the process of grieving over events 

such as the Wounded Knee Massacre of 1890, in 

which the U.S. Army killed between 150 and 300 

Lakota men, women, and children. 

observed that contemporary American Indians 

and Alaska Natives continued to experience grief 

about traumatic events in their history that they 

were unable to resolve, and this was further exacerbated by additional disruptions in native cultures 

(e.g., forced out-of-home placement of children 

into boarding schools, the banning of traditional 

ceremonies and practices), which in turn affected 

traditional responses to grieving, such as described 

in “Traditional Cultures and Historical Trauma” 

(Brave Heart et al., 2011). 

You may fnd that your American Indian and Alaska 

Native clients experience grief for somewhat 

different reasons than other clients do. Common 

reasons for grief include the loss of their communities, loss of life, loss of freedom, loss of land, 

loss of self-determination, loss of traditional 

cultural and religious practices, loss of native 

languages, and the removal of children from their 

families. Historical trauma may involve events that 

happened hundreds of years ago or more recent 

traumatic events, such as forced placement in 

boarding schools or environmental disasters (e.g., 

the Exxon Valdez oil spill, gasoline pipeline breaks 

on the Crow reservation in Montana), which have 

done both material and cultural harm. 

Brave Heart and others found that traditional 

models of responses to trauma were inadequate to 

explain the whole complex of behavioral and social 

problems that American Indians and Alaska Natives 

20 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

have experienced. When you view the larger 

picture, historical trauma appears to contribute to 

various problems, including socioeconomic effects, 

problematic behaviors, and, especially, various 

mental and substance use disorders. Other relevant 

factors that mark historical trauma as different from 

other trauma are that the distress resulting from 

the trauma is collective rather than individual, and 

the cause of trauma comes from people outside 

the community affected by it (Evans-Campbell, 

2008). Historical trauma is also intergenerational in 

that the original trauma continues to have effects 

on subsequent generations that did not experience 

it directly. 

You might fnd it helpful in your practice to use 

some of the measures that have been developed 

to evaluate how salient historical trauma is for 

your clients. Research using those measures does 

indicate that American Indians and Alaska Natives 

frequently think about historical losses (Whitbeck, 

Adams, Hoyt, & Chen, 2004). 

The Efects of Historical Trauma on 

American Indians and Alaska Natives 

Today 

Many providers who work with American Indians 

and Alaska Natives believe that historical trauma 

can cause anger, grief, and shame that contribute to 

substance use disorders, suicidality, and increased 

vulnerability to mental disorders such as posttraumatic stress disorder (PTSD). These, in turn, 

increase risk for additional trauma, perpetuating its 

effects (Exhibit 1.1-2). 

EXHIBIT 1.1-2. Cycle of Historical Trauma 

History of trauma and 

historical trauma 

Cycle of 

Historical Trauma 

Traumatic stress reactions 

including grief and other strong 

emotional/physical reactions 

Increased risk of substance 

abuse and dependence 

Increased vulnerability of 

suicidality and mental disorders 

(e.g., PTSD, anxiety, depression) 

Increased risk of experiencing other 

traumas (e.g., accidents, violence, 

physical and sexual abuse) 

Chapter 1 21 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Traumatic events often have material, economic, 

psychological, and cultural repercussions. Among 

American Indians and Alaska Natives, historical loss 

is associated with greater risk for substance abuse, 

depressive symptoms, more feelings of anger, and 

a higher likelihood of engaging in binge eating 

(Clark & Winterowd, 2012; Ehlers, Gizer, Gilder, & 

Yehuda, 2013; Whitbeck et al., 2004; Whitbeck, 

Walls, Johnson, Morrisseau, & McDougall, 2009). 

Historical trauma may also affect future generations in a number of ways at national, community, 

family, and individual levels (Sotero, 2006). Trauma 

can affect future generations physically (e.g., by 

raising the risk of certain diseases), socially (e.g., 

by increasing child abuse and domestic violence), 

psychologically (e.g., by causing depression or 

PTSD), and spiritually (e.g., by losing hope for 

the future). Some theorists suggest trauma is also 

stored on a biological level; that is, one generation 

passes it down to the next. 

One important way historical trauma is transmitted across generations is through its effects on 

parenting. Brave Heart (1999) suggests that trauma 

experienced by parents can disrupt traditional 

parenting practices and increase substance abuse, 

which in turn negatively affects parenting. Trauma 

may affect trust and intimacy and the ability to form 

a healthy bond with one’s children. Parents tell 

stories of historical events or of their own experiences that may cause secondary traumatization. 

Children also witness and, to some extent, internalize their parents’ reactions in times of stress when 

their parents’ responses to traumatic situations are 

triggered. 

STORY OF THE SACRED HOOP OF 100 EAGLE FEATHERS 

In Black Elk’s vision, the Hoop of the World referred to the communities 

of Native people. In his vision, he saw the Native people going through a 

long time of suffering during which the hoop was broken. And then he 

saw that the people would begin to heal. The Elders have told us that we 

have now entered the time of healing and the ‘coming together time.’ The 

Sacred Hoop is the symbol of that time of healing. The Sacred Hoop of the 

Wellbriety Movement was born from a vision in 1994....” 

Mission of the Sacred Hoop: Healing Individuals, Families, Communities, 

and Nations 

The Hoop was built in a sweat lodge over a weekend in May of 1995. On the 

frst day of summer that year, a multicultural Elders gathering was held in 

Janesville, WI, to provide prayers for the Hoop and align its purpose to the 

coming healing time. The Elders placed the four gifts of Healing, Hope, Unity, 

and the Power to Forgive the Unforgivable into the Hoop. The frst Sacred 

Hoop Journey began in the spring of 1999. 

“Since the Sacred Hoop was blessed, it has traveled over 53,000 miles to 

Native American communities across the United States.... When the Sacred 

Hoop comes to a community, the people gather for ceremonies and talk 

about living a sober and healthy life that is balanced emotionally, mentally, 

physically, and spiritually.” 

Source: Coyhis, 2007. Reprinted with permission. 

22 Chapter 1 
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Part 1—Guide for Providers Serving American Indians and Alaska Natives 

Adverse childhood events, beyond actual trauma 

and including things such as parental illness or 

inadequate family resources, affect the psychological development of children and increase their risk 

for problems such as PTSD and substance abuse. 

TIP 57, Trauma-Informed Care in Behavioral Health 

Services, includes additional information on the 

effects of trauma on parenting and on behavioral 

health in general (SAMHSA, 2014b). 

The Benefts of Focusing on Historical 

Trauma 

The concept of historical trauma is intended to 

help you, the provider, fnd ways of discussing 

current trauma and emotional or behavioral 

problems in a context that is not “stigmatizing” 

(Brave Heart et al., 2011). By working with a 

concept of historical trauma, you can present 

trauma as a collective experience, and thus one 

that communities can work together to overcome 

(Gone, 2013). You may fnd that the most effective 

methods of treating the effects of historical trauma 

typically involve families and communities and supportive networks of people working to overcome 

similar problems or challenges (e.g., tribal canoe 

journeys in the Pacifc Northwest). These networks 

often work to connect clients with their traditional 

cultural beliefs and practices and may include tribal 

elders and healers who offer spiritual guidance 

and healing in a manner that is congruent with 

American Indian and Alaska Native beliefs. 

We are many. We are diverse. We 

represent our many cultures. We 

are a resource. We infuence our 

people. We have roots and heritage. 

We live in two worlds. We feel unity 

when we gather. We have dual 

citizenships. We are the caretakers 

for many of our aging elders and 

children. We are the link to those 

who have left home. We are you.” 

—Katherine Gottlieb, Aleut, President, 

South Central Foundation, Anchorage, 

AK 

Source: National Urban Indian Family Coalition, 

2009, p. 5. 

American Indians and Alaska Natives 

Today 

If you have even a modest familiarity with American 

Indians and Alaska Natives, you know that they 

lead diverse lives. American Indians and Alaska 

Natives are professionals, business people, scientists, academics, athletes, artists, soldiers, teachers, 

community builders, and clergy. They are hunters, 

fshers, harvesters of wild and cultivated foods, and 

medicine men and women or traditional healers. 

Your clients may live in a relatively small geographic 

area and share a tribal identity. As a whole, the 

American Indian and Alaska Native population is 

extremely diverse and encompasses people from 

573 federally recognized tribes, each with its own 

culture, and many more tribes that are recognized 

by states only or that are seeking federal recognition 

(Indian Entities Recognized, 2018). American Indians 

and Alaska Natives speak more than 150 different 

languages, and diverse tribes have varying customs 

and beliefs. American Indians and Alaska Natives, 

even those from the same culture, may have widely 

differing levels of identifcation with those native 

cultures. 

As a provider, you know the importance of treating 

each client as an individual. With that in mind, 

much of the information that follows describes 

how American Indians and Alaska Natives as an 

entire population differ from other groups and 

may not apply to specifc American Indian and 

Alaska Native clients. Talking individually with your 

clients about their culture and its meaning to them 

is essential before you make decisions about how 

to treat those clients. The West section presents a 

discussion of assessment, including the assessment 

of cultural identifcation, and TIP 59 (SAMHSA, 

2014a) contains a chapter on culturally responsive 

evaluation and treatment planning. 

According to Census estimates released in 2018, 

6.8 million people in the United States identifed 

as Native American, either alone or in combination 

with another race. This number represented only 

2.1 percent of all people in the United States. 

Chapter 1 23 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Of those 6.8 million, 4.1 million identifed solely 

as Native American, and 2.7 million identifed as 

Native American in combination with another race 

(Census Bureau, Population Division, 2018). 

The number of people who identify as Native 

American has been growing since the 1960s. This 

appears to be because a growing percentage of 

the population has chosen to identify as Native 

American. The choice often is based on people’s 

Native American ancestry, not because of cultural 

affliation. This is a subject of some debate within 

the American Indian and Alaska Native population, 

with some individuals welcoming these “new” 

Native Americans and others being concerned 

that these individuals are ignoring the importance 

of American Indian and Alaska Native cultures in 

defning themselves as Native American. For the 

latter group, belonging to an American Indian 

and Alaska Native tribal entity is the best way to 

identify whether someone is “culturally” Native 

American (Gone & Trimble, 2012). 

The American Indian and Alaska Native population 

is younger than the United States population as a 

whole, with a median age of 31.3, compared with 

38.0 for the whole population (Census Bureau, 

Population Division, 2018). One unfortunate 

reason for this is that American Indians and Alaska 

Natives tend to die earlier from a number of health 

problems (see the discussion under the “Physical 

Health” section). Like other Americans, most 

American Indians and Alaska Natives work in urban 

areas, but they are more likely than the population 

as a whole to live in rural areas. According to the 

HHS Offce of Minority Health (2018), 60 percent 

of American Indians and Alaska Natives live in 

urban areas. About 22 percent live on reservations 

or off-reservation trust lands. American Indians 

and Alaska Natives whose primary residence is on 

reservations, trust lands, or bordering rural areas 

often migrate between cities and those rural areas 

and maintain ties in both areas. 

American Indians and Alaska Natives account for 

a greater proportion of the population in certain 

states, particularly Western ones. According to the 

Census Bureau’s Population Division (2018), the 

states with the highest proportion of native populations are Alaska (where native people make up 20.0 

percent of the population), followed by Oklahoma 

(13.8 percent), New Mexico (12.2 percent), and 

South Dakota (10.4 percent). 

WHO ARE NATIVE AMERICAN 

TRIBAL MEMBERS? 

Having Native American ancestry does not 

automatically qualify a person as a member of a 

Native American nation or tribe. Tribal members 

are those who are offcially enrolled in a tribe or 

similar entity. Tribes have the right—because 

they are sovereign nations with their own 

governments—to decide who is and is not a 

member. The criterion used most often by tribes 

is “blood quantum,” or documentation that one 

is descended from historical tribal members. 

Blood quantum refers to the amount of tribal 

blood a person possesses as determined by his or 

her ancestors. In some tribes, a person might be 

full-blooded Native American but may not meet 

the requirement for tribal membership, because 

some ancestors were members of other tribes. 

The Status of American Indian and 

Alaska Native Tribes 

American Indians and Alaska Natives are unique 

among racial/ethnic groups in the United States. In 

addition to being U.S. citizens only since 1924, they 

may be members of federally recognized sovereign 

nations or tribes within the United States. As of this 

publication, the U.S. government has recognized 

573 tribal entities (Indian Entities Recognized, 

2018). Other native communities are only recognized by certain states or are in the process of 

applying for recognition. Not all nations refer to 

themselves as “tribes.” For example, American 

Indians in the Southwest may refer to their nation as 

a pueblo, other tribes may refer to their community 

as a “band,” and Alaska Natives may identify 

according to the village to which they belong. 

These sovereign nations are subject to federal law, 

but to only some state laws. Federal law recognizes 

that native sovereign nations have the authority to 

manage certain functions of their own government 

on tribal lands and that, in turn, the federal government has a duty to protect members of these 

nations and to provide them certain services (e.g., 

health care) according to obligations set out in 

treaties with individual tribes. 

24 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

U.S. GOVERNMENT TREATIES 

Treaties are made between the governments of nations. Therefore, making a treaty was a recognition by the 

U.S. government (and earlier, European and colonial governments) that native communities were sovereign 

nations and that the land belonged to the native communities that were granting rights to it in exchange 

for certain guarantees and payments. Those treaties and federal laws enacted afterward meant that the 

federal government had legal and fnancial responsibilities in relation to federally recognized tribes. 

Much of the time, especially early on, these treaties made little sense to tribes. The agreements were 

explained in languages foreign to them and were presented in a written form that was incomprehensible to 

the tribal leaders, so they were forced to rely on interpreters to understand what was being proposed. The 

whole concept of owning land and rights to it was alien to American Indian and Alaska Native people. The 

fact that the United States did not fulfll its treaty obligations created a complex network of problems that 

took decades to untangle. Nevertheless, recognition of the sovereignty of native communities has provided 

the foundation of the tribes’ claims on the United States ever since. 

American Indians and Alaska Natives governed 

themselves and related to each other as sovereign 

nations long before the European colonization 

began. Tribal authorities today may police their 

own lands, create laws to govern them, manage 

their own courts, provide other essential services, 

provide housing, run schools, and, in some cases, 

manage health care in part through the use of 

IHS funds. Some tribes also run businesses for the 

beneft of tribal members. Research suggests that 

native people who have self-governance are more 

economically prosperous and may have better 

behavioral health outcomes, such as a lower suicide 

rate, as well (Chandler & Lalonde, 2008; Taylor & 

Kalt, 2005). 

MYTHS AND FACTS ABOUT AMERICAN INDIANS AND ALASKA NATIVES 

Myth: All American Indians and Alaska Natives have a distinctive physical appearance that you can use 

to identify them. 

Fact: Given the diversity among tribes after centuries of intertribal and interracial marriage, there are no 

distinguishing features that identify American Indians and Alaska Natives. 

Myth: Most American Indians and Alaska Natives live on reservations. 

Fact: About 22 percent of American Indians and Alaska Natives live on reservations or on trust lands offreservation, according to the HHS Offce of Minority Health (2018). Another 60 percent live in urban areas. 

Myth: Gambling casinos are making many American Indians and Alaska Natives wealthy. 

Fact: Fewer than half of the federally recognized tribes operate gaming facilities. Most profts from gaming 

go to improve a broad range of tribal services, and only about one-quarter of tribes with gaming give 

direct payments to tribal members. The size of those payments varies considerably, but in most cases it is 

only a small supplement. Several smaller tribes account for a disproportionate share of revenues that are 

dispersed to individuals (Kalt et al., 2008). 

Myth: All Alaska Natives are Eskimos. 

Fact: The U.S. government recognizes more than 200 tribes in Alaska. The Alaska Native Heritage Center 

identifes 11 distinct cultures. The Unangax and Alutiiq, who occupy the Aleutian Islands, were affected most 

heavily by contact with Russian explorers and adopted elements of their religion, cuisine, and language. 

Their life around the oceans makes their lives and livelihoods very different from inland cultures, such as 

the Athabascans, who have traditionally migrated with the seasons, and the Inupiaq and St. Lawrence 

Island Yup’ik of the far North. In some areas, the term “Eskimo” is considered derogatory. 

Continued on next page 

Chapter 1 25 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

MYTHS AND FACTS ABOUT AMERICAN INDIANS AND ALASKA NATIVES 

(CONTINUED) 

Myth: American Indians and Alaska Natives have an innate, unquenchable appetite for alcohol and become 

extremely violent when they consume too much. 

Fact: When Native Americans were frst exposed to alcohol in the 18th and early 19th centuries, some 

abstained, and others drank in moderation. They did not display an immediate craving for alcohol. 

No evidence suggests that American Indians and Alaska Natives uniformly respond violently to being 

inebriated. 

Myth: American Indians and Alaska Natives are more susceptible to the effects of alcohol than are people of 

other races. 

Fact: This has no basis in science. Genes that increase the risk of substance use disorder and related factors, 

such as tolerance and craving for alcohol, are no more common among Native Americans than among 

White Americans. This myth defects attention from the historical context of the introduction of alcohol into 

native communities by European traders and explorers and the effects of historical trauma. 

Myth: The solutions to problems in native communities—alcohol abuse in particular—have to come from 

outside those communities. 

Fact: The most successful substance abuse treatment programs have originated within native 

communities and use local models of recovery. This allows clients to link their health and well-being to 

that of the community. The myth serves to perpetuate the dominance of the mainstream culture and a 

patronizing attitude. 

Myth: American Indians and Alaska Natives receive a lot of services at no cost, such as education and 

health care. 

Fact: A safety net of local, state, and federal tax dollars helps maintain educational and healthcare 

institutions in native communities, just as it contributes to other economically impoverished areas. 

Regarding education, about 93 percent of more than 600,000 Native American students attend public 

schools, which are supported by local, state, and federal funds. About 42,000 students attend 183 Bureau of 

Indian Education schools, most of which are tribally controlled. 

A combination of Medicaid, IHS funding, state and local funds, federal discretionary grants, and tribal funds 

pays for behavioral health services for American Indians and Alaska Natives. Individuals may be eligible for 

funding from some or none of these sources. About 2 million people from federally recognized tribes and 

34 urban Indian communities (of the 5.2 million who identifed as Native American in the 2010 Census) 

received health care from IHS over a 3-year period (IHS, 2011). Increasingly, tribes have contracted for 

behavioral health services, which they operate themselves. 

Myth: American Indians and Alaska Natives are honored by American Indian mascots. 

Fact: These portrayals are coarse stereotypes. Although some depictions may be less offensive than others, 

they are all caricatures that obscure the uniqueness of the individuals who make up the population. Most 

American Indians and Alaska Natives are offended by these mascots. 

The Economic and Social Conditions of 

American Indians and Alaska Natives 

As you know, the lives of American Indians and 

Alaska Natives vary widely, but Native Americans 

are more likely than members of other racial or 

ethnic groups to face economic hardships and 

social problems. Many of these problems likely 

contribute to behavioral health issues among 

American Indians and Alaska Natives. 

Income and poverty 

Poverty is a signifcant and consistent variable 

across all social conditions that American Indians 

and Alaska Natives face. According to the 

Census Bureau (2018), 25.4 percent of American 

Indians and Alaska Natives were living in poverty, 

compared with 13.4 percent of the total population. American Indians and Alaska Natives had a

median household income of $41,882, compared 

26 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

with $60,336 for the population as a whole. 

The percentage of American Indians and Alaska 

Natives living in poverty was even higher in some 

states—as high as 51 percent for native households 

in South Dakota. Research with a variety of populations, including American Indians and Alaska 

Natives, suggests that poverty can contribute to 

the development, persistence, and severity of 

some mental and substance use disorders. 

Unemployment 

Unemployment is high among American Indians 

and Alaska Natives; in 2017, 7.8 percent were 

unemployed, compared with 3.8 percent of White 

Americans (Department of Labor, Bureau of Labor 

Statistics, 2018). Four years earlier, the American 

Indian and Alaska Native unemployment rate had 

been above 10 percent for 5 consecutive years 

(Austin, 2013). The unemployment rate is even 

higher for Native Americans living on reservations 

and other tribal lands (Pettit et al., 2014). In 2010 

there were numerous states (which included Alaska, 

Arizona, California, Maine, Minnesota, Montana, 

New Mexico, North Dakota, South Dakota, and 

Utah) where fewer than 50 percent of Native 

Americans ages 16 and older living on or near 

reservations were employed (Department of the 

Interior, Offce of the Assistant Secretary–Indian 

Affairs, 2014). This included people out of the 

labor force. Unemployment is associated with an 

increased risk for substance abuse for American 

Indians and Alaska Natives, and it may contribute 

to other behavioral health problems. 

Housing and homelessness 

American Indians and Alaska Natives have a high 

rate of homelessness. In 2017, 3 percent of people 

entering homeless shelters were Native Americans, 

although they made up less than 2 percent of 

the population (Henry, Watt, Rosenthal, & Shivji, 

2017). American Indians and Alaska Natives who 

have houses are also more likely than the general 

population to live in overcrowded conditions or to 

lack kitchen facilities or complete plumbing (Pettit 

et al., 2014). In part, this crowding may occur as 

a result of accepting relatives into the household 

who may not have housing. For more comprehensive information on homelessness, see TIP 55, 

Behavioral Health Services for People Who Are 

Homeless (SAMHSA, 2013a). 

Fewer than half of all American 

Indian and Alaska Native women who 

experience violence report the crime 

to police. Of those who report, an 

estimated 60 to 90 percent of cases 

are not prosecuted. Native women 

who experience violence and live 

on reservations or in villages face 

the greatest barriers in obtaining 

prosecution because of jurisdictional 

conficts, lack of jurisdiction, and 

limited tribal criminal justice funding. 

Sources: Amnesty International, 2006; Bachman et al., 

2008. 

Education 

Compared with the general population, American 

Indians and Alaska Natives are less likely to 

graduate from high school or to have an equivalency, bachelor’s, or advanced degree (Ogunwole, 

2006). Education protects against substance abuse, 

depression, suicidality, and other behavioral health 

problems for American Indians and Alaska Natives, 

as well as for other populations. 

Trauma 

Compared with members of other major ethnic 

or racial groups (i.e., African Americans, Asian 

Americans, Latinos, White Americans), American 

Indians and Alaska Natives are more likely to suffer 

from many different types of trauma. Rates of 

trauma exposure are especially high for American 

Indian and Alaska Native women, relative to 

women in the population as a whole (Manson, 

Beals, Klein, Croy, & AI-SUPERPFP Team, 2005). 

Higher rates of certain types of trauma exposure 

(e.g., car accidents, unintentional injuries from 

other accidents) are related to the fact that many 

American Indians and Alaska Natives live in rural 

areas, where they may engage in more outdoor 

activities and have poorer infrastructure (e.g., 

bad roads, greater driving distances). High rates 

of binge drinking and other substance abuse can 

Chapter 1 27 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

also increase risk for accidents. There are fewer 

hospital facilities on native lands, so accidents are 

more likely to be fatal; American Indian and Alaska 

Native people are about two and a half times 

as likely to die from unintentional injuries as are 

members of the general population (IHS, 2017). 

Socioeconomic conditions, health disparities, 

and racism that contributes to violence against 

American Indians and Alaska Natives affect other 

types of trauma. 

Different types of trauma exposure are associated 

with increased risk for a number of different behavioral health issues (see Ehlers, Gizer, Gilder, & 

Yehuda, 2013). For more information on the links 

between trauma and mental and substance use 

disorders, see TIP 57 (SAMHSA, 2014b). 

Violent crime 

American Indians and Alaska Natives are more 

likely to experience violent crime than are 

members of any other major racial or ethnic 

groups—about twice as likely to experience it 

than African Americans, 2.5 times more likely than 

White Americans, and more than 4.5 times as 

likely as Asian Americans (Perry, 2004). What may 

be even more remarkable is that, compared with 

every other major racial or ethnic group, Native 

Americans are more likely to experience violence 

from members of other racial or ethnic groups 

and are more likely to experience violence from 

strangers (Harrell, 2012). Native women are more 

likely than members of any other major racial/ 

ethnic group to be survivors of rape. Acts of sexual 

violence against American Indian and Alaska Native 

women are mostly committed by members of 

other races. A recent report showed that, among 

American Indian and Alaska Native victims of 

sexual violence, 96 percent of women had experienced sexual violence by non-natives, whereas 

only 21 percent reported sexual violence by other 

Native Americans (Rosay, 2016). At the same time, 

arrest rates for most other crimes among American 

Indians and Alaska Natives are comparable to 

those for the general population (Department of 

Justice, Federal Bureau of Investigation, 2018). 

BEYOND TRAUMA: SOUTH 

DAKOTA URBAN INDIAN HEALTH 

South Dakota Urban Indian Health (SDUIH) 

provides holistic health and behavioral health 

services by integrating traditional ways into its 

treatment programs. SDUIH created a culturally 

specifc recovery group called Beyond Trauma in 

response to community need. Beyond Trauma 

recognizes that many substance use disorders 

in the American Indian community stem from 

historical, childhood, and ongoing trauma. The 

program holds that addressing trauma is crucial 

to support ongoing recovery and improve the 

quality of relationships with self, family, and the 

community—a key ingredient in recovery. The 

Beyond Trauma support group helps participants 

“create rewarding and enjoyable lives, beyond a 

survivor identity” (p. 10). The group opens with a 

prayer and smudging. Then, participants share 

their challenges and celebrate how they have 

overcome those challenges. Participants develop 

strong, trusting relationships with one another. 

The recovery group is also an opportunity to forge 

lasting relationships and share substance-free 

activities with others in the community. One key 

beneft of Beyond Trauma is the opportunity for 

participants to see resilience in their peers and 

then, through self-refection, begin to recognize it 

in themselves. 

Source: Urban Indian Health Institute, 2014. 

Child abuse 

Abuse and neglect in childhood are associated 

with increased risk for substance abuse, anxiety 

disorders, and mood disorders. Research 

conducted with American Indians and Alaska 

Natives confrms this link (e.g., Libby, Orton, 

Novins, Beals, & Manson, 2005). 

Rates of childhood abuse among American Indians 

and Alaska Natives vary considerably among tribes, 

and different studies have found widely different 

rates. Native children continue to be overrepresented in the child welfare system, with higher 

rates of reported child maltreatment compared 

with other racial and ethnic groups. One study 

also found that American Indian and Alaska Native 

children were more likely to die from abuse than 

were White American or African American children 

(Dakil, Cox, Lin, & Flores, 2011). 

28 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

Domestic violence 

American Indian and Alaska Native men and 

women are more likely to report having experienced domestic violence than are men and women 

from other racial/ethnic groups (Breiding, Chen, & 

Black, 2014). As with other types of violent crime, 

non-Native Americans commit the majority of 

domestic violence toward Native Americans. 

Having experienced domestic violence has been 

associated with binge drinking and other types 

of substance abuse for American Indians and 

Alaska Natives (Oetzel & Duran, 2004), and severe 

intimate partner violence has been associated 

with increased risk for mood disorders and anxiety 

disorders for American Indian and Alaska Native 

women (B. Duran et al., 2009). (See also TIP 51, 

Substance Abuse Treatment: Addressing the 

Specifc Needs of Women [Center for Substance 

Abuse Treatment, 2009b].) 

Physical health 

American Indians and Alaska Natives are more 

likely than other racial or ethnic groups to have 

certain physical problems, including tuberculosis, 

diabetes, and cardiovascular disease (National 

Center for Health Statistics, 2014). They are also 

more likely to report current health as only poor to 

fair. Mortality rates from many causes are higher for 

Native Americans than for the general population. 

Death rates are higher related to alcohol (520 

percent higher), diabetes (177 percent higher), 

chronic liver disease and cirrhosis (369 percent 

higher), and tuberculosis (450 percent higher) than 

for the general population (IHS, 2014). 

Many health problems in American Indians and 

Alaska Natives have a behavioral component. 

Seven of the 10 leading causes of death for Native 

Americans have a behavioral component and relate 

to lack of exercise, poor diet and nutrition, tobacco 

use, or alcohol use (Kochanek, Murphy, Xu, & 

Tejada-Vera, 2016). 

A lack of access to quality health care also contributes to American Indians’ and Alaska Natives’ poor 

health. Although most Native Americans live in 

urban areas, IHS provides care at a limited number 

of urban sites, and these sites receive only a small 

percentage of IHS funds. Thus, even American 

Indians and Alaska Natives who are eligible for 

IHS services may not have access to a program. 

Moreover, IHS offers services only for members of 

federally recognized tribes, which excludes nearly 

two-thirds of American Indians and Alaska Natives. 

Many American Indians and Alaska Natives who do 

not receive IHS services lack medical insurance and 

may not seek medical care because they cannot 

afford it (Urban Indian Health Institute, 2008). 

THE ROLE OF CULTURE IN 

BEHAVIORAL HEALTH SERVICES 

As a treatment provider, you will want to help 

your clients be as healthy as possible and lead 

a balanced and meaningful life. To do so, you 

need to understand how a client defnes health, 

balance, meaning, and similar constructs, as 

well as the specifc culture or cultures that are 

relevant for each client. Many American Indian 

and Alaska Native cultures share certain values 

and beliefs; however, what is important for one 

person or community may differ from another 

individual or tribe. And, as with any racial, ethnic, 

or cultural group, differences exist within the 

same community among members. 

For many American Indians and Alaska Natives, 

the process of healing a mental or substance 

use disorder will involve reconnecting with their 

traditional culture, although for others, it may 

involve distancing themselves from some cultural 

activities that were connected with substance 

abuse. Researchers have found that a stronger 

connection to one’s traditional native culture 

or to certain parts of it (such as spirituality) can 

be a protective factor against some mental and 

substance use disorders, although other variables 

such as gender and place of residence affect 

this as well. Reconnecting clients with their 

traditional culture may, depending on the clients’ 

preferences, also aid in the treatment of those 

disorders. (See the West section discussion of 

traditional healing and other cultural practices in 

behavioral health services.) 

The Importance of American Indian and 

Alaska Native Culture to Your Clients 

To determine the widely varying role of American 

Indian and Alaska Native culture in your clients’ 

lives, you will need to discuss it with and assess 

each client. Some associate very strongly with 

Chapter 1 29 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

their traditional native culture, whereas others 

consider themselves to be members of mainstream 

American culture and have little or no connection 

to native culture. Still others have high acculturation to another nonmainstream culture while 

maintaining a connection with their tribal culture. 

Many American Indians and Alaska Natives are multicultural, and they are able to successfully navigate 

among cultures including mainstream culture. 

The process whereby a person from one cultural 

group learns and adopts another culture is called 

acculturation. If an individual fully adopts another 

culture, it is called assimilation. An individual who 

practices biculturalism is considered to be equally 

fuent in both his or her culture of origin and mainstream culture. This is often referred to as “walking 

in two worlds” among American Indians and Alaska 

Natives. “Enculturation” is a term describing 

the process by which one learns about a culture. 

It often describes an individual’s knowledge of 

and connection with his or her traditional culture 

(Stone, Whitbeck, Chen, Johnson, & Olson, 2006). 

Exhibit 1.1-3 shows a sample cycle of assimilation 

and reconnection of native cultural identity, 

beginning with traditional native identity and 

proceeding to reconnection. 

EXHIBIT 1.1-3. Cycle of Assimilation and Reconnection 

Traditional

• Speaks only native language 

• Lives on reservation, native 

village, or trust land 

• Participates in native traditions 

(e.g., subsistence lifestyle, 

ceremonies, traditional medicine) 

• Being native is core identity: 

Walks in the native world 

Bicultural

• May speak native language and English 

• May live in or near native community or migrate back 

and forth between native community and urban areas 

• Participates in both traditional and non-native activities 

(e.g., employment, education, interests, relationships) 

• Being native is key, yet not sole identity 

Assimilated

• Speaks only English 

• Has no connection with 

native communities, 

spirituality, or traditions 

• Doesn’t identify with 

native identity 

Reconnection

• Makes conscious effort to return and learn native ways 

• Begins to participate in native community activities and customs 

• Invests in learning native language, arts, and sociopolitical issues 

• Begins to reconnect with identity as native 

Mainstream Native

30 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

Acculturation is not a static process. At different 

points in time, individuals may be at different 

places on this continuum. It does not represent a 

hierarchy of values; there is no right or wrong place 

to be on this continuum. What is important is that 

clients feel comfortable with their levels of acculturation and not feel acculturative stress because of 

pressure to be one way or the other. 

The East (right) side of the circle in Exhibit 1.1-3 

indicates that some native people live traditional 

lives in traditional American Indian and Alaska 

Native communities. They may have little contact 

with non-Native Americans; they may speak 

only their own languages. They may engage in a 

subsistence lifestyle, although they may make use 

of modern technology, such as using snowmobiles 

instead of dogsleds when hunting. Their worldviews are very similar to those held by their people 

over centuries. People who are totally immersed in 

their indigenous cultures would be unlikely to seek 

treatment from outsiders. When they seek help, 

they will more likely work with traditional healers. 

On the West (left) side of the circle are people 

who seldom think of their native culture and do 

not see it as a defning characteristic of who they 

are. They may recognize that they have native 

ancestry and even identify their race as American 

Indian or Alaska Native because of it, but they are 

very comfortable with mainstream culture, have 

mainstream values and worldviews, and do not feel 

that their native ancestry should play a role in their 

behavioral health services. 

Most American Indians and Alaska Natives fall 

somewhere between these two poles. They may 

live away from their tribal lands at least part of the 

time. If they live in a city, they may be active in an 

American Indian and Alaska Native community 

center and participate in traditional ceremonies, 

pow wows, and other native cultural gatherings on 

weekends or during vacations. They may socialize 

with other natives as well as non-Native Americans. 

Some know their tribal language and speak it at 

home, but most do not, although they may wish 

they had learned it. They consider themselves 

bicultural (South). 

The North (upper portion) of the circle represents 

reconnection, thus completing the cycle. Many 

American Indians and Alaska Natives are making 

a conscious effort to reconnect with native ways. 

They are reconnecting and investing in developing 

a native identity. This may include reengagement 

of tribal-specifc or pan-Indian cultural activities. 

Consider this circle for a moment in regard to 

your own ethnic heritage. How important are the 

cultures of your ancestors? How do those cultures 

affect you? 

Commonalities Among American Indian 

and Alaska Native Cultures 

Despite the diversity among American Indian and 

Alaska Native cultures, similarities among them 

provide common ground. Some beliefs and values 

are shared by most American Indian and Alaska 

Native cultures and are distinct from those of mainstream American culture. These are beliefs that are 

likely to be held by American Indians and Alaska 

Natives who at least partially associate themselves 

with native cultures, although for those who are 

fully acculturated to mainstream American culture, 

even these broad beliefs may not be relevant. 

The American Indian and Alaska Native 

worldview 

The way American Indians and Alaska Natives 

look at life and the world around them—their 

worldviews—differ vastly from those of mainstream 

Americans. Europeans who came to this country 

believed that the earth and its creatures should 

serve their needs. American Indians and Alaska 

Natives believe that they are only one part of 

creation, dependent on nature, and meant to live in 

harmony with all things—not just people, but also 

animals, plants, and the elements. Native traditions 

teach that all these things have life and deserve 

respect. Native Americans also traditionally believe 

in the importance of balance and harmony at all 

levels of life: internally for the individual, socially 

among people, and naturally in relationships with 

animals and the rest of creation. This worldview 

continues to infuence American Indians and Alaska 

Natives. 

Chapter 1 31 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

ALASKA NATIVE VALUES 

Alaska Native cultures have certain values that 

are of paramount importance to their members. 

Below are some values that the fve major Alaska 

Native cultures share, although there may be 

some minor variations among them. 

Show respect to others: Each person has a 

special gift. 

Share what you have: Giving makes you richer. 

Know who you are: You are a refection on your 

family. 

Accept what life brings: You cannot control 

many things. 

Have patience: Some things cannot be rushed. 

Live carefully: What you do will come back to 

you. 

Take care of others: You cannot live without 

them. 

Honor your elders: They show you the way in life. 

Pray for guidance: Many things are not known. 

See connections: All things are related. 

Source: Alaska Native Knowledge Network, 2006. 

The importance of community for American 

Indians and Alaska Natives 

Native cultures are more community oriented than 

mainstream American culture and less concerned 

with the importance of individual efforts and privileges. American Indians and Alaska Natives defne 

themselves as members of a family, community, 

tribe, and nation. Native cultures are most strongly 

maintained by those living in an Alaska Native 

village or on tribal lands, but those who live some 

distance from those lands may still identify strongly 

as members of a tribe. 

Community norms and values play an important 

role in all aspects of life for American Indians 

and Alaska Natives, including treatment for and 

recovery from mental and substance use disorders. 

Involving family and community members in 

treatment is important in providing effective 

services for most American Indians and Alaska 

Natives. When you provide services in a location 

that is predominately Native American, you will 

want to elicit input from community members 

on how services are rendered and what types of 

services are needed. However, keep in mind that 

shame concerning behavior or treatment-seeking 

related to substance use or mental illness can also 

affect your American Indian and Alaska Native 

clients, who may be wary of seeking services 

because of what others in the community may 

think. 

American Indians and Alaska Natives typically 

value connectedness and personal relationships. 

Your interest in the community and in building 

relationships with community members can help 

them accept you as a provider and your program. 

Individuals may be more willing to seek your 

services and have a more positive experience in 

treatment. By not limiting your involvement in 

the community to the treatment milieu but also 

engaging in the cultural, social, and recreational 

activities of the community, you will better understand how life there functions. 

Family structure 

The family is extremely important to American 

Indians and Alaska Natives, and native families 

differ in some ways from the mainstream American 

norm. Some native societies are matrilineal in social 

organization and descent. This means, in part, that 

families may trace their ancestral lineages through 

the maternal side, pass property through female 

heirs, grant women key decision-making roles in 

governance, and readily assign custody to mothers 

or grandmothers. American Indians and Alaska 

Natives typically defne family as extending beyond 

the nuclear unit, sometimes including people who 

are not blood relations. About half of American 

Indian and Alaska Native family households include 

members of the extended family, and about 

one-quarter include people who are not directly 

related to the primary residents. About 30 percent 

of American Indian and Alaska Native families are 

headed by single mothers. Grandparents also often 

raise children, sometimes with assistance from 

other members of the extended family. 

Because extended families are often very close, 

you may fnd that they expect to be involved 

in the treatment process along with their loved 

ones. Grandparents, aunts, uncles, cousins, and 

“adopted” family members who are not blood 

32 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

relatives may play important roles. It is important 

for you to ask your clients about their families and 

their willingness to be involved in treatment. You 

can ask new American Indian and Alaska Native 

clients questions such as, “Where did you grow 

up?” “Who raised you?” or “Who are the members 

of your family?” 

American Indian and Alaska Native spiritual 

beliefs 

American Indians and Alaska Natives observe 

many spiritual practices. Although these spiritual 

practices refect diverse, specifc beliefs about 

such things as the creation of the world or the 

appropriate ceremonies to perform at given times, 

many share certain basic spiritual principles. These 

involve living in harmony and balance with others 

and with the world, believing that there is order to 

the universe, and feeling a connection with others 

and with all life. 

Spirituality is important for most American Indians 

and Alaska Natives. For example, 79.2 percent 

of American Indians and Alaska Natives ages 12 

to 17 in 2014 stated that religious beliefs are an 

important part of their lives, and 72.3 percent 

believed that their beliefs shape decision making 

(Center for Behavioral Health Statistics and Quality, 

2015). Having a stronger commitment to traditional 

spirituality is a protective factor against suicide 

and some mental and substance use disorders for 

American Indians and Alaska Natives (Eastman & 

Gray, 2011; Garroutte, Goldberg, Beals, Herrell, & 

Manson, 2003). 

Many American Indians and Alaska Natives are 

Christians, although many belong to groups that 

incorporate some native beliefs and practices into 

Christianity, such as the Native American Church. 

Less than 0.3 percent of the U.S. population (about 

one-sixth of the Native American population) 

identify as practicing traditional Native American 

religions (Pew Forum on Religion & Public Life, 

2008). Still, even among American Indians and 

Alaska Natives who identify solely as Christian, 

traditional native spiritual beliefs may affect their 

view of the world and their place in it. In some 

native communities, both Christian and native ceremonial rituals occur at the same time (e.g., taking 

frst communion and wearing regalia, smudging at 

baptisms). 

What You Need To Understand About 

the American Indian and Alaska Native 

Experience Today 

American Indians and Alaska Natives are, genetically or by adoption, members of a community 

that has experienced centuries of assault on their 

culture and still survives. To the extent that your 

American Indian and Alaska Native clients have 

been connected to native family and community, 

they know this history, and it likely continues to 

affect them. They also probably have a strong 

positive connection with their people and the 

place from which they come. American Indians and 

Alaska Natives today are more likely than members 

of other groups to face a host of problems, 

including poverty, unemployment, trauma, criminal 

victimization, physical health problems and disparities, and mental and substance use disorders. 

However, they continue to be a resilient people who 

can draw on the strength of their cultures, communities, and families to help face these problems. 

The Navajo concept of hozhq is used in everyday speech to express one’s 

interconnectedness with other people and the land, balance, and harmony in one’s 

life—elements that are part of one’s health and happiness. For example, when 

someone is leaving another individual, the person may say, hozhqqgo naninaa 

doo: “May you walk about according to hozhq.” In part, it is a reminder to go about 

deliberately. 

Source: Witherspoon, 1977. 

Chapter 1 33 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Realize that we as human beings 

have been put on this earth for 

only a short time and that we 

must use this time to gain wisdom, 

knowledge, respect, and the 

understanding for all human 

beings since we are all relatives.” 

—Cree proverb 

Source: Saskatchewan Indian Cultural Center, 2014. 

Moving to the South: The 

Direction of Cultural Awareness 

and Competence 

Because you are reading this TIP, you must already 

be concerned about cultural competence. If you 

want to know more about treating clients from 

American Indian and Alaska Native cultures, you 

need to make some changes in your practice 

to best meet their needs, and that means you 

recognize a need for cultural competence. 

Cultural competence is important for all clients, 

but this section discusses how your cultural 

Cultural Awareness 

and Competence 

(South) 

Part 1: 

Providers 

Part 2: 

Administrators 

Part 3: 

Researchers 

competence can affect your treatment of American 

Indian and Alaska Native clients specifcally and 

how you can build cultural competence when 

working with those clients. Sections that follow 

investigate how your cultural competence in 

relation to native ideas of health and healing 

can positively affect treatment (the West) and 

how cultural competence can help you tailor and 

implement treatment and prevention services for 

mental illness and substance abuse to make them 

appropriate for your American Indian and Alaska 

Native clients (the North). TIP 59 (SAMHSA, 2014a) 

has a more detailed discussion of how to provide 

culturally responsive treatment for all clients and 

includes information on assessing your own cultural 

identity, models of cultural identity development, 

and core competencies for providers related to this 

topic. 

You develop cultural competence in stages, 

starting with cultural awareness, which is itself a 

three-stage process. If you have cultural awareness, 

you will examine how your own beliefs, experiences, 

and biases affect your defnitions of normal and 

abnormal behavior, behavioral health, and recovery 

from behavioral health problems. After developing awareness, you will need to expand your 

knowledge of American Indian and Alaska Native 

cultures, then work on applying that knowledge 

to your practice. You can also work to ensure that 

the organization that employs you takes cultural 

competence seriously and builds its own organizational cultural responsiveness, a topic discussed 

at greater length in Chapter 4 of TIP 59 (SAMHSA, 

2014a). 

Developing Cultural Awareness 

Three steps are involved in developing cultural 

awareness. Becoming aware of cultural differences 

is the necessary frst step. The second step is 

gaining awareness of your own cultural values and 

the role they play in your life. The third step is 

developing an understanding of cultural dynamics, 

such as cultural barriers, prejudice, and racism, 

which may occur when members of diverse cultures 

interact. 

Step 1: Awareness of cultural diferences 

The frst step in providing culturally responsive 

treatment, no matter what the population, is to 

34 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

become aware of the differences between the 

culture with which you identify and that of your 

clients. Once you do so, you will better understand 

how your clients’ cultures may affect them and how 

your culture affects your interactions with people 

from other cultures. 

We are social beings; as Alaska 

Natives we possess a strong history 

of successes through unity and 

togetherness. We feel a need to 

belong. A danger in not knowing 

who you are is the attraction to be 

somebody else.” 

—Students of the Gaalee’ya Project 

Source: University of Alaska Fairbanks, 2013, p. 5. 

Your American Indian and Alaska Native clients are 

probably already aware of the differences between 

mainstream American cultures and native cultures. 

They have likely had to negotiate these differences 

all their lives. As noted in the discussion of acculturation, most American Indians and Alaska Natives 

are somewhat acculturated to mainstream society 

while also being at least somewhat comfortable 

with their traditional cultures. However, even the 

most traditional American Indians and Alaska 

Natives will be exposed to mainstream culture 

sometimes, whereas most mainstream Americans 

will have little contact with Native American 

cultures. This means that you will likely have a lot 

more to learn about American Indian and Alaska 

Native cultures than Native American clients will 

have to learn about mainstream American culture. 

If you are completely enmeshed in mainstream 

American culture, it is easy to assume that your 

values are the norm. You may not be aware of how 

other cultures defne values and beliefs because 

you assume that everyone naturally shares your 

values and beliefs. In some cases, you may even 

consider signs of straying from that norm as 

symptomatic of mental illness, even though that 

behavior may be perfectly acceptable within your 

clients’ cultures (e.g., a client who has had visions 

during a sweat lodge or another ceremony might 

be considered psychotic in mainstream culture). 

When you lack cultural awareness, you may 

make assumptions based on the attitude that 

your American Indian and Alaska Native clients 

are pretty much the same as you are—or that 

they should be if they are to recover from their 

problems. Without cultural awareness, you more 

easily discount the importance of how culturally 

defned beliefs, values, and attitudes infuence your 

impressions of clients and the treatment plans you 

formulate with them. 

Some practitioners assume that 

all Native American clients have 

diffculty in making eye contact. This 

preconception can oversimplify your 

clients’ behavior and often overshadow 

the need to explore other explanations 

if they are quiet, take time to respond, 

or are looking away. Be overly cautious 

of stereotypes. Your clients have many 

sound and historical reasons for being 

wary of treatment. Your responsibility 

is to be trustworthy and to take the 

time needed to build trust and to 

invest in relationships. 

Of course, your cultural identity may differ from 

that of mainstream society. Your family may be 

immigrants or come from a culture within the 

United States that has values that differ from 

the mainstream. In that case, you are probably 

further along in the process of becoming culturally 

aware and have already thought about your own 

cultural identity and its relationship to mainstream 

American culture. Still, even in those cases, you 

must be careful not to assume that the experiences 

of a Native American negotiating these cultural 

differences are the same as the experiences of 

those in your own cultural community. American 

Indians and Alaska Natives have a unique history 

and face unique challenges in their interactions 

with mainstream culture and its institutions. Even if 

you have worked with American Indian and Alaska 

Native clients before or have a cultural connection 

of your own to American Indian and Alaska Native 

Chapter 1 35 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

cultures, you may still not understand the specifc 

culture of an individual American Indian and Alaska 

Native client. You will want to keep in mind the 

diversity of American Indian and Alaska Native 

cultures and remember that acceptable practices in 

one culture may not be acceptable in another. 

One way to begin noticing cultural differences 

is becoming conscious of how your own culture 

shapes your beliefs, values, perceptions, and 

behavior. Observe your reactions to American 

Indian and Alaska Native clients’ responses and 

presentation and take time to look at how their 

cultural, linguistic, and historical experiences may 

differ from your own; do not assume that every individual from the same cultural group will respond 

the same way. It is a delicate balance—being 

aware that culture plays a signifcant role while 

avoiding generalizations and allowing for individual 

differences. 

Step 2: Self-assessment of your values 

The next step in becoming culturally aware is to 

look at how your culture affects your beliefs and 

values. Your culture may be tied to your racial or 

ethnic identity, or you may identify with mainstream 

American culture, in which case that culture will 

help defne your beliefs and values. Your culture 

will shape other things too: perhaps the music 

you listen to, the food you eat, the holidays you 

celebrate, the religious or spiritual beliefs you 

have, your choice of occupation, and the way 

you spend your leisure time. It will infuence your 

attitudes toward authority, health and wellness, and 

behavioral health services. Your cultural identity is 

unlikely to be static, and even the act of becoming 

aware of your cultural beliefs can cause some 

change to those beliefs, or at least an openness to 

changing them. 

One way to evaluate how culture affects your 

beliefs is to look at some beliefs and values 

common to most, if not all, American Indian and 

Alaska Native cultures and consider how your 

beliefs may be similar or different. Exhibit 1.1-4 

lists eight cultural values and offers possible explanations as to why these values became important 

for native societies and how they affect behavior. 

As you think about these, also think about how 

your own beliefs and values may differ. It is not a 

matter of judging one value as right and the other 

as wrong, but rather, improving your understanding 

of American Indian and Alaska Native values and 

beliefs as well as your own. 

Step 3: Understanding the efects of cultural 

diferences 

After examining just these few cultural differences, 

you can see the potential for misunderstanding 

and miscommunication in relationships with 

American Indian and Alaska Native clients. If you 

do not understand American Indian and Alaska 

Native cultures, you might easily mistake modesty 

and humility for a lack of engagement or a lack 

of interest in working to acquire wealth as being 

unmotivated or lazy. 

Such misunderstandings feed prejudice, discrimination, and microaggressions at a societal level and 

in treatment. The third part of developing cultural 

awareness is understanding how cultural differences can result in prejudice, stereotyping, and 

racism. Within the treatment setting, this involves 

evaluating how cultural differences can create 

misunderstandings that in turn lead to inadequate 

treatment for American Indian and Alaska Native 

clients. This is not an easy topic to explore; it 

requires that you also look at ways in which you 

and your organization may have discriminated or 

been biased against people from a culture that is 

different from your own. 

Your American Indian and Alaska Native clients’ 

priorities, values, and styles of communication may 

differ from yours. Their reasons for seeking healing 

may be different from what you have experienced 

before. Their goals may be different from what 

you expect, and their behaviors in your treatment 

setting may differ from what you ask of them. You 

may be frustrated when clients seem slow to open 

up, arrive late or not at all for sessions, do not speak 

up in group discussions or group therapy, do not 

look you in the eye, and evade answering your 

questions. 

But what about the American Indian and Alaska 

Native clients’ frustrations? From their point of 

view, the provider may seem uninterested in 

understanding them. He or she may seem to 

think that a diagnosis—labeling a person—is the 

36 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

EXHIBIT 1.1-4. Traditional American Indian and Alaska Native Values 

and Beliefs 

NATIVE CULTURAL BELIEFS AND VALUES QUESTIONS ABOUT YOUR BELIEFS AND VALUES 

Cooperation, collectivism, and harmony. 

Historically, native societies needed a high level of 

cooperation to survive (e.g., obtaining suffcient 

food). American Indians and Alaska Natives place 

value on the importance of the group rather than 

on the individual. Sharing is vital. Likewise, there is 

considerable emphasis on living in harmony with 

nature and with others. To ensure group harmony, 

groups generally reach decisions by consensus rather 

than by majority rule. 

Are you more cooperative or competitive? Do you 

value individual efforts more or less than group 

efforts? Do you see value in arguing? Do you see 

benefts to a more cooperative society? Do you 

see drawbacks? Do you see the infuence of your 

family and your family’s culture in these beliefs? Is 

nature something to be conquered or organized? 

Modesty and humility. In some ways, this grows 

out of a focus on collective effort and harmony. 

In American Indian and Alaska Native cultures, 

efforts at self-aggrandizement are typically seen as 

inappropriate. 

Modesty means that native people may appear 

cautious with words and actions. Being humble 

means that one listens to others and doesn’t talk for 

the sake of talking or to make oneself appear more 

important. Words are used sparingly, and because 

words are believed to have power, a lot of thought 

is given to the content and delivery of speech. 

Sometimes nothing is said. 

Avoiding eye contact is another aspect of humility, 

because direct eye contact may be considered a 

challenge. 

Do you feel the need for personal recognition? 

How important is modesty to you? Does your 

culture reward humility? 

Do you think people who don’t talk much are shy 

or disengaged, or do you see other reasons for 

such behavior? Do you appreciate people who 

are good conversationalists? Do you assume 

that people who talk about themselves are more 

open? Are you suspicious of people who don’t? As 

you listen, do you feel that you need to fll up the 

silences? 

Do you think it is important to make eye contact 

to assert yourself or to create a connection with 

another individual? Do you assume that people 

who don’t make eye contact have something to 

hide? 

Respect for personal freedom and individual 

autonomy. Although at frst this may seem contrary 

to the emphasis on cooperation and valuing the 

group above the individual, it is actually an important 

part of it. For a close-knit society to work, each 

member has to respect that others will act honorably 

and for the good of the whole. This also means that 

personal advice is not often given, because to do so 

might suggest that the person receiving the advice 

did not already know the correct course of action. 

Do you think it helps other people to be 

instructed on how to act? In your culture, is 

advice freely given? Is being able to give and take 

criticism considered important? In your culture, 

is it important for people to make their own 

mistakes, or is it important for someone to give 

advice when they believe it is needed? 

Continued on next page 

Chapter 1 37 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

EXHIBIT 1.1-4. Traditional American Indian and Alaska Native Values 

and Beliefs (continued) 

NATIVE CULTURAL BELIEFS AND VALUES QUESTIONS ABOUT YOUR BELIEFS AND VALUES 

Respect for tradition and elders. Valuing tradition is 

necessary if a culture is to survive against the social 

forces that push it to assimilate. American Indian and 

Alaska Native cultures perceive respect for tradition 

as more important than innovation and change. 

Native cultures have a great deal of respect for elders 

as those who survived adversity and gained wisdom 

from it. Those elders help maintain traditions. 

American Indian and Alaska Native cultures originally 

communicated by spoken word, which contributes 

to their respect for this oral tradition. Such cultures 

prioritized spoken traditions and endeavored to keep 

them unchanged, whereas written tradition allows 

change while still preserving past versions. In many 

native communities, maintaining oral traditions is 

very important; some forbid writing down traditional 

stories. 

How important are your own cultural traditions 

to you? Does your culture’s history infuence how 

you value those traditions? Do you think that 

the ability to change is more important than 

maintaining ties to the past? Are children in 

your culture taught the traditional language of 

the family? Do you know songs or stories in your 

primary language? 

Does your culture value youth more than age? 

Does your culture look on its elderly as sources of 

wisdom gained from experience? In your culture, 

are the older members emulated as role models? 

Work should be done to meet needs, not to 

accumulate wealth. Native societies did not 

traditionally stockpile resources or wealth. Strong 

communal bonds fostered resource sharing. People 

were not left to fend for themselves. Some native 

languages do not even have words for ownership 

in the same sense that European languages do. In 

these cultures, people who take more than they need 

would be viewed with suspicion. 

People may gain respect not for having lots of 

possessions, but rather for their generosity in giving 

possessions away. Native societies value generosity 

and hospitality. Some native cultures traditionally give 

gifts or distribute surplus wealth. The Athabaskan 

and other Northwest native cultures hold potlatches 

to celebrate or honor specifc events, whereby one 

group may host the celebration and distribute gifts to 

the guests (Langdon, 2002). 

How important are material things to you? Does 

your culture praise people who are wealthy? Does 

it consider wealth a mark of greatness? Does 

your culture encourage people to work no matter 

what? Does it encourage accumulation as a 

bulwark against future problems? Is it important 

to pass on wealth to children? 

How important is it in your culture for people 

to be independent, and does that affect your 

attitude toward giving to others and accepting 

others’ generosity? Can you trace your beliefs 

about money, such as the relative importance of 

generosity or thriftiness, to your family and your 

family culture? 

Spiritual orientation in all aspects of life. American 

Indian and Alaska Native spiritual traditions do not 

separate the spiritual and material, but rather see the 

two as inexorably linked. Thus, the spiritual pervades 

daily life and is not compartmentalized. This also 

means that the natural world can itself be perceived 

as spiritual or mystical, and what is observed in daily 

life can teach a spiritual lesson. 

How central to your life are your own spiritual 

and religious beliefs? Are they always present, 

or do you put aside times to focus on spiritual 

matters and at other times concern yourself with 

practical things? Does your culture or religion 

see the physical world as cut off from the divine 

or spiritual world? Does your culture defne the 

spiritual as embodied in one host or in everything 

and every being? 

Continued on next page 

38 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

EXHIBIT 1.1-4. Traditional American Indian and Alaska Native Values 

and Beliefs (continued) 

NATIVE CULTURAL BELIEFS AND VALUES QUESTIONS ABOUT YOUR BELIEFS AND VALUES 

Cooperation with nature. According to American 

Indian and Alaska Native spiritual beliefs (described in 

the East), all of nature is alive and worthy of respect. 

The Earth and all that is on it are considered sacred 

and worthy of protection. Native societies could 

traditionally gain sustenance from the natural world 

in a relatively resource-rich environment, which 

encouraged this respect. These cultures found that 

maintaining balance helped resources last. 

What are your attitudes toward nature and your 

place in it? Does your culture believe human 

beings are at the summit of all things on Earth or 

merely a part of it, and how does that belief affect 

attitudes toward the rest of the world? Do you 

think that scarcity of resources and competition 

with others means that people should take what 

they can get from the Earth while it lasts? 

The present is more important than the future. 

Emphasis is on living from day to day and is 

measured by natural occurrences (e.g., seasonal 

changes, sunrise/sunset, moon phases). This, 

combined with attitudes that prioritize listening 

and paying attention to the world around them, 

leads these societies to be focused on the present. 

Focusing too much on the future might keep people 

from paying attention to the present. Some native 

languages do not even have a future tense. 

American Indian and Alaska Native cultures also value 

patience, believing that things will be done in their 

own time. This means that it is not as important to 

get things done on time as it is to let things go their 

natural course. 

How important is it in your culture to plan for 

the future? Do you think society needs careful 

planning to function best? Do you believe that 

schedules and deadlines are necessary to be 

productive? 

What are your attitudes about time and 

promptness? Which do you value more: getting 

things done on schedule or taking the time to 

get things done as they should be? Can you trace 

your attitude about promptness to your family’s 

habits? Is your family from a culture where people 

value promptness? Does your culture value 

patience? 

WHAT ARE MICROAGGRESSIONS? 

Microaggressions are brief, everyday slights, insults, snubs, derogatory statements, or indignities that 

communicate hostility or negative, judgmental messages to a person in a marginalized group based 

on his or her race, ethnicity, religion, nationality, sexual orientation, gender expression, gender identity, 

disability, age, socioeconomic status, or other identity characteristics. Microaggressions may be intentional 

or unintentional, conscious or unconscious, or verbal or nonverbal acts or environmental cues. Racial 

microaggressions are a subtle form of racism based on stereotypes of a specifc racial or ethnic group. 

Examples of microaggressions perpetrated against American Indian and Alaska Native people include 

Indian mascots in high school, college, and professional sports; a White supervisor at work jokingly calling 

an American Indian subordinate “Chief”; a teacher in a mainstream class singling out an Alaska Native 

student to stop being so quiet and speak up; or a non-native behavioral health service provider diagnosing 

an American Indian client with a social anxiety disorder because he has diffculty maintaining eye contact. 

Microaggressions have harmful consequences, including damaging the mental health of recipients; 

exacerbating the psychological effects of historical trauma; contributing to health problems; creating a 

hostile work or school environment; promoting and perpetuating stereotypes in the broader society; and 

contributing to the creation of inequities in education, employment, and health care. When providers 

are unaware of their prejudices and biases toward American Indians and Alaska Natives, their acts of 

microaggression can damage the therapeutic relationship, increase the premature termination of 

treatment, and signifcantly affect treatment. 

Source: Sue et al., 2007. 

Chapter 1 39 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

important thing, not the individual. The provider, 

or the program, is full of advice based on that label 

and tells the client what he or she should do, as if 

the client were a child and not capable of reaching 

his or her own conclusions. The provider seems 

rude, taking notes, completing paperwork frst, 

or looking directly at the client in a manner that 

seems disrespectful and sometimes challenging or 

intrusively intimate. The provider asks a question 

but is too impatient to wait for the client to think 

carefully about what is a true and important 

response. In the group sessions, not only do 

others give the client advice, but they also expect 

the client to give advice to others, which is not 

how one shows respect to others. Much of what 

typically occurs in treatment may be offensive or 

at least strange to an American Indian or Alaska 

Native client. 

Culturally responsive behavioral health agencies 

that serve American Indian and Alaska Native 

clients adapt to best ft the needs and preferences 

of those clients. This does not mean that you have 

to ignore problems, but rather, you need to fnd 

a way to address them that will not alienate your 

American Indian and Alaska Native clients. This 

is an ongoing process of learning for you, and 

beginning that process is the next step in developing cultural competence. 

Next Steps in Developing Cultural 

Competence 

After building cultural awareness, you will want 

to further expand your cultural competence by 

improving your knowledge of American Indian and 

Alaska Native cultures. Then, you will look for ways 

to apply that knowledge, using your knowledge of 

these cultures to frame treatment-related issues in 

an appropriate manner, adapt treatment strategies 

and interventions to be culturally appropriate, and 

develop new ways to provide services for your 

clients (e.g., through working with American Indian 

and Alaska Native traditional healers). You will need 

to regularly reassess your knowledge and your 

program so that changes can be made to improve 

the cultural relevance of your services. A helpful 

acronym for understanding how your knowledge of 

native cultures (or any cultures, for that matter) can 

assist in treatment is given in the box that follows. 

RESPECT: A MNEMONIC FOR 

CULTURALLY RESPONSIVE 

ATTITUDES AND BEHAVIORS 

• Respect: Become familiar with communication 

styles. Understand how respect is shown in 

American Indian and Alaska Native cultures 

and show respect through verbal and 

nonverbal communications. Learn to listen. Be 

comfortable with silence and never interrupt or 

point with your fngers in conversations. 

• Explanatory model: Devote time to 

understanding how clients perceive their 

presenting problems, how these problems are 

understood in American Indian and Alaska 

Native cultures, and how healing takes place. 

Be respectful of traditional approaches to 

healing. 

• Sociocultural context: Recognize how tribal 

affliation, culture, language, gender, gender 

roles, education, socioeconomic status, 

sexual and gender orientation, community, 

family, social organization (e.g., matrilineal), 

geographic location, and so forth affect 

treatment. 

• Participation: Appreciate that clients may have 

different expectations about treatment. Take 

time to understand your clients’ perspective 

and attitudes toward treatment. Discuss the 

clients’ expectation of roles. 

• Empathy: Express, verbally and nonverbally, 

the signifcance of your clients’ concerns so 

that they feel you understand. If possible, share 

some of your own experiences. 

• Concerns and fears: Elicit clients’ concerns and 

apprehensions about entering a treatment 

setting and about the behavioral health system. 

• Therapeutic alliance/Trust: Commit to 

behaviors that enhance the therapeutic 

relationship; recognize that trust is not inherent 

but that you must earn it. Native clients are 

likely to place more importance on who you 

are, rather than what you accomplished, in 

determining their level of trust in you. 

Sources: Bigby & American College of Physicians, 2003; 

Campinha-Bacote et al., 2005. 

40 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

Improving Your Knowledge of American 

Indian and Alaska Native Cultures 

You can use a number of ways to improve your 

grasp of American Indian and Alaska Native 

cultures, and it is best if you try to make use of all 

of them. You can learn through reading, attending 

trainings and seminars, listening to other providers 

who work with this population, and, most importantly, talking with your clients and other American 

Indians and Alaska Natives. 

Native people can tell you a lot about their 

cultures, either directly through their responses to 

questions about their cultures or indirectly through 

observation both in and out of the treatment 

setting. You can also talk to other American Indians 

and Alaska Natives in the community to clarify what 

you hear from your clients and evaluate it sensibly 

(e.g., do not assume that the client who engages in 

binge drinking is speaking for the community when 

he says that such drinking is acceptable). Working 

with traditional healers or elders (discussed further 

in the North section) or identifying a community 

member who is willing to serve as a cultural 

consultant are two ways to develop relationships 

with American Indians and Alaska Natives who are 

not clients. It also can be helpful for you or your 

program to become involved in community activities beyond the treatment setting. 

To many American Indians and Alaska Natives, 

mental and substance use disorders do not 

only affect clients who enter the doors of your 

treatment center; they affect the entire native 

community or communities to which those clients 

belong. By engaging in activities in these communities, you and your program can improve your 

standing with them and begin to enlist their aid 

in promoting the recovery of your clients, as well 

as improving your understanding of your clients’ 

cultures. This involvement may take the form of behavioral health-related community education and 

prevention services, which are a natural extension 

of treatment services. However, other types of 

engagement, such as in community recreational 

and cultural activities, can also be helpful. 

Applying Your Knowledge to Behavioral 

Health Services 

As you learn about your clients’ cultures, you can 

practice applying that knowledge in different ways 

that will help you improve your interactions with 

American Indian and Alaska Native clients. You 

will learn what is appropriate and inappropriate 

as far as behavior is concerned, which sorts of 

interactions are likely to elicit positive responses, 

and which will elicit negative responses from 

your clients. Communication styles and the use 

of personal space are culturally defned, and by 

learning about them, you can make your communications with American Indian and Alaska Native 

clients more effective. For instance, both research 

and clinical experience suggest that they respond 

poorly to providers who try to instruct them on 

how to behave. They respond well to providers 

who share their own experiences, use stories, and 

give examples of how behavioral changes have 

helped in their own lives, provided the sharing is 

not excessive. 

You will also learn how American Indian and Alaska 

Native cultures affect behavior in and out of the 

treatment setting and how cultural beliefs and 

values can be used to help create positive behavioral changes. Knowing about the socioeconomic 

and political forces at work in native communities 

and about Native American history will further 

help you understand the mental and substance use 

disorders that affect these communities. 

Improving Your Cultural Competence 

You will need to continually reevaluate your 

knowledge of American Indian and Alaska Native 

cultures and your skills in interacting with clients 

from those cultures. This may involve correcting 

false impressions and learning new ways to apply 

knowledge in practice. You may learn that information that applied to clients from one native culture 

is not effective with those from another culture (see 

“The Importance of Knowing the Specifc American 

Indian and Alaska Native Cultures of Your Clients” 

box for an example). 

Several instruments are available to help you assess 

your cultural competence. These are discussed in 

TIP 59 (SAMHSA, 2014a) and Part 2, Chapter 2, 

Chapter 1 41 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

of this TIP. Other resources are available online, 

including the Cultural Competence Health 

Practitioner Assessment from Georgetown 

University’s National Center for Cultural 

Competence and the American Speech–Language– 

Hearing Association’s Self-Assessment for Cultural 

Competence. 

It is important to regularly reassess your own 

skills and knowledge, but you will also need the 

assistance of your program to evaluate the quality 

of care provided to American Indian and Alaska 

Native clients. Providing culturally responsive 

treatment should improve the quality of care and 

outcomes for these clients. 

THE IMPORTANCE OF KNOWING 

THE SPECIFIC AMERICAN 

INDIAN AND ALASKA NATIVE 

CULTURES OF YOUR CLIENTS 

This TIP emphasizes that not all native cultures 

are the same. For that reason, you need to learn 

about the specifc culture or cultures of your 

American Indian and Alaska Native clients. As 

an example, consider the case of 12-Step groups. 

A common criticism by American Indians and 

Alaska Natives is that the groups place a great 

deal of importance on self-disclosure and 

confession, which are practices that run counter 

to many native beliefs concerning humility and 

appropriate public behavior. However, not all 

American Indian and Alaska Native cultures have 

problems with such behavior, and the case of the 

Coast Salish people is an important exception. 

This group of tribes traditionally lived on the coast 

of what is now Washington State and British 

Columbia in extended families of hundreds of 

people that did not have established leaders, but 

rather, reached group decisions democratically. 

The Salish had a tradition of public confessional 

dancing, and some later adopted the Shaker 

religion in which public confessions of “sin” were 

common. Given these traditions, the public 

confession aspect of 12-Step groups and the loose 

democratic organization of those groups may 

ft well with Salish culture, and Salish people in 

recovery from substance abuse have generally 

felt very comfortable with the practices of 12-Step 

groups. 

Source: Jilek-Aall, 1981. 

Continuing West: Cultural 

Perspective on Behavioral Health 

As you may expect, traditional American Indian 

and Alaska Native views on health and healing are 

considerably different from the mainstream models 

of health, illness, and treatment with which you 

are probably very familiar. In the West section, you 

will fnd more information about American Indian 

and Alaska Native concepts of health and wellness, 

illness and disease, and medicine and healing. This 

section introduces traditional healing practices and 

the function of native healers, a topic much larger 

than can be fully addressed here. This section also 

addresses American Indian and Alaska Native preferences and beliefs about behavioral health and 

seeking out behavioral health services. Although 

the focus is on mental and substance use disorders, 

the division between physical and behavioral health 

is not one that is typically recognized in native 

cultures, so the section begins with a discussion of 

health in general before moving on to behavioral 

health. 

Cultural 

Perspective 

on Behavioral 

Health 

(West) 

Part 1: 

Providers 

Part 2: 

Administrators 

Part 3: 

Researchers 

Although the material that follows is useful, it 

is very general. You will beneft from further 

exploring the specifc health and healing beliefs 

of the American Indian and Alaska Native cultures 

to which your clients belong. The Part 3 literature review (available online) summarizes some 

resources that may be of assistance. Talking to 

medicine men and women, healers, and spiritual 

guides from the cultures you work with would be 

especially helpful. 

42 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

American Indians’ and Alaska Natives’ 

Concepts of Health and Illness 

There is no single American Indian and Alaska 

Native view of health and healing. Even traditional 

native cultures differ considerably regarding 

specifc beliefs about the causes of illness and how 

best to treat them. As discussed further below, 

most American Indians and Alaska Natives try to 

balance traditional and mainstream views of health 

and healing, and many will seek help from both 

mainstream providers and traditional healers. 

Certain basic principles apply to health and 

illness as they are understood by most, if not all, 

American Indian and Alaska Native cultures: 

• Health is viewed holistically. American Indian 

and Alaska Native cultures rarely make a distinction among physical, mental, emotional, and 

spiritual health. One aspect of health is believed 

to affect the others; addressing a problem 

at one level may help heal problems at other 

levels. A holistic view also means that prevention 

and treatment are not divided but seen as part 

of the same process. 

• Illness affects an individual’s community 

as well as the individual. The holistic view 

of health may also extend to the relationship between the individual and his or her 

community. A health problem that affects one 

person will have effects on a family, community, 

tribe, and other individuals as well. This also 

means that healing the community can positively 

affect individual health and that the process of 

healing may need to occur at the community 

level to be effective for the individual. 

• Being healthy means living in harmony and 

balance. Illness occurs when an individual is out 

of harmony, and healing is a process of restoring 

balance. This balance is both internal (affecting 

one’s internal mental, physical, and spiritual 

state) and external (affecting one’s relationships 

with all living beings). Another potential source 

of imbalance is cultural; American Indians and 

Alaska Natives may feel a loss of balance or 

harmony in trying to fnd equilibrium between 

the values of two cultures. This is one reason 

why healing may involve reconnecting with a 

traditional culture. 

• Illness may be purposeful or personifed. An 

illness may be purposeful, in the sense that it 

occurs because an individual or a relative has 

broken some cultural taboo or natural law, which 

creates a state of disharmony and hence a state 

of illness. These violations may have occurred 

recently, in the past, or in a previous generation. 

Because of this, in some American Indian and 

Alaska Native cultures, a person may be held 

at least in part responsible for developing an 

illness, and the individual who has the illness 

may see it as his or her responsibility to bear the 

symptoms. An illness may also be personifed 

in the sense that it has a spirit, and that spirit 

may need to be addressed as part of the healing 

process. 

Be thoughtful about how you discuss 

presenting problems. Remember that 

your clinical training is infuenced by 

the culture and common practices 

of mainstream health care. These 

practices can confict with or be 

insensitive to American Indian and 

Alaska Native beliefs. Native people 

may see labeling an illness (i.e., giving 

it a name) as a naming ceremony that 

increases its power. Likewise, they 

may view discussing prognosis or 

consequences of a behavior or illness 

as a prediction or prophecy, believing 

that thought and language have the 

power to shape reality and the future. 

Traditional medicine and healing 

The traditional view of medicine and healing is 

signifcantly different from that of the mainstream 

healthcare system. Even the word “medicine” has 

a different meaning in American Indian and Alaska 

Native tradition. Medicine, in native cultures, 

is the essence of being or spirit that exists in 

everything on Earth (Garrett, 1999). Medicine may 

be good or bad, depending on how it affects the 

individual. For example, it is good if it restores 

balance and harmony and bad if it disrupts balance 

Chapter 1 43 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

and harmony. When counseling American Indian 

and Alaska Native clients with drinking problems, 

one provider suggests to clients that alcohol is 

medicine and that by taking it without proper 

knowledge, the drinker is practicing a form of 

witchcraft on himself or herself by consciously 

ingesting bad medicine (E. Duran, 2006). 

Traditional healers may be referred to as 

“medicine men” or “medicine women,” but to 

avoid confusion among different meanings of 

“medicine,” this TIP refers to American Indian and 

Alaska Native “healing practices” rather than to 

“medicine.” However, terms such as “services” and 

“practices” may not make sense to some American 

Indian and Alaska Native clients, so when framing 

inquiries on the use of traditional healers, it is 

probably better to use the term “help-seeking.” 

Traditional Native American healing is a body of 

wisdom for transforming illness into health through 

the integration of mind, body, emotion, and spirit. 

Traditional healing usually involves physical actions 

like participating in ceremonies or taking herbal 

remedies. Often, a whole family or community 

is involved in the healing process through group 

rituals. Traditional healing can beneft clients in a 

number of ways (see the “How Does Traditional 

Healing Work?” box). 

In traditional healing, there is much less concern 

with diagnosis. Healers may have no specifc 

label for a problem but will focus on what may 

have caused the problem (e.g., breaking a taboo, 

diffculties stemming from mainstream culture, 

social or relational conficts) and what can be done 

to address it. In some American Indian and Alaska 

Native cultures, some illnesses or problems (e.g., 

alcohol dependence) may be recognized as outside 

or “White man’s” problems that traditional healers 

cannot properly treat, instead requiring mainstream 

providers’ attention. 

Behaviors that mainstream providers might label as symptoms of mental illness 

may be seen among American Indians and Alaska Natives as the expression of 

special gifts (e.g., hallucinations, manic symptoms). Native peoples may also perceive 

physical conditions as sacred; for example, dementia may be viewed as a process or 

sign that the person’s spirit has already crossed over into the next world. Although 

the body has remained behind as it prepares to leave, the person’s spirit is already 

communicating in the spirit world, making it diffcult for those left behind to 

understand the person’s language and behavior. Therefore, caring for individuals 

who are transitioning may be perceived as sacred work. 

HOW DOES TRADITIONAL HEALING WORK? 

• American Indian and Alaska Native healing practices typically involve community and serve to restore a 

sense of connection to tribe and culture. 

• Traditional practices often increase social support, thereby improving health outcomes. 

• Healing rituals improve participants’ coping abilities and quality of life. Traditional healers are the keepers 

of stories with the tribal community. These stories represent themes and often serve to guide individuals 

on how to handle various problems. 

• Traditional healing helps individuals transcend their experiences by identifying the meaning and purpose 

of those experiences within the context of the community, including the environment. 

• Some traditional healing rituals alter participants’ consciousness, which in turn can produce a spiritual 

transformation that affects overall health. 

Part 3, the online literature review, has more information on traditional healing’s effectiveness. 

44 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

Traditional Healers 

Traditional healers are people who were often 

recognized even as children as being empathic 

and having a gift for working with people to lessen 

their pain. If these talents are recognized in a 

youth, he or she might be taken as an apprentice 

by the tribe’s traditional healer. If not, he or she 

will learn from other healers. Training goes on over 

many years. Some American Indian and Alaska 

Native cultures (e.g., the Navajo) have carefully 

defned ceremonies and practices for healing that 

need to be taught. Other native cultures (e.g., the 

Inuit) have traditions in which the individual healer 

must learn through visions and interactions with 

spiritual entities, and the practice of healing may 

vary among individual healers. 

In urban areas, it may be diffcult 

to fnd a traditional healer. Often, 

individuals have to travel far or go to 

the reservation to fnd healers with the 

same cultural traditions. Depending 

on tribal affliation, traditional healers 

from other tribes may be accepted 

or rejected. It may depend on the 

historical relationships between tribes, 

individuals’ beliefs and practices, and 

the traditional healer’s willingness 

to work with individuals who are not 

members of the same tribe. 

The healer does not have the same relationship to 

the client as a medical provider does, nor is healing 

something that just occurs in a specialized facility. 

A traditional healer will recognize that healing 

is not something that is done by one person to 

another, but involves participation by the individual, spiritual entities, family, and friends, as well as 

the healer. Traditional healing may be provided in 

the client’s home, other homes or buildings in the 

community, or outside the community in a natural 

setting. 

Traditional healers will often only work with 

members of their own tribe, but some may be 

willing to work with other Native Americans or 

even with people of other races. Most traditional 

healers are spiritual guides and practice traditional 

native spirituality. Some American Indians and 

Alaska Natives may not want to work with traditional healers because of religious differences. 

Christian traditions such as those associated with 

the Native American Church and the Pentecostal 

Church also provide healing rituals to American 

Indians and Alaska Natives. Traditional healing 

practices and beliefs may be expressed within a 

Christian context. 

Generally, traditional healers do not charge fees 

for treatment but will accept gifts for services 

rendered and money for transportation, if needed. 

There is no offcial body that sanctions traditional 

healers, and there are fraudulent practitioners who 

claim to represent native traditions. As a provider, 

you should obtain recommendations of traditional 

healers from tribal members and leaders. If healers 

are accepted by their tribes’ elders and community 

leaders, they can generally be expected to be 

authentic. 

“Plastic shamans” is a term used for 

individuals who pose as traditional 

healers or spiritual leaders without 

any true affliation to the traditions, 

healing practices, and culture that they 

claim to represent. Most often, but not 

always, they are non-native individuals 

who steal, misrepresent, and exploit 

indigenous practices, native knowledge, 

and sacred ceremonies for monetary or 

other self-gratifying gains. 

Equally important, you should not facilitate traditional healing practices with native or non-native 

individuals unless you are an authentic native 

healer. From time to time, non-native providers 

have become so enthralled with native culture that 

they begin to incorporate their interpretation of a 

Chapter 1 45 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

traditional healing practice with clients, implying 

that it is a native practice. Offering this practice to 

clients misrepresents and exploits native cultures 

and crosses many ethical boundaries, beginning 

with the failure to practice within your area of 

competence. 

American Indian and Alaska Native 

Healing Practices 

The specifc practices, rituals, and ceremonies 

involved in traditional native healing vary considerably among tribes, and clients may feel uncomfortable with or feel that they will gain no beneft 

from practices associated with other tribes. Some 

American Indians and Alaska Natives may not feel 

comfortable with ceremonies that have overtly 

“supernatural” elements (Hartmann & Gone, 2012). 

Religious preferences may also affect whether a 

client fnds traditional healing practices acceptable; 

for example, an American Indian with a strong 

Christian identity may seek healing from his or 

her church and feel strongly about not wanting to 

participate in ceremonies that come from traditional spiritual practices. 

Many American Indians and Alaska Natives, especially those in urban settings, may be interested 

in traditional healing but not know much about it. 

These clients may want education about traditional 

healing practices before committing to them. Such 

education should be provided by individuals experienced in these healing traditions—either healers 

themselves or community elders with strong ties to 

their traditional cultures. 

Some traditional healing practices are common to 

more than one tribe, including: 

• Offering tobacco with one’s prayers, often done 

in a group. 

• Burning herbs or smudging for purifcation, 

which can be done alone or in a group. 

• Participating in a talking circle, where an object 

is passed from one person to the next, and each 

participant is listened to, allowing everyone to 

express feelings and thoughts. 

• Giving herbal medicines either to an individual 

or to members of a group as part of rituals or for 

their medicinal properties. 

• Performing a sweat lodge or spirit lodge, in 

which participants sit in an enclosed structure 

around a pit of hot rocks—a communal experience of purifcation, prayer, and healing that has 

been found to improve emotional and physical 

well-being. 

• Performing tribal dances—community events, 

some of which may be physically strenuous. 

• Chanting and singing in groups, which require 

intense participation and can go on for days. 

• Creating personal medicine bags that hold 

specifc meaning for the owner. 

• Engaging in other traditional ways, such as 

going to a winter fsh camp, carving, tanning 

hides, and the like. 

In the North section, you will read more about how 

to integrate American Indian and Alaska Native 

spiritual and healing practices into a behavioral 

health program. 

American Indian and Alaska Native 

Perspectives on Behavioral Health 

Problems 

American Indian and Alaska Native clients’ views 

of behavioral health interventions will likely contain 

elements of both traditional and mainstream 

treatment services and possibly from Christian 

healing traditions. Native people often use both 

types of treatment services. Nonetheless, as 

a provider, you need to remember that traditional healing practices do not separate mental 

disorders from physical and spiritual ones. They 

do, however, recognize problems that mainstream 

health care identifes as mental and substance 

use disorders, even if they are only symptomatic 

of other underlying problems. Traditional healers 

may look at someone who would be diagnosed 

with depression and view the same symptoms as 

problems stemming from breaking a taboo or from 

unbalanced relations with family or community. 

Whatever the cause, the symptoms would still call 

for treatment to restore balance and harmony. 

For many behavioral health issues (e.g., substance 

abuse, suicidality), the underlying cause may be 

the loss of connection to traditional native culture, 

historical trauma, and confict between native 

and mainstream culture. For example, Native 

46 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

American recovery movements have traditionally 

viewed alcohol as an instrument in the European 

subjugation of native peoples. This is one reason 

that many American Indians and Alaska Natives 

talk about their culture as a form of healing or 

prevention, particularly in relation to mental and 

substance use disorders. Participation in traditional 

cultural activities (e.g., potlatches, pow wows, 

crafts, singing, dancing) is a component of many 

behavioral health programs that provide services 

primarily to American Indian and Alaska Native 

clients. However, if clients in early recovery have 

used alcohol or drugs during community activities 

in the past, they may need to limit participation 

or acquire support before and during community 

activities as a relapse prevention step. 

METHAMPHETAMINE IN INDIAN 

COUNTRY 

Methamphetamine has disproportionately 

devastated native tribal communities. Mexican 

drug cartels have been deliberately targeting 

rural reservations for the sale of meth and 

as distribution hubs. Native Americans now 

experience the highest meth usage rates of any 

ethnic group in the United States. 

“Some of the reasons drug cartels have targeted 

Native communities are the complex nature of 

criminal jurisdiction on Indian reservations, and 

because Tribal governmental police forces have 

been historically under funded and understaffed. 

However, given this new challenge, Tribal leaders 

have been at the forefront of new and creative 

solutions and approaches that many other 

communities may fnd helpful in their struggles” 

(National Congress of American Indians, 2006, p. 1). 

For more information on substance use patterns 

and their effects on behavioral health, see Part 3, 

the online literature review, and the American 

Indian/Alaska Native Behavioral Health Briefng 

Book (IHS, 2011). 

IS BINGE DRINKING 

DANGEROUS? 

Binge drinking, or consuming large amounts of 

alcohol in a short period, causes serious health 

risks despite the recovery periods between 

binges. The body metabolizes alcohol at a fairly 

steady rate. When larger amounts of alcohol 

are consumed, the body is not able to keep up 

with the consumption. Higher blood alcohol 

concentrations occur, and the body and its 

organs are exposed to the higher concentrations 

for longer periods. This leads to cumulative and 

devastating effects on the body. Binge drinking is 

associated with higher death rates, injuries, heart 

attacks and other cardiac problems, liver damage, 

poor control of diabetes, and cancer. Additional 

factors, such as gender and age, infuence the 

body’s ability to metabolize alcohol. 

Mental and Substance Use Disorders 

Among American Indians and Alaska 

Natives 

You are already aware that American Indians and 

Alaska Natives are at increased risk for certain 

behavioral health conditions (e.g., substance use 

disorders, anxiety disorders) and related problems 

(e.g., suicidality). The sections that follow will 

help you understand how such disorders affect 

American Indians and Alaska Natives and the 

reasons behind this increased risk. For a detailed 

review, please refer to the TIP’s online literature 

review. 

Alcohol and other substance use disorders 

American Indians and Alaska Natives generally 

start using alcohol and other substances at a 

younger age than do youth from other major racial/ 

ethnic groups. Early substances use is linked with 

greater risk for substance use disorders. Poverty 

and unemployment, common problems for Native 

Americans, are themselves risk factors for alcohol 

and other substance use disorders, as are the 

disruption of families, trauma exposure, historical 

trauma, and continuing discrimination. 

The primary substance of abuse for American 

Indians and Alaska Natives, as it is for Americans 

in general, is alcohol. Although many Native 

Americans do not drink at all, binge drinking and 

alcohol use disorders occur at high rates relative to 

other populations. Binge drinking among American 

Indians and Alaska Natives largely refects the 

drinking patterns to which they were frst exposed 

when alcohol was introduced to their cultures 

through the drinking patterns of White American 

frontiersmen, fur traders, and others. Other factors 

Chapter 1 47 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

also infuence binge drinking, such as the diffculty 

of consistently getting alcohol on dry reservations 

or in remote native villages, the perceived or 

established social norms surrounding the use of 

or abstinence from alcohol at local community 

events, and unemployment and poverty (which may 

mean for some that alcohol can only be purchased 

intermittently). 

The second most common substance of abuse 

for Native Americans is marijuana, and American 

Indians and Alaska Natives are more likely to 

develop cannabis use disorder than are members 

of many other racial groups. Both methamphetamine and prescription opioid abuse are growing 

problems for American Indians and Alaska Natives 

and are of major concern in a number of native 

communities. Geographic factors partly affect 

patterns of substance use (e.g., Native Americans 

are more likely to live in states where methamphetamine abuse is more common), as do the same risk 

factors that affect alcohol abuse. 

Mental disorders 

Among American Indians and Alaska Natives, the 

most signifcant mental health concerns today are 

traumatic stress, depression, anxiety, and bipolar 

disorders (see Part 3’s literature review for more 

information). Research suggests that American 

Indians and Alaska Natives are more likely than 

the general population to have psychological 

distress that interferes with daily functioning and to 

have higher suicidality. As with other populations, 

mental disorders in American Indians and Alaska 

Natives frequently co-occur with substance misuse 

and substance use disorders. 

Important differences exist among native cultures 

as to the types of symptoms they most often 

express or report to providers. For instance, 

American Indians and Alaska Natives are more 

likely to report somatic (physical) symptoms related 

to depression. Keep in mind that physical and 

psychological symptoms are not typically separated 

from each other. 

Depression is a common diagnosis associated 

with traumatic stress and is one psychological 

consequence of it. American Indians and Alaska 

Natives experience very high rates of trauma with 

the background of historical trauma. Individual 

traumas—including suicides in the community, 

domestic violence, physical and sexual assaults, 

and accidents—are the most common traumas 

contributing to the development of traumatic 

stress disorders. The effects of historical trauma 

and other traumas can negatively affect behavioral 

health and may increase the risk of developing 

substance use, mood, and anxiety disorders. 

Preferences and Barriers Regarding 

Behavioral Health Services 

Preferences 

Many providers believe the myth that American 

Indians and Alaska Natives do not seek treatment 

for mental and substance use disorders. In stark 

contrast to this stereotype, native people actively 

seek help from traditional healing, mainstream 

treatment, and mutual-help groups, or a combination of these interventions. American Indians and 

Alaska Natives who live in native communities and 

are more traditional prefer services provided in the 

community to those provided off the reservation or 

outside the community and traditional healers over 

mainstream behavioral health service providers. 

However, even on reservations, clients will use 

both mainstream and traditional healing. Although 

some individuals may prefer American Indian and 

Alaska Native providers, cultural competence and 

interpersonal qualities play a signifcant role when 

it comes to provider preference. 

Some individuals may prefer to travel 

a considerable distance to seek 

services off the reservation if they are 

concerned about maintaining their 

anonymity in their local community. 

For instance, it is highly probable that 

clients will know people working at 

the treatment program if they seek 

services within their community. Your 

clients may also be reluctant to attend 

the program because it is located 

somewhere where it is diffcult to 

remain anonymous when entering the 

building or parking their cars. 

48 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

American Indians and Alaska Natives use behavioral health services at a rate second only to White 

Americans and may be even more likely to use 

substance abuse services specifcally. They are 

more likely to believe that people with mental 

disorders can get better without professional help 

and less likely to believe that therapy can teach 

people new ways of coping with problems. 

It may be easy to mislabel clients’ reluctance to 

use mental health services as treatment resistance 

or the result of prejudice against people with 

mental illness. However, reluctance may result 

from well-grounded, historically based mistrust in 

outside institutions. This is a response to events 

such as the history of boarding school placement 

and unwarranted removal of native children to 

non-native foster and adoptive homes. 

Screening and assessment of psychotic 

disorders are diffcult in some Native 

American cultures that consider seeing 

visions a positive event not necessarily 

indicative of psychosis. 

Barriers to treatment services 

American Indians and Alaska Natives face many 

barriers to accessible health care, including behavioral health services. These obstacles contribute 

signifcantly to the development of health disparities among native people. There are different levels 

of barriers regarding the use of behavioral health 

services (e.g., sociocultural, systemic, individual), 

and these obstacles need to be anticipated. 

Addressing systemic barriers, such as insuffcient 

government funding, may be too great a challenge 

for an individual provider, but some obstacles are 

within your control. You may be able to address 

these obstacles directly or fnd creative ways 

around them; the frst step is taking the time to understand the most common barriers. The following 

list highlights common barriers to treatment: 

• Physical distance from service providers 

• Concerns about maintaining anonymity in 

smaller communities 

• Shame and prejudice associated with mental 

health services 

• Lack of child care and transportation 

• Perception that treatment contradicts cultural 

values of noninterference and self-reliance 

• Limited number of American Indian and Alaska 

Native providers 

• Lack of culturally competent providers who fully 

understand things such as emotional expressions, the role of historical trauma in presenting 

symptoms, and the effects of the cumulative 

stress of violence and discrimination 

• Failure to consistently conduct individual assessments on cultural identifcation and traditional 

healing practice preferences 

• Limited funding or treatment options of tribal or 

community services 

• Failure to establish cultural brokers, including 

tribal leaders or native mentors, to help in 

arranging traditional healing practices from 

authentic providers 

• Inability to provide services in native languages 

• Mistrust of government-funded social services 

The North section that follows presents more 

information on how to adapt your program to 

make it more effective for American Indian and 

Alaska Native clients, including how to integrate 

traditional healing and cultural activities and how 

to modify standard behavioral health interventions 

to integrate native culture. 

Arriving in the North: The 

Direction of Culturally Specifc and 

Responsive Skills and Practices 

How can your knowledge about American Indian 

and Alaska Native cultures help you provide 

treatment that is more effective for your clients? In 

the North quadrant, you will fnd answers to that 

question. The North will give you information about 

how to modify your behavioral health services to 

best meet the needs of American Indian and Alaska 

Native clients. 

Native American clients will likely feel more comfortable in treatment and have better outcomes 

if they fnd that you understand their culture and 

respect it and them. Prevention programs are more 

effective for American Indians and Alaska Natives 

if you spend time learning about their community 

and culture. 

Chapter 1 49 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Culturally Specifc and 

Responsive Skills and Practices 

(North) 

Part 1: 

Providers 

Part 2: 

Administrators 

Part 3: 

Researchers 

Not all American Indian and Alaska Native clients 

identify with or wish to connect with their traditional cultures, but culturally responsive services 

offer all clients a chance to explore the impact 

of culture (including historical and generational 

traumas), acculturation, discrimination, and bias 

and how these relate to their mental and substance 

use disorders. They also assist interested clients 

in recognizing cultural strengths that can support 

recovery. Adding American Indian and Alaska 

Native cultural practices to a program can improve 

outcomes for all clients. 

Cultural competence is important throughout the 

continuum of outreach, prevention, treatment, and 

continuing care. Part 2 of this TIP discusses considerations for cultural responsiveness in outreach, 

operational issues, and treatment environments, as 

does TIP 59 (SAMHSA, 2014a). Health problems are associated with 

higher rates of depression. American 

Indians and Alaska Natives often report 

a triad of depression, diabetes, and 

alcohol abuse. Cardiovascular disease 

has joined this equation and is a 

leading cause of death in native people 

in recent years. 

Culturally Responsive Relationships: 

Provider Guidelines and Considerations 

As your understanding of native cultures increases, 

you will see how your behavior in treatment 

settings can positively or negatively affect your 

relationships with American Indian and Alaska 

Native clients, whom mainstream behavioral 

health services often fail. Providers sometimes 

label American Indian and Alaska Native clients 

as unresponsive or resistant to treatment because 

they do not recognize their clients’ preferences or 

needs and how best to positively address those 

needs and concerns that initially brought them to 

treatment. This failure may occur at a programmatic level, but it can also result from interactions in 

which clients perceive providers as paternalistic, 

impatient, disrespectful, or ill-informed about their 

cultures. 

To avoid some potential problems in counseling 

American Indian and Alaska Native clients, 

remember the following general guidelines for 

providing care, fostering communication, and 

building relationships. These guidelines may 

improve services for many American Indian and 

Alaska Native clients, but consider each in light of 

what you know about your individual client. 

Knowing yourself 

Be who you are. American Indians and Alaska 

Natives prefer providers who are authentic—who 

can simply be themselves. Respect your own 

cultural heritage and be willing to talk about it from 

the outset. Do not try to be “Native American” or 

to act in preconceived ways that ft your views of 

how American Indians and Alaska Natives behave. 

Doing so disrespects clients’ culture. However, 

you should adjust your treatment approach to be 

culturally responsive. 

Use your own experience. American Indian and 

Alaska Native clients may not respond well if you 

simply tell them what they should do, but they 

will respond positively to you if you share your 

own experiences of how you have coped with 

50 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

problems or of how others in your practice have 

dealt with their presenting issues. Remember that 

many native people often see those giving them 

advice as meddlers. This perception can be simply 

stated, “If I respect you, I will not interfere in your 

life.” Native clients are more likely to be initially 

suspicious of services or individual providers until 

a relationship has formed—so be wary of giving 

advice too quickly. If you offer suggestions, make 

sure you yourself can follow them. Remember, 

“Walk the walk; do not just talk the talk.” For 

example, if you emphasize the value of community, 

then it is important to periodically attend local 

community cultural events. 

Supporting communication 

Listen and respect silence. The most important 

thing you can do is listen. Many American Indian 

and Alaska Native people are slow to speak. There 

are good reasons for this; they believe that words 

are important and must be chosen, and your clients 

may need to think carefully about what they are 

going to say before they say it. In some native 

cultures, being quiet is a way of showing respect. 

If English is a second language, clients may pause 

between sentences to allow themselves to translate 

their thoughts before speaking. Make sure to give 

people time to formulate an answer before you 

move on. Accept that there will be times of silence 

and that this silence is not “unproductive.” Be 

patient and avoid jumping in to fnish your clients’ 

sentences. 

Adjust your eye contact. In some American Indian 

and Alaska Native cultures, it is disrespectful to 

hold eye contact. You will have to judge what 

seems appropriate for the client you are treating. 

If your client does not want to make eye contact, 

then do not, and do not assume because he or she 

looks away that he or she is not interested or being 

dishonest. Your client may be trying not to be 

disrespectful to you, or he or she may be thinking 

about how to respond. 

Observe nonverbal communication. As you listen 

and observe, you may feel that you miss important 

parts of the conversation. Some communication is 

unspoken, implied, or embedded in the conversation or story. Nonverbal communication and the 

space between verbal exchanges are important. 

The best way to learn communication styles is to 

observe clients and others in the community and 

to ask questions about nonverbal communication, 

including nonverbal cues. 

A man’s life proceeds from his 

name, in the way that a river 

proceeds from its source.” 

—N. Scott Momaday (1976, p. 49), Kiowa, 

quoting his great-grandfather, 

Pohd-lohk 

Native American Indian 

communication style can be 

comparable to the spokes on a wheel, 

and, out of respect for the listener, the 

main point may be left implicit. 

Source: LaFromboise, 1995. 

Determine and value linguistic preferences and 

abilities. Language is important. Many anthropologists believe language is culture: once language 

is lost, the knowledge that accompanies that 

language is lost as well. This is particularly devastating for native communities, which have relied on 

the oral tradition, particularly for storytelling. Many 

American Indian and Alaska Native communities 

are working to save their languages before the few 

elders who are fuent are gone. 

For most American Indians and Alaska Natives, 

English is their primary language, but about 15 

percent speak a native language in their home, 

and about 13 percent speak another language 

other than English, usually Spanish (Siebens & 

Julian, 2011). A number of those individuals speak 

English as a second language. You should ask 

American Indian and Alaska Native clients whether 

they are comfortable receiving services in English, 

and if not, connect them to services in their own 

language or fnd a trained translator to assist in 

providing services. Some native languages have 

fairly few speakers, so a translator may not be 

available in your area, but providing services with 

a translator who is teleconferenced into treatment 

sessions is one option that you may consider 

Chapter 1 51 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

(TIP 60, Using Technology-Based Therapeutic Tools 

in Behavioral Health Services [SAMHSA, 2015], has 

more information on this option). 

Use hopeful language and avoid labeling. 

Mainstream behavioral health models often 

emphasize diagnosing and treating the “disorder.” 

However, focusing on naming the disorder is likely 

to be counterproductive with American Indian and 

Alaska Native clients. In native cultures, names and 

naming traditions are extremely important. Naming 

a person identifes those traits a person is expected 

to live up to. Thus, labeling a client as having a 

specifc disorder can be a form of self-fulflling 

prophecy. Naming a disorder may also be shaming 

to American Indian and Alaska Native clients. 

The same concerns apply to discussing prognosis. 

Some clients may believe that stating something 

that could happen in the future will cause the event 

to occur. You may fnd this belief particularly challenging if you tend to focus on the consequences 

of substance abuse. Yet American Indian and 

Alaska Native community members may not readily 

seek treatment with you if prognosis is a common 

part of your approach. They may believe that the 

future is unknowable, save to the Creator. Before 

discussing consequences of behaviors or disorders, 

seek the counsel of someone knowledgeable about 

your clients’ culture and ask clients about their 

beliefs and preferences. 

Frame things in more hopeful terms and use a 

strengths-based perspective whenever possible. 

Calling an American Indian or Alaska Native “a 

person in recovery” rather than “a person with an 

alcohol use disorder” will likely improve the client’s 

reaction and possibly the prognosis. 

As a counselor working at the 

university’s health services serving 

Native American students, I found 

that setting aside recurring time 

slots during the week for drop-ins 

increased participation in other 

services, including prevention 

activities. This open-door approach 

created a welcoming atmosphere.” 

—Anonymous 

Remaining fexible and embracing new 

opportunities 

Be fexible with your time. American Indians and 

Alaska Natives sometimes speak of “Indian time,” 

which refects an attitude that things will get done 

in their own time or in the “right” time and not 

according to predetermined schedules. If possible, 

try to accommodate this, and be prepared for 

clients who may want to contact you after your 

offce hours. Have an open-door policy and hold 

offce hours for drop-in visits. Do not take it 

personally when clients arrive late; work with them 

to fnd solutions that meet both your needs. 

Expect more family involvement. For many 

American Indians and Alaska Natives, family is 

central. Family can be an excellent motivator for 

help-seeking and a support to recovery. If your 

client is connected with family, he or she may want 

family members to participate. However, as with all 

families, some family members may be a source of 

confict or unsupportive. If your client is estranged 

from family, this is an important issue. 

It is likely that your American Indian and Alaska 

Native clients’ families will want to be involved to 

a greater extent than families from other racial and 

ethnic backgrounds. The defnition of “family” for 

American Indian and Alaska Native clients will likely 

include extended relations, such as second cousins, 

family friends, and other unrelated community or 

village members. It is important to avoid using your 

own defnition of family in determining who should 

participate in family sessions. Likewise, family 

hierarchies, structure, traditions, roles, and rules 

may vary from tribe to tribe. Therefore, it will be 

crucial to learn about families and family systems in 

the context of tribal affliation, acculturation level, 

and individual and community historical events. 

Anticipate laughter. Most American Indians and 

Alaska Natives have an incredible sense of humor. 

This love for laughter and the use of humor span 

many generations. Humor is often a means of 

addressing and surviving many diffcult and painful 

situations. It can also help address a specifc 

52 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

problematic behavior without showing disrespect 

to an individual or family. The role of humor and 

its intricacies within native cultures cannot be 

explained in one or two paragraphs. It is a central 

aspect of native life, yet this attribute often goes 

unnoticed by non-natives. 

As a provider, you need to know that humor may 

signifcantly help your client to be more resilient. 

Humor can promote healing. Equally important, 

humor can have implied or hidden meanings. Do 

not readily assume that humor is a defense to 

distract from underlying issues. Think about the 

context of the humor. It may express straightforward humor, indirectly emphasize the importance 

of something, distract from painful experiences, or 

signal that trust is evolving in the relationship. 

AMERICAN INDIAN AND ALASKA NATIVE HUMOR: ITS ROLE IN 

COMMUNICATION AND HEALING 

“One of the best ways to understand a people is to know what makes them laugh. 

Laughter encompasses the limits of the soul. In humor, life is redefned and 

accepted. Irony and satire provide much keener insights into a group’s collective 

psyche and values than do years of research. 

“It has always been a great disappointment to Indian people that the humorous side 

of Indian life has not been mentioned by professed experts on Indian Affairs. Rather 

the image of the granite-faced grunting redskin has been perpetuated by American 

mythology. 

“The Indian people are exactly opposite of the popular stereotype. I sometimes 

wonder how anything is accomplished by Indians because of the apparent 

overemphasis on humor within the Indian world. Indians have found a humorous 

side of nearly every problem, and the experiences of life have generally been so well 

defned through jokes and stories that they have become a thing in themselves. 

“For centuries before the white invasion, teasing was a method of controlling social 

situations by Indian people. Rather than embarrass members of the tribe publicly, 

people used to tease individuals they considered out of step with the consensus of 

tribal opinion. In this way, egos were preserved and disputes within the tribe of a 

personal nature were held to a minimum. 

“Gradually people learned to anticipate teasing and began to tease themselves as a 

means of showing humility and at the same time advocating a course of action they 

deeply believed in. Men would depreciate their feats to show they were not trying to 

run roughshod over tribal desires. This method of behavior served to highlight their 

true virtues and gain them a place of infuence in tribal policymaking circles. 

“Humor has come to occupy such a prominent place in national Indian Affairs that 

any kind of movement is impossible without it. Tribes are ... brought together by 

sharing humor of the past.” 

Source: Deloria, 1988, pp. 146–147. 

Chapter 1 53 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Give things time. You may misjudge the strength 

of relationships with American Indian and Alaska 

Native clients because you think suffcient time 

has passed for these relationships to solidify. 

Therapeutic relationships with American Indian 

or Alaska Native clients may take more time to 

develop than relationships with other clients. 

Native clients may be suspicious because of prior 

provider experiences that did not go well or 

because they see you or your program as representations of a government that has, more often 

than not, hurt rather than helped American Indians 

and Alaska Natives. The time it takes for American 

Indian and Alaska Native clients to develop a 

relationship with you may also indicate that they 

are taking the relationship seriously and evaluating 

it carefully. Thus, it is essential that you take suffcient time to show clients that the relationship is 

important to you as well and that you value each 

client as a person, rather than as a “task” that you 

are trying to complete. 

Plan to provide practical assistance as well as 

therapy. From a holistic perspective of health and 

healing (i.e., perceiving everything as connected), 

it is natural for clients to expect broader discussions and to seek help that falls outside a 

typical behavioral health focus. This may include 

discussing concerns about or seeking suggestions 

from others in the community. Like many clients 

who seek behavioral health services, American 

Indians and Alaska Natives have multiple needs. 

Treatment planning should include a “case management” approach that helps address housing, 

transportation, education, vocational training, 

unemployment, legal assistance, physical health 

care, child care, relationship and community 

concerns, and domestic safety. A more expansive 

view of treatment will strengthen your therapeutic 

relationship and help you give native clients the 

support necessary for long-term recovery. 

Be open to new ways of conducting treatment. 

As you work with American Indian and Alaska 

Native clients and with other providers who are 

experienced in providing services for Native 

Americans, you will likely hear of different techniques and activities that can enhance services for 

your American Indian and Alaska Native clients. 

You may need to consider using different interventions or altering interventions in some way. For 

example, if talk therapy is diffcult for your clients, 

you might consider incorporating more experiential exercises in the session, such as walking 

meditation, using artwork to tell a story or display 

a current struggle, visualizations, or sculpting 

(see the “Sculpting: An Experiential Approach to 

Treatment” box). 

Mainstream approaches may not be an effective 

avenue, and they may not be the frst step in 

treatment. It is important for some native people 

to seek consultation with a traditional healer prior 

to coming to a counseling program. For others, a 

referral to a culturally oriented program may be 

more appropriate (e.g., Alaska Native spirit and 

cultural camps). Adjustments will need to be made 

on an individual basis to provide the most appropriate treatment, but it will be helpful if you can 

present clients with options. 

SPIRIT AND CULTURAL CAMPS 

“For those working with individuals who struggle with the effects of alcohol and other substance abuse 

in their lives, it has become increasingly evident that the pathway to healing is substantially stronger for 

those who have been raised with traditional Alaskan values [when they] reunite with those values” (First 

Alaskan Institute, n.d., p. 9). In the past decade, communities have developed several treatment program 

alternatives using a camp setting model to provide spiritual and cultural guidance (e.g., the Tanana Chiefs 

Conference Old Minto Family Recovery Camp, an Athabascan alternative to substance abuse treatment). 

The camps offer a path to prevention for children and adults and a way to recovery for families. Many 

camps are seasonal and provide opportunities to connect, experience, and practice traditional ways 

(e.g., subsistence practices, language, dance, history). Some camps are specifcally organized to address 

substance use disorders and recovery through an integrated cultural approach using community, group, 

and individual modalities. 

54 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

SCULPTING: AN EXPERIENTIAL 

APPROACH TO TREATMENT 

Sculpting is a tool for making an external picture 

of an internal process such as an experience, 

a perspective, feeling, or presenting concern. 

It includes the use of postures, positions, 

gestures, spacing, and objects to demonstrate a 

presenting issue or theme. For example, imagine 

a family photograph. Now picture the client as 

the photographer who asks other participants 

to stand in a certain position in relationship 

to one another. In sculpting, the client is the 

photographer, and you are the assistant who 

guides the process. 

The photographer (client) repositions other 

people in the room to demonstrate current 

concerns. In a group setting, you might have 

the person create a picture using other group 

members to demonstrate the potential barriers 

to abstinence. The client would discuss and 

name each barrier, then each group member 

would represent one or two barriers, and 

the client would position them according to 

importance. Or you, the provider, might become 

the photographer so that you can demonstrate a 

concept or pattern for the client. For example, you 

might help the client name personal strengths 

that he or she has demonstrated throughout 

his or her life, followed by setting up a picture of 

these strengths, either using group members or 

a drawing (if it is an individual session). In doing 

so, the individual receives a powerful picture: it 

is knowledge that the client will not likely forget, 

because it goes beyond words. It is a powerful 

physical, emotional, and visual experience. 

Recognize and support the signifcant role 

of prevention in American Indian and Alaska 

Native communities. As a provider, you need to 

understand that native communities believe that 

cultural knowledge and practice are the pathway 

to prevention and healing. Many American Indians 

and Alaska Natives view mental and substance use 

disorders through a historical lens whereby such 

disorders are illnesses of infiction characterized 

by historical losses, deculturation, and racism. 

Individual behavioral health conditions are seen as 

symptomatic of the aftereffects of this history in the 

community. Honoring children and young people 

is a common tenet of American Indian and Alaska 

Native cultures. Without culture and the young, 

there is no future. Therefore, considerable efforts 

are underway to maintain, introduce, and teach 

cultural traditions and other cultural knowledge 

as prevention activities. Likewise, communities are 

using community readiness assessment and prevention strategies to help address specifc problems 

represented within the community. As a provider, 

it is important to promote, support, house, and 

help facilitate the development of these prevention 

activities in native communities. 

Making introductions as a provider: First 

meeting 

Remember American Indian and Alaska Native 

etiquette for introducing yourself. Be sure not 

only to give your name and job title, but also to 

explain briefy something about yourself, what 

you are doing, and why. It may help if you can use 

some examples from your own experience. It is 

often far more important to talk about who you are 

than what you have done. For example, talk about 

things such as your family (past or present), your 

birthplace, and where you grew up. You should also 

introduce your program and what it does, as not all 

clients will have prior experience with behavioral 

health services or understand how they work. 

American Indians and Alaska Natives generally 

want to know who you are before deciding if they 

should trust you. Take your cue from clients when 

it comes to offering a handshake and expect that 

it may be very light rather than hearty; this is a sign 

of politeness and respect in some tribes. Keep 

your eye contact brief at frst until you observe 

the habits of your clients. This, too, could be a 

sign of respect. Listen carefully to how your clients 

introduce themselves. Get comfortable with your 

own silence rather than allowing your potential 

anxiety about silence in a conversation to push you 

to talk too much or ask too many questions. 

Explain confdentiality. All clients may have 

concerns that information about themselves and 

what they say in treatment might be shared with 

others, but this is an especially strong concern in 

smaller, rural communities such as those that exist 

on many reservations. You should tell new clients 

what information will be shared and with whom. 

As mentioned earlier, clients may have strong 

concerns about being seen entering a treatment 

Chapter 1 55 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

facility or parking their car outside. One solution 

is arranging alternative transportation, if available. 

Another major concern about confdentiality is 

that clients may know someone who works at the 

facility. In a small community, it is common to have 

relatives or other people clients know working 

in the program they are attending. This can be 

a signifcant barrier. Clients may not believe in 

the promises and policies of confdentiality. After 

gaining consent, connecting clients with other 

community members who are in recovery may 

help decrease these concerns. Sometimes, these 

concerns will only be alleviated by referring clients 

to another facility. 

American Indians and Alaska Natives 

have historical cause to wonder 

whether behavioral health service 

providers will recognize them for 

who they are, respect them, and 

assist them in walking their life 

paths. History has taught native 

peoples that it is dangerous to trust 

outsiders. Their lives—the lives of 

their parents and grandparents— 

have been taken or forever altered 

by outsiders. 

Choosing Directions: Intake, Assessment, 

and Treatment Planning 

This section is not a primer on how to complete 

intakes or assessments or how to develop 

treatment plans; it is expected that you know how 

to conduct these tasks. Instead, the suggestions 

presented below highlight several key ingredients 

and considerations when planning services with 

your American Indian and Alaska Native clients. 

Obtain clients’ perspective frst. Ask how your 

clients see the current situation, what led up to 

the current concerns and the decision to enter 

treatment, what caused the problems, and what 

thoughts they have about how to return to a more 

balanced state. Ask what clients have already heard 

about the kinds of concerns or problems they are 

having and what steps or paths they have already 

Your clients may view intakes and 

assessments as unnecessary. Some 

American Indians and Alaska Natives 

are accustomed to traditional healers 

who know what their problems are 

without taking a history. Engage the 

client before paperwork. 

taken to heal or gain relief. How do they see the 

problem? Ask how it affects different aspects of 

their lives: spiritual, relational, emotional, physical, 

and mental. How does what other people say 

about the problem affect your clients? Ask them 

what they may need to do to heal and what successful healing would look like for them. Also listen 

for clients’ motivation for recovery. Common motivations for addressing mental illness and substance 

use disorders include the need to be a responsible 

parent or involved family member, the importance 

of religious and spiritual practices, criminal justice 

involvement, and the need to support a healthy 

community. 

Explore and assess cultural identity. It is vital 

to spend time understanding the way individuals 

frame their own cultural heritage throughout 

their lifetime—from the past to the present. As 

you spend time with your clients, listen for the 

importance and infuence of native culture. Some 

clients may have little connection or identifcation 

with American Indian and Alaska Native culture; 

other clients may have strong ties to native culture 

and primarily relate to the world in traditional ways. 

Most clients will identify with a particular native 

culture or cultures, but some will have a more 

pan-Indian identity. Many who grew up in traditional and mainstream culture will have adopted a 

bicultural perspective, maintaining their identity as 

American Indian or Alaska Native and operating in 

both the traditional and the mainstream cultures. 

Cultural identity does not need to be assessed 

using an infexible continuum that perceives the 

process of becoming acculturated to a new culture 

as lessening one’s identifcation with one’s original 

culture. American Indians and Alaska Natives have 

clearly demonstrated fortitude, resourcefulness, 

and an ability to negotiate both cultures at the 

same time. There are a few instruments available 

56 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

to assess cultural identity for American Indians 

and Alaska Natives, such as the Native American 

Acculturation Scale (Garrett & Pichette, 2000). 

QUESTIONS TO HELP YOU 

ASSESS CULTURAL IDENTITY 

Learning how your clients identify with their 

culture will help guide the healing process and 

infuence the selection of treatment approaches. 

Asking open-ended questions will help you learn 

more about your clients’ treatment preferences 

and needs as well as their identifcation as 

American Indians and Alaska Natives. For 

illustrations on how to ask questions, use the 

Native American Motivational Interviewing 

Manual (Venner, Feldstein, & Tafoya, 2006). It 

suggests questions such as, “For many native 

people, cultural identity is important, and people 

have all different levels of comfort and belonging 

with one or more cultures. What is important for 

me to know about your cultural identity as we 

begin to work together?” (p. 53). 

Below are some sample questions. As a 

precautionary note, remember not to move 

quickly from one question to the next. Take 

your time. In addition, remember that it is 

inappropriate and disrespectful to ask for 

detailed information about ceremonies. 

• How do you self-identify? 

• Who raised you? 

• Where were you raised? 

• Who is in your family? Who is helping to raise 

your children? 

• How have you been exposed to the culture of 

your tribe? Stories? Ceremonies? Community 

events? 

• What languages do you speak? Which do you 

prefer? 

• How would you describe your spiritual beliefs? 

How do you practice your spirituality? 

• What is your experience with traditional 

healing practices? 

• How important is it to you to work with a 

healer or medicine person in addition to your 

treatment here? 

• Do you have a traditional healer or advisor who 

is currently working with you? 

Assess trauma, including historical trauma. 

American Indians and Alaska Natives experience 

high rates of trauma and traumatic stress responses, 

such as PTSD. They disproportionately experience 

many kinds of trauma, including types that may 

be particularly diffcult for clients to discuss (e.g., 

childhood abuse, sexual abuse). Still, it is important 

that you evaluate the trauma experiences of your 

American Indian and Alaska Native clients, as such 

experiences can affect behavioral health in many 

ways. TIP 57 (SAMHSA, 2014b) discusses how 

trauma can affect behavioral health and how to 

assess trauma and its effects. 

As you read in the East section, historical trauma is 

an important concept for understanding American 

Indians’ and Alaska Natives’ behavioral health, 

and many clinicians who work with this population identify the assessment of historical trauma 

response as a key element in behavioral health 

services for American Indians and Alaska Natives. 

The “Symptoms of Historical Trauma Response” 

box presents possible symptoms of response to 

historical trauma. 

SYMPTOMS OF HISTORICAL 

TRAUMA RESPONSE 

• Survivor’s guilt 

• Depression 

• Psychic numbing 

• Emotional fxation on trauma 

• Low self-esteem 

• Victim identity 

• Anger 

• Self-destructive behavior 

• Substance misuse 

• Hypervigilance 

• Compensatory fantasies 

• Preoccupation with death 

• Death identity (e.g., fantasies of reunifcation 

with the deceased) 

• Loyalty to ancestral suffering and the deceased 

• Internalization of ancestral suffering 

• Internalized oppression 

Source: Brave Heart, 2005. 

Chapter 1 57 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Identify treatment goals that are important to 

your clients. As with all your clients, you will need 

to help your American Indian and Alaska Native 

clients identify treatment goals that are appropriate 

and meaningful for them. If your program primarily 

serves American Indians and Alaska Natives, then 

your program and your colleagues will help guide 

you in developing effective treatment plans. 

Experience working with American Indian and 

Alaska Native clients will improve your ability to 

develop culturally responsive plans. 

Your planning should refect information you 

have gathered from talking to and spending time 

with your clients. As you learn more about your 

clients’ lives, their degree of cultural affliation, 

their religious or spiritual beliefs, and the stories 

of family members, you will need to adjust your 

plans to make the best use of clients’ strengths, 

supports, values, and cultural identity. 

Keep in mind that your client’s values and beliefs 

may be different from yours. For example, you may 

hear less about goals of personal achievement and 

success and more about goals of being a contributing family and community member and upholding 

the pride and traditions of the native culture. 

Spend time discussing with your client what he or 

she might need to do to obtain balance in life and 

heal from present diffculties. 

The following are some common themes that may 

be identifed in treatment planning: 

• Connect or reconnect with traditional ways of 

life and practices. 

• Identify cultural strengths and how to use these 

strengths when distressed or in maintaining 

recovery from substance abuse. 

• Gain greater understanding of the role of 

personal and historical trauma in presenting 

symptoms and substance misuse. 

• Find opportunities to participate in community 

events that support recovery. 

• Refect on how alcohol or other substances have 

interfered with cultural identity or practices and 

affected relationships with others. 

• Consider how introduction, sale, and use of 

alcohol and drugs contributed to oppression. 

• Identify elders, family members, and other 

community members who will support recovery. 

• Explore how spirituality might help with present 

diffculties. 

Incorporate options for cultural activities in 

treatment planning. Connecting or reconnecting 

American Indian and Alaska Native clients to 

cultural practices can improve their behavioral 

health and quality of life. If clients so desire, 

treatment plans should accommodate cultural 

and spiritual activities that can support recovery 

from mental and substance use disorders. Seek 

help from members of clients’ tribes to determine 

the appropriateness of an activity, because a 

community event may involve alcohol, thus increasing your clients’ exposure to alcohol and other 

substances that may compromise recovery. 

The specifc activities involved will vary according 

to the client’s preferences and the native culture 

to which he or she belongs. Some activities (e.g., 

spirit camps, ceremonies, traditional hunting or 

fshing) may need to be scheduled independently 

outside the treatment center, whereas others (e.g., 

sweat lodges, traditional crafting, smudging or 

purifcation, talking circles) may be conducted at 

the program site and integrated with counseling 

activities. By providing opportunities to meet 

community elders, traditional healers, and native 

peer support and recovery coaches, your client will 

have a clearer image of what healing pathways he 

or she needs to choose. Providing these activities 

can help your client connect to traditional practices 

that may more effectively communicate important 

lessons and address his or her presenting 

problems. 

Provide alternative methods for receiving 

services, if needed. If you work in a program that 

already provides telecounseling, uses the Internet 

for videoconferencing, or holds recovery meetings 

by conference call, you know these are effective 

ways of providing behavioral health services. (See 

TIP 60 [SAMHSA, 2015] for more information on 

using these technologies.) Many Native Americans, 

particularly in Alaska, live in remote areas and 

may be unable to access services at an agency 

or program. In such cases, phone or computer 

technology may be the best way for clients to 

58 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

connect with behavioral health services. Another 

alternative method is the use of mobile treatment 

programs for integrated behavioral health services 

that provide more services than the more common 

mobile crisis units (see Jiwa, Kelly, & Pierre-Hansen, 

2008). Although the approach is still in its infancy, 

integrated mobile units can provide a one-stop 

center to address health from a holistic perspective, including substance abuse, mental illness, 

and other health issues. Mobile units are a viable 

alternative for native communities that face barriers 

to accessibility. 

After participating in specifc 

ceremonies, the client may need 

to observe practices as outlined by 

the healer, such as avoiding specifc 

types of food. You can talk with the 

traditional healer and the client 

to understand any restrictions or 

practices that the client will need 

to follow. 

Engage American Indian and Alaska Native 

healers in treatment. There are many paths to 

recovery, and traditional healing practices can work 

well alongside the treatment you offer. Traditional 

healing ceremonies can be powerful experiences 

that help heal a variety of behavioral health issues. 

Traditional healers can also be valuable allies, 

helping you adapt your treatment to be more 

effective. When your client is working with a traditional healer, ask if he or she would like to invite 

the healer to help plan the treatment. Traditional 

healers may be able to help connect your client 

to American Indian and Alaska Native recovery 

communities and can continue to support his or 

her recovery and promote positive change after 

your client has left the program. Ask him or her to 

coordinate with you in your work with American 

Indian and Alaska Native clients. 

If your client is not working with a traditional healer, 

ask if he or she would like to do so. Your client may 

know of a healer or may need assistance in locating 

one who is appropriate, as there are different 

types of traditional healers and traditional healing 

practices, depending on the tribe and training of 

the traditional healer. Although you may want to be 

helpful in contacting a traditional healer, your client 

may have a specifc belief about the type of healer 

best suited to his or her problems. Therefore, talk 

with your client frst, and determine together how 

to arrange access to a traditional healer. 

There are no organizations to certify native 

traditional healers, so you will need to talk with 

clinical supervisors, other providers, elders, tribal 

organizations, or people in the community to fnd 

appropriate ways to integrate authentic traditional 

healers. Some healers will only work with members 

of their own tribe, just as some clients will only 

want to engage in healing practices that are 

from their own tribe. Some clients will also avoid 

traditional healers because of religious differences, 

although their own church (e.g., the Indian Shaker 

Church, the Pentecostal Church) may have healing 

practices. Also, some traditional rituals are only 

meant for men, and healers may exclude women 

from participating. Some healers may not support 

all types of behavioral change. If your client population is drawn from several tribes, you will need 

to develop a network of traditional healers that 

represent these tribes. Some treatment providers 

and programs develop a formalized process and 

agreement with traditional healers ahead of time 

so that their services are readily available when 

needed. 

Even if an American Indian or Alaska Native client 

is uninterested in traditional healing, he or she may 

still wish to have more involvement in traditional 

native cultural practices. Encourage such participation, as it may have a number of benefts. You can 

help your client fnd cultural activities in your area 

that are appropriate for him or her. 

Considering Culturally Adapted 

Treatment Approaches 

The adaptation of mainstream treatment approaches across cultures is still in its infancy, but 

it is clear that culturally adapting evidence-based 

interventions congruent with American Indian and 

Alaska Native worldviews and cultural practices is 

an effective approach. In choosing an approach 

with American Indian and Alaska Native clients, 

it is important to examine the acceptability of 

the belief system that underlies the modality. For 

Chapter 1 59 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

example, therapeutic modalities often focus on 

the past, present, and future, and, as highlighted 

earlier, living in the present—the here and now—is 

a key concept for many native cultures. However, 

this does not mean that the treatment focus should 

avoid historical trauma and other trauma (including 

discrimination), but rather that the discussion 

should be oriented to present-day paths toward 

healing and resolutions. 

Other considerations in adapting an approach 

include assessing how the approach matches 

communication styles, traditional cultural values, 

cultural taboos and practices, and cultural identity 

(for review, see Gray & Rose, 2012). For example, 

rational emotive behavioral therapy is very directive 

compared with motivational interviewing (MI) and 

other cognitive–behavioral approaches. Directive, 

advice-laden, confrontational treatment approaches that deemphasize the therapeutic relationship 

are contraindicated for American Indian and Alaska 

Native clients (J. King, Trimble, Morse, & Thomas, 

2014). Such approaches can create resistance in 

people across cultures but are especially culturally 

insensitive to native people. Of course, this also 

depends on individuals’ cultural identity, level of 

acculturation, and treatment expectation. 

American Indian and Alaska Native clients generally 

respond well to various treatment modalities, 

including individual-, group-, family-, and communitybased approaches. (For a review of various 

programs and projects, see Urban Indian Health 

Institute, 2014.) When considering group therapy, it 

is important to think about the constellation of the 

group. Who is in the group? If there are non-natives 

in the group, how will this affect American Indian 

and Alaska Native participants? How do you need 

to conduct the group differently? If all participants 

are native, does the group contain individuals from 

diverse tribes? If so, what is the relational history 

among the specifc tribes? Some individuals may 

initially have a diffcult time participating with a 

member from a particular tribe; other individuals 

may worry about confdentiality if members from 

their own tribe or community are in the group. 

When it comes to family treatment, it is essential to 

identify who is family. As with any family process, 

it will be important to understand and honor 

the family’s history, system, hierarchy, and other 

dynamics. Culture, historical trauma, and outside 

infuences greatly affect family dynamics. For 

example, what is the impact of a grandparent’s or 

great-grandparent’s boarding school experience 

on the family system? How does this history 

infuence parenting skills, cultural identity, trust, 

and traumatic stress? 

Community-based interventions are another 

powerful modality; they address current individual problems through a larger lens. If individual 

substance use disorders and mental illness are 

viewed as symptoms of the native community’s 

history of trauma and discrimination, then it is 

natural to address problems from a broader 

perspective using culturally based community 

approaches rather than, or in combination with, 

individual and family modalities. These approaches 

are in line with cultural values, and traditional 

healing practices can easily be an essential ingredient. Community-based interventions are built on 

a belief in self-determination: that healing and the 

solutions to behavioral health come from within 

the community. These interventions will need 

guidance from native facilitators. They also require 

a presence and investment in the community, as 

well as initial permission, acceptance, and participation of tribal leadership and other infuential 

tribal members. Community interventions need 

to include youth, elders, and other community 

members. 

Native nations have developed many 

behavioral health programs and 

interventions to address and fnd 

solutions to community problems, such 

as substance misuse, diabetes, other 

health issues, suicide, parenting issues, 

and sexual violence. Talking circles, 

educational groups, youth gatherings, 

drum-assisted recovery, outdoor 

adventure, and cultural heritage days 

are a few examples of communitybased interventions used over the past 

two decades. 

60 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

Although culturally adapted EBPs are few, 

American Indian and Alaska Native practice-based 

approaches are evolving. Practice-based approaches (knowing what works through experience, 

clinical judgment, cultural knowledge, and client 

feedback) are much more culturally responsive and 

accepted in native communities than EBPs are. 

Keep in mind that the importance of using EBPs is 

generated from mainstream ideology. Thus, there 

is danger in an “outsider” attempting to impose 

an approach without considering the culture and 

self-determination of American Indian and Alaska 

Native communities. Moreover, the research that 

supports EBPs generally fails to have adequate 

American Indian and Alaska Native representation. 

Culturally adapted treatment practices 

are generally passed orally from one 

therapist to another at meetings or 

other gatherings of providers for native 

people (Gray & Rose, 2012). 

Exhibit 1.1-5 provides information on a selection 

of culturally adapted treatment practices. Some 

other prevention and treatment interventions have 

been evaluated with American Indian and Alaska 

Native clients, and the number of such interventions continues to grow. For further discussion, 

see Part 3, the online literature review. Culturally 

adapted approaches include MI, family systems 

(i.e., network therapy), community reinforcement, 

mindfulness approaches, and cognitive–behavioral 

therapy (CBT). Take into account that this is only a 

sample and that if an approach is not mentioned 

below, it does not mean that the approach is a 

poor choice for American Indian and Alaska Native 

clients or that it can be provided without modifcation. When selecting culturally adapted approaches, 

consider them in light of the specifc culture; cultural 

identity; traditional healing practices; presenting 

problems; strengths; and needs of the client, family, 

and community (Trimble, Scharron-del-Rio, & Hill, 

2012). 

EXHIBIT 1.1-5. Examples of Culturally Adapted Treatment Approaches 

THEORETICAL 

APPROACH 

POTENTIAL BENEFITS 

OF APPROACH 

ADAPTATIONS FOR NATIVE 

AMERICAN CULTURES 

SPECIFIC INTERVENTIONS 

AND RESOURCES 

Motivational 

Interviewing (Miller 

& Rollnick, 2013) 

MI is client centered 

and focuses on 

active listening, 

stages of change, 

self-talk, empathy, 

and other core 

elements to elicit 

“change talk.” 

• Is found to be effective 

for treating American 

Indians and Alaska 

Natives 

• Is nonconfrontational 

and noninterfering 

• Uses active listening 

skills 

• Teaches the culturally 

appropriate idea 

that what you say to 

yourself is what will 

happen 

• Emphasizes the 

importance of 

relationships and 

empathy 

• Have adequate training 

and use current American 

Indian and Alaska Native 

adaptations 

• Have clients create 

personal stories for each 

stage of change 

• Present stages of change 

model as a circle 

• Remember that 

self-disclosure is 

not a traditional 

communication style 

• Native American 

Motivational 

Interviewing: Weaving 

Native American and 

Western Practices—A 

Manual for Counselors 

in Native American 

Communities (Venner et 

al. 2006) 

• Trainer’s Guide 

to Motivational 

Interviewing: 

Enhancing Motivation 

for Change—A 

Learner’s Manual for 

the American Indian/ 

Alaska Native Counselor 

(Tomlin, Walker, & 

Grover, 2014) 

Continued on next page 

Chapter 1 61 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

EXHIBIT 1.1-5. Examples of Culturally Adapted Treatment Approaches 

(continued) 

THEORETICAL 

APPROACH 

POTENTIAL BENEFITS 

OF APPROACH 

ADAPTATIONS FOR NATIVE 

AMERICAN CULTURES 

SPECIFIC INTERVENTIONS 

AND RESOURCES 

Family Therapy 

Therapies that 

incorporate family/ 

community systems, 

are developmental, 

have a community 

orientation, or have 

a generational focus 

are more relevant 

for American Indian 

and Alaska Native 

clients. 

• Uses the natural 

support system of the 

individual 

• Provides treatment 

in a small community 

context 

• May be designed to 

accommodate large 

extended families (i.e., 

network therapy) 

• Can easily take place in 

the client’s home 

• Recognizes the 

importance of families 

in the context of the 

community 

• Focuses on 

strengthening 

families and family 

cohesiveness 

• Decreases risk for 

substance misuse and 

improves treatment 

outcome 

• Recognize cultural 

differences in hierarchy, 

dynamics, and history 

• Determine how family is 

defned 

• Explore how every family 

member feels about 

being in a session with 

one another and with you 

• Invite other key 

individuals into the 

session (e.g., community 

elders) when appropriate 

• Consider home visits 

• Use genograms to explore 

family patterns, strengths, 

history, social support, 

and so on 

• Use family sculpting 

technique, which uses 

a more kinesthetic 

approach to learning 

• Have families develop 

their own stories of 

strength 

• Network Family 

Therapy was originally 

developed to treat 

American Indians 

and Alaska Natives 

living in urban 

communities; it uses 

the individual’s natural 

support system and 

community (Attneave, 

1969; Galanter, 1999; 

LaFromboise & 

Fleming, 1990) 

• American Indian 

Families: An Overview 

(Sutton & Broken Nose, 

2005) 

Trauma-Informed 

Treatment 

Interventions focus 

on how trauma may 

affect an individual’s 

life and his or her 

response to services. 

• Recognizes the 

importance of trauma, 

including historical 

trauma, in providing 

care for individuals, 

families, and 

communities 

• Integrates knowledge 

about trauma into 

procedures, practices, 

and settings 

• Creates pathways 

to healing through 

developing awareness, 

safety, and support 

• Improves treatment 

outcomes 

• Use for grief resolution 

and trauma mastery 

• Incorporate into 

parenting programs 

• Integrate traditional 

practices and healing 

approaches 

• Historical Trauma 

and Unresolved Grief 

Intervention (Brave 

Heart, 1998) 

• Pathway to Hope: An 

Indigenous Approach 

to Healing Child Sexual 

Abuse (Payne, Olson, & 

Parrish, 2013): A traumainformed training 

program focused on 

ending the silence 

surrounding sexual 

abuse in rural Alaska 

Native communities 

and promoting 

community-based 

approaches to healing 

Continued on next page 

62 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

EXHIBIT 1.1-5. Examples of Culturally Adapted Treatment Approaches 

(continued) 

THEORETICAL 

APPROACH 

POTENTIAL BENEFITS 

OF APPROACH 

ADAPTATIONS FOR NATIVE 

AMERICAN CULTURES 

SPECIFIC INTERVENTIONS 

AND RESOURCES 

Community 

Reinforcement 

Approach (CRA) 

This model was 

developed using 

behavioral therapy 

principles for 

substance use 

disorders. 

• Relies on positive 

reinforcement drawn 

from the client’s 

community and family 

• Provides an alternative 

to substance use with 

cultural practices 

• Presents an 

opportunity for 

community to 

participate 

• Design reinforcements 

specifc to community 

needs and with 

governance input 

• Navajo version of CRA 

makes use of relational 

ties and reinforces the 

use of Navajo cultural 

and spiritual practices 

(Miller, Meyers, & HillerSturmhöfel, 1999) 

Mindfulness-Based 

Interventions 

Mindfulness 

approaches for 

behavioral health 

combine CBT and 

Asian philosophies 

of spirituality. They 

are focused on 

attending to current 

experiences and 

thoughts as an 

observer. 

• Is more accepting 

because the 

philosophy was 

developed outside 

mainstream behavioral 

health 

• Matches more 

consistently with the 

belief systems and 

importance of a focus 

on the present found 

in many American 

Indian and Alaska 

Native cultures 

• Consider using walking 

meditations, which easily 

ft into traditional coping 

strategies 

• Suggest and talk about 

how to use mindfulness 

exercises while engaged 

in traditional and 

subsistence practices 

• Consider using 

Acceptance Commitment 

Therapy; it combines 

mindfulness and valuebased decision making 

and behavior 

• Mindfulness-Based 

Relapse Prevention 

(Witkiewitz, Greenfeld, 

& Bowen, 2013) 

• Suicide Prevention for 

Native American Youth 

(Le & Gobert, 2013) 

CBT 

CBT develops 

specifc skills to 

promote behavioral 

change. 

• Adapts cross-culturally

with ease 

• Focuses on the 

present 

• Recognizes the 

importance of 

accepting personal 

responsibility for 

changing behavior 

• Includes attitude of 

partnership between 

provider and client 

• Can address a 

variety of issues (e.g., 

parenting) 

• Honor the principle of 

noninterference 

• Avoid overuse of a very 

directive approach; 

instead, assume 

the honored role of 

consultant and provider of 

resources for the client 

• Adapt for videoconferencing when 

appropriate 

• Cognitive–Behavioral 

Therapy With American 

Indians (McDonald & 

Gonzales, 2006) 

• Cognitive–Behavioral 

Therapy for Native 

American Youth With 

PTSD Symptoms 

(Goodkind, LaNoue, & 

Milford, 2010) 

Continued on next page 

Chapter 1 63 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

EXHIBIT 1.1-5. Examples of Culturally Adapted Treatment Approaches 

(continued) 

THEORETICAL 

APPROACH 

POTENTIAL BENEFITS 

OF APPROACH 

ADAPTATIONS FOR NATIVE 

AMERICAN CULTURES 

SPECIFIC INTERVENTIONS 

AND RESOURCES 

Matrix Model 

This is a structured 

treatment 

experience provided 

in various formats 

for intensive 

outpatient 

programs. 

• Uses a variety of 

support strategies 

• Educates clients and 

their families 

• Builds skills 

• Includes relapse 

prevention 

• Integrates CBT, 

contingency 

management, MI, 12-

Step facilitation, and 

family involvement 

• Be careful not to focus so 

much on the manual and 

process that it overrides 

the time needed to build 

a trusting provider–client 

relationship 

• Foresee problems of 

becoming too structured 

and infexible in schedule 

• Use culturally adapted 

tools 

• Matrix Model: Culturally 

designed client 

handouts for American 

Indians and Alaska 

Natives (Matrix Institute 

on Addictions, 2014) 

Behavioral Therapy 

This therapy 

focuses on 

changing behavior 

using learning 

principles and 

psychoeducation. 

• Is less culturally biased 

than some other 

treatment models 

• Does not rely on 

culturally defned 

ideas of family and self 

for basic principles 

• Focuses on present 

behavior, rather than 

on the past, which is 

consistent with many 

American Indian and 

Alaska Native cultures 

• Have clients identify their 

own goals for behavioral 

change 

• When using positive and 

negative reinforcement 

to support change, make 

sure reinforcements are 

culturally appropriate 

• Do not suggest goals or 

behavioral reinforcement 

based on another 

population; doing so 

would be an attempt to 

enforce conformity 

• The Coping With 

Depression model 

(Lewinsohn, 

Antonuccio, 

Breckenridge, & Teri, 

1984) was adapted 

for use with Native 

American older 

adults by Manson and 

Breenneman (1995) 

Building Supports and Supporting 

Recovery 

Most people across cultures fare better in recovery 

if they have an adequate support system. This is 

also true for American Indians and Alaska Natives: 

community support is often a key ingredient 

whether you are providing care for someone who 

lives on a reservation, in another rural area, or in 

an urban area. Below are some suggestions for 

how you can improve support systems for your 

American Indian and Alaska Native clients. 

Connect clients to American Indian and Alaska 

Native recovery supports. Get to know the 

traditional healers, providers, and programs in your 

community and the home communities of your 

clients. By helping your clients connect with traditional healers, family, and community programs, 

you can help them build a support system that 

will promote recovery long after they leave your 

program. You will also need to search out recovery 

resources in your area that support American Indians 

and Alaska Natives and learn about their methods. 

You may need to identify specifc supports that are 

available for tribal members in your area as well as 

those that might be useful to American Indians and 

Alaska Natives regardless of tribal affliation. You 

can begin by talking with service providers from 

tribes or urban native programs and your state’s 

behavioral health division. Besides typical recovery 

64 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

supports (such as mutual-help groups), involvement 

in community activities, when and where appropriate, is an important avenue in recovery promotion 

for American Indians and Alaska Natives. 

Identify appropriate support. Establishing a 

support system is only effective if it addresses 

the unique needs of the individual and family. For 

example, although social support is one of the 

most important factors in maintaining recovery, 

the perceived and real probability of encountering 

social confict or social pressure is a greater risk 

factor for relapse of substance use or a reoccurrence of psychological symptoms among American 

Indians and Alaska Natives than among any other 

ethnic or racial group. Therefore, it is important not 

just to ensure support, but also to explore potential 

conficts and minimize exposure at least in the early 

stages of recovery from substance abuse or mental 

distress. Some individuals have shared that they 

needed to make major changes in the frst year of 

recovery by staying away from some people and 

community events to avoid social pressure to use. 

Here the destruction stops. 

We will heal ourselves, 

We will heal our wounded 

relationships, 

We will heal our children, 

We will heal our Nations. 

On this day, our future history 

begins.” 

Source: White Bison, 2002, p. C. 

Use mutual-help approaches that are culturally 

appropriate. Mutual-help is often an important 

part of long-term recovery for people with mental 

and substance use disorders, including many native 

people. American Indians and Alaska Natives have 

a long history of using mutual-help specifcally to 

address alcohol use disorders that continues to this 

day. Some American Indians and Alaska Natives 

may have diffculty with the public speaking (and, in 

particular, public confession) aspect of mutual-help 

groups, but for those who do participate, mutualhelp groups appear to be benefcial. 

The 12-Step model is helpful for many American 

Indians and Alaska Natives in recovery from 

substance use disorders who typically fnd its 

focus on nondenominational spirituality culturally 

relevant. American Indians and Alaska Natives have 

made adaptations to this model to make it more 

culturally appropriate. For example, the Salish 

Indians (mentioned in “The Importance of Knowing 

the Specifc American Indian and Alaska Native 

Cultures of Your Clients” box), whose culture had 

historical precedents for group talk and confession, 

have made their own adaptations to the model. 

The Red Road to Wellbriety is an example of 

melding together the older teachings of native 

recovery, recovery circles, the code of Handsome 

Lake, ancestral teachings, and the 12-Step 

program. “The Red Road is a way of achieving 

sobriety and healing personal and cultural wounds. 

The Red Road is a way of breaking the cycle of 

destruction that so often accompanies historical 

trauma and oppression” (White Bison, 2002, p. E). 

Fostering Community Connections 

As an individual provider, you can informally build 

relationships in American Indian and Alaska Native 

communities that will help you be more effective 

and better received by the community, improve 

how clients and their families and friends perceive 

you, increase your understanding of your clients’ 

culture, and become aware of the strengths and 

problems of the communities in which your clients 

live. If you want to deliver prevention messages, 

they will likely be better received coming from 

other community members than from you or your 

program alone. 

Not all areas will have a signifcant native 

community, but even away from Indian Country, 

American Indians and Alaska Natives may have 

support networks based either on shared tribal 

identity or, in cases where no tribes are dominant, 

on a pan-Indian identity. In urban native communities, there are often informal community 

leaders who are known to and respected by many 

American Indians and Alaska Natives and to whom 

they may go for advice. What follows are some 

suggestions to guide you in developing community 

relationships within American Indian and Alaska 

Native communities. 

Chapter 1 65 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Non-native people often talk to get to 

know a person. Native Americans may 

expect that you wait until you know 

someone before you speak to them in 

depth or in confdence. 

Take your time. Do not move too quickly to 

establish yourself. Take time listening and learning 

about how things work in the community. The 

last thing you want to do when you are new in a 

community is step on someone’s toes or make a 

mistake that you have to live down later. As an 

example, a counselor arrives in a small community. 

Within the frst 2 days, the counselor confronts the 

program director and his supervisor because some 

staff members are relatives. The director’s niece 

and the supervisor’s sister work within the same 

program. Rather than waiting to build community 

relationships and to understand the community 

environment, the counselor runs roughshod over the 

treatment community and erodes the potential for 

building relationships inside and outside the center. 

Learn about the culture. American Indians 

and Alaska Natives have very distinct beliefs, 

languages, traditions, and nations. What is the 

history and tradition of the people as they tell it? 

What is their clan system, if they have one? Do 

they identify more strongly with the mother’s or the 

father’s lineage? What are the customs in extended 

family relationships? Learn as much about the 

culture as you can through interacting with others, 

reading native writings, and being an observer 

and respectful participant in community events. 

Know proper etiquette in attending community 

events or if you are invited to ceremonies. When 

is it appropriate to speak or to be silent? Do not 

attempt to participate in a dance, drumming, or 

any other ceremony without a guided invitation. 

Learn culturally correct terms (e.g., “regalia” 

instead of “costume”). If you can, fnd a community 

member, such as an elder, a provider, or a person in 

recovery, with whom you can build a close relationship and who can guide you. 

Introduce yourself. Try to introduce yourself to all 

community members whom your work may affect 

(in a small community, that may be everyone). Tell 

them what brings you there and what you are there 

to do and fnd out how you can best work together 

without duplicating services. Show respect for how 

each person lives and for his or her privacy and 

mind your own business. Remember that you are 

a guest; they will decide in their own time how 

they see you based on how you handle yourself. 

Act graciously and remember that you are there to 

learn, not to instruct. 

Learn from elders. Showing respect for elders is 

extremely important in American Indian and Alaska 

Native cultures. They are the bearers of native 

history, language, knowledge, and ways. Spending 

time with elders is a good way to learn about the 

community and earn trust. One way to show respect 

is by listening without interruption or imposing time 

limits. This may lead to broader acceptance in the 

community. Learn the protocol for consulting an 

elder; you may want to bring a gift. 

See and be seen. Learn what kinds of events and 

gatherings are important to community life and 

attend them if it is appropriate for you to do so. 

Educational programs, school and sporting events, 

and music programs are common community 

events. If you attend, bring food to share at the 

event. In some communities, hunting, fshing, 

gathering berries and roots, tapping trees for 

maple syrup, and processing these foods are 

time-honored traditions that are often done as a 

community, and it may be possible to participate 

in such activities if you are invited or if you ask. A 

provider who only stops by to hold offce hours 

risks being seen forever as an outsider who does 

not understand or even want to understand what 

life is like in the community. 

Respect the intellectual property of native 

culture. You are not in the position to interpret or 

comment on cultural values, events, or ceremonies. 

Equally important, it is not ethical to publish; blog 

about; or post videos, comments, or pictures 

related to such cultural property on any social 

network platform. Confdentiality needs to extend 

beyond clients’ personal information: native culture 

is the intellectual property of tribal members 

themselves. Whether or not a tribe asks you to 

sign a confdentiality agreement regarding their 

cultural and intellectual property, keeping cultural 

information private is the correct, moral, and legal 

thing to do. 

66 Chapter 1 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

Since colonization, American Indians and Alaska 

Natives have had their culture stolen, destroyed, 

misused, romanticized, and misrepresented without 

much thought to the history and existing realities of 

oppression. As a provider, you need to be sensitive 

not only to the history of the government’s efforts 

to eradicate native culture, but also to individual 

actions that have eroded and can further erode 

native culture. Native culture belongs only to native 

people. The culture includes, knowledge pertaining 

to beliefs, language, ceremonies, ways of being, 

traditions, hunting and gathering sites, medicine, 

events, sacred items or sites, and artwork. 

You may be in a position to provide presentations, 

reports, or information to other agencies or organizations regarding the use of services, research, 

demographic data, or case studies of American 

Indians and Alaska Natives. If so, it will be critical 

that you frst review all releases of information with 

the appropriate governing body of the particular 

tribe or people to get approval. 

Use your program or facility to provide 

community services. Many behavioral health 

programs that serve American Indians and Alaska 

Natives have found it helpful to integrate a range 

of services and to host or house cultural and 

community activities. Some behavioral health 

programs have integrated services including, but 

not limited to, HIV testing and prevention, medical 

services, childcare and family services, housing 

assistance, job training, life skills training, and 

parenting classes. Integration of services increases 

accessibility for clients. Also, the facility needs to 

invest in the community. A simple approach is to 

use the facility’s space for hosting cultural events, 

educational programs, and community activities 

(e.g., a New Year’s Eve sobriety pow wow). Doing 

so increases program visibility and, potentially, 

community trust. It is far easier to go to a facility 

that you know than to one that is disconnected 

from the community. 

Be prepared to help communities develop 

community-wide initiatives. As described in 

the West section, American Indians and Alaska 

Natives typically have a holistic view of health that 

encompasses the individual, the family, and the 

community, and many native communities have had 

success with interventions that involve efforts at 

the community level, such as gathering of Native 

Americans and community readiness programs 

(Plested, Jumper-Thurman, & Edwards, 2015). 

Such interventions may combine legal, prevention, 

treatment, cultural, and other community-building 

elements to address health problems, such as 

substance abuse, HIV, diabetes, sexual violence, 

suicide, and their effects on the entire community. 

Treatment programs should not be the main 

actor in the development of such initiatives. To be 

effective, community-based interventions need to 

develop from the will of the community. Usually a 

few concerned community members will start the 

ball rolling and may reach out to local providers 

for assistance. Programs can then provide information, technical assistance, and other support to 

community members who want to help. 

Gathering of Native Americans is a 

4-day community event that focuses 

on health and well-being to bring about 

community healing. This approach 

values traditions while increasing the 

community’s strengths. This community 

event addresses topics such as historical 

and cultural trauma, suicide, and 

substance abuse, among others. 

Where Do You Go From Here? 

As you have read this chapter, you probably started 

thinking about how it translates to your day-to-day 

interactions and responsibilities as a provider. Now 

that you have some fundamental information, the 

next chapter will provide more specifc information 

and examples of providing culturally responsive 

care. You will meet a number of American Indian 

and Alaska Native clients who are experiencing 

or have experienced substance abuse or psychological distress. Part 1, Chapter 2, provides 

stories, examples of client–provider dialogs, and 

ideas about how to provide care. As you proceed, 

bear in mind that being a culturally competent 

provider involves a commitment to learning cultural 

knowledge, exploring cultural awareness and 

Chapter 1 67 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

competence, understanding cultural perspectives 

of behavioral health, and adopting culturally 

specifc and responsive skills and practices. Not 

only that, but it also necessitates a willingness to 

invest in relationships with your clients and the 

community. 

68 Chapter 1 
Part 1, Chapter 2 

Introduction 

In this chapter, you will meet four American Indian 

and Alaska Native clients and their providers. 

Some of the providers are non-native, and others 

are native, although they may be working in tribes 

different from their own. The consensus panel has 

made signifcant efforts to present realistic counseling scenes using culturally responsive approaches 

that include integrating traditional healing with 

mainstream approaches such as motivational interviewing (MI), family therapy, and psychoeducation, 

as well as other modalities. 

This chapter centers around four stories. Each story 

includes some background for the provider, tells the 

history of the client, and highlights learning objectives as well as client–provider dialog that demonstrates specifc knowledge and skills for providing 

behavioral health counseling to American Indians 

and Alaska Natives. The stories capture culturally 

relevant issues in a variety of specifc situations 

and treatment settings. These stories highlight key 

elements and tools for providing culturally responsive care that supports healing. The consensus panel 

does not intend to imply that the approach used 

by the provider in each story is the best option, 

but rather, that it is an informed, practice-based 

approach that refects culturally competent skills you 

can implement in real-world settings. 

Be mindful that some of your clients 

may see recovery as a journey in 

whole-person wellness, including 

spiritual, physical, emotional, and 

cognitive health combined. They may 

be less focused on simply getting relief 

from presenting symptoms and more 

focused on fnding their footing and 

walking in balance within themselves 

and for their family and community. 

TIP 61 BEHAVIORAL HEALTH SERVICES FOR 

AMERICAN INDIANS AND ALASKA NATIVES

MASTER PROVIDER NOTES 

These are comments about the strategies 

used, possible alternative techniques, and 

insights into the client–provider relationship. 

These notes represent the combined 

experience and wisdom of the consensus 

panel and other contributors to this TIP. As you 

proceed, keep in mind that some suggestions 

may not be culturally congruent or appropriate 

for your client. Moreover, it is important that 

you, as the provider, have the necessary 

training and clinical supervision to engage in 

these clinical activities. 

About the Stories and Vignettes 

A collaborative effort using a consensus process led 

to development of these four stories. The consensus 

panel used a composite of client experiences in 

counseling to come up with the backgrounds, 

geographic regions, and other identifying details of 

the clients in the vignettes, so that the histories and 

client–provider dialogs are not complete accounts of 

specifc people. Any associations with actual people, 

presenting problems, or events are coincidental. 

The consensus panel took great care in creating 

histories that demonstrate common, yet diverse, 

themes in behavioral health services. Panel members 

chose a series of American Indian and Alaska Native 

stories that represent differences in geographic 

location, gender, cultural identity, age, alcohol and 

drug use, and behavioral health concerns. However, 

the consensus panel has had to be selective out of 

necessity; histories and vignettes cannot capture 

every aspect of culturally responsive treatment or 

represent the wide variations in presenting problems 

among American Indians and Alaska Natives. 

69 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

How To Approach the Stories and 

Vignettes 

Each story consists of an introduction outlining the 

provider’s cultural background and work setting; 

the client’s story, including presenting concerns and 

treatment needs; learning objectives for readers; the 

client–provider dialog; and a summary. To complement the client–provider dialog, clinical information 

relevant to the dialog is embedded at times into the 

transcripts using italic text in brackets and through 

master provider notes and other informational text 

boxes. In some cases, you will learn about consultations between the provider and his or her supervisor 

or native consultant. 

The four stories and vignettes incorporate the key 

concepts discussed in Part 1, Chapter 1: 

• The frst vignette demonstrates the importance 

of engaging and building a trustworthy relationship between the provider and client (Vicki). 

Through honoring traditional ways, the session 

addresses Vicki’s personal commitment to 

treatment. 

• In the second vignette, the provider meets Joe, 

the client, in a pretreatment session prior to his 

transfer to court-mandated treatment. Joe lives 

on a reservation and has a history of methamphetamine dependence. The vignette demonstrates key ingredients of culturally responsive 

treatment using a pretreatment and a treatment 

session. 

• The third vignette focuses on ways to facilitate 

support, to honor family, and to help Marlene, 

the client, reconnect to traditional ways to 

maintain recovery living in a remote Alaska 

Native village. The vignette contains an individual and a family session. 

• The fourth vignette begins with addressing 

homelessness in Alaska. Philip, the client, has 

been living in a camp outside an Alaskan urban 

area, far removed from his village and family, 

without the means to return to his village. 

Beginning with an initial outreach strategy, the 

story highlights how Philip accesses treatment 

and other social services to begin his recovery. 

The story reveals the role of traditional ways in 

sustaining recovery. 

Exhibit 1.2-1 highlights provider and client characteristics for each vignette. 

70 Chapter 2 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

EXHIBIT 1.2-1. Vignette Summary Table 

Vignette 

Client 

Demographics Family History 

Cultural and Spiritual 

History 

Educational and 

Vocational History 

1 

Vicki 

Female; age 50; 

single; enrolled 

in tribe in the 

Midwest; has lived 

on a reservation her 

entire life 

Raised by grandparents and parents; 

grandparents were 

very traditional; both 

parents are alcohol 

dependent; she is 

guardian of two nieces 

(5 and 7); sister is drug 

dependent 

Raised in traditional 

spirituality; mother was 

Catholic 

Sent to boarding 

school in Oklahoma 

from 8 to 12 years 

of age; completed 

general education 

development (GED); 

not working now 

2 

Joe 

Male; age 28; single; 

enrolled and living 

on a reservation 

in the Southwest; 

migrates on and off 

reservation 

Grew up with parents 

and grandparents 

on reservation; 

grandparents practice 

traditional ways; oldest 

of seven; parents 

drank and smoked 

marijuana 

Bilingual; traditional 

upbringing 

Sent to boarding 

school; dropped 

out of school; 

works off and on in 

construction and as 

an artist 

3 

Marlene 

Female; age 30; 

married; lives in a 

village in western 

Alaska 

Grew up in an Alaska 

Native village; family 

member died by 

suicide 15 years 

ago; mother and 

grandmother had 

depression; lives with 

husband and four 

children; husband 

misuses alcohol 

Bilingual; traditional 

upbringing; considerable 

subsistence skills 

and involvement in 

subsistence activities 

Finished 10th grade; 

works seasonally as 

fsh processor; parttime employment 

as store clerk and 

janitor; prefers 

subsistence lifestyle 

4 

Philip 

Male; age 40; 

divorced; grew up 

in a remote Alaska 

Native village; 

moved from village 

in Arctic Slope to a 

more urban area; 

currently camping 

outside city with 

other individuals 

who are homeless 

Raised by paternal 

grandparents; 

mother was alcohol 

dependent; father 

left village before his 

birth; youngest of 

four children; history 

of physical and 

emotional abuse; no 

contact with son or 

ex-wife in 7 years 

Bilingual; traditional 

upbringing but feels 

confict between his 

cultural traditions and 

Catholic Church; good 

subsistence skills; 

involved in subsistence 

activities; traditional 

artist 

Traditional wood 

carving skills; high 

school graduate; 

accepted into 

Navy but rejected 

after drug testing 

positive for 

marijuana; worked 

in small engine 

repair; not currently 

working 

Continued on next page 

Chapter 2 71 
TIP 61

-

Behavioral Health Services for American Indians and Alaska Natives 

EXHIBIT 1.2-1. Vignette Summary Table (continued) 

Vignette 

Alcohol and Drug 

History 

Co Occurring Conditions 

and Other Clinical 

Concerns* Legal History 

Provider 

Characteristics 

1 

Vicki 

Alcohol is primary 

drug of choice; two 

prior treatment 

episodes; has had 

periods of sobriety 

History of diabetes and 

being overweight; history 

of emotional, physical, 

and sexual abuse at 

boarding school; lifelong 

history of depression; 

potential retraumatization 

at being mandated to 

residential treatment; 

historical trauma 

Two convictions for 

driving under the 

infuence (DUIs); 

child endangerment 

charge; driver’s 

license suspended; 

involved in tribal 

wellness court 

Karen grew up in 

a predominantly 

White suburban 

area, but has some 

native blood in her 

background with 

a mix of cultures 

represented in her 

family’s traditions; 

provider at the 

residential treatment 

center for 3 years; 

licensed alcohol and 

drug counselor 

2 

Joe 

Methamphetamine 

is primary drug 

of choice; began 

drinking at 13; 

alcohol binges 

began at 14; dealt 

drugs previously; 

drug-free for 2 

months 

Protracted withdrawal 

symptoms; some 

confused thinking and 

paranoia initially as well as 

nightmares 

Spent a total of 

4 years in prison; 

recently released 

after 2 months in 

jail; court-ordered 

to alcohol and drug 

evaluation and 

treatment 

Mike grew up on 

the reservation; 

provider at the tribe’s 

treatment center for 

4 years; in recovery 

3 

Marlene 

Alcohol (mainly 

homebrew) is 

primary drug of 

choice; referred 

to residential 

treatment; relapse 

history; drinks to 

self-medicate; 

frst residential 

treatment 

Unresolved grief issue; 

history of sexual abuse 

by stepfather; history 

of depression; family 

concerns 

Offce of 

Children’s Services 

involvement 

Nolee, Alaska Native, 

grew up in remote 

village; interned 

as village-based 

provider; counselor at 

residential treatment 

program 

4 

Philip 

Alcohol is primary 

drug of choice; 

periodic use of 

marijuana; began 

experimental 

alcohol and drug 

use at age 9; drinks 

daily; no prior 

history of treatment 

Homeless; history of 

suicide in his family; 

unresolved grief 

associated with losses 

of family members and 

friends; has no money 

to return home to his 

village; feels disconnected 

from his relatives; worried 

about prejudice as an 

Alaska Native, leading to 

hesitation in asking for 

help 

Two old 

misdemeanor 

convictions; one 

DUI and public 

intoxication charge 

Anthony, Alaska 

Native; received 

scholarship from his 

village corporation; 

attended school 

in Arizona; made 

commitment to give 

back to his native 

community on his 

return; provider at 

a native treatment 

center 

*Effects of historical trauma are assumed across all vignettes. 

72 Chapter 2 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

TRADITIONAL HEALING 

“Traditional Healers and Elders say that the Great Spirit works through everyone, so that everyone has the 

ability to heal, whether it’s the mother who tends to the scrapes of her child, a friend who eases your pain 

by kind words or the Healer who heals your sickness. Everything that was put here is healing—the trees, the 

earth, the animals and the water. In the past, knowledge of the medicines was a natural part of everyone’s 

learning. We knew what plant medicines were for and how to prepare offerings for them. When we needed 

special help beyond what was common knowledge, we looked to our Medicine men and women and 

Healers. This familiarity with the healing properties of the plants that grew around us was empowering. It 

was something that belonged to the community. This knowledge is no longer widespread and many of 

the illnesses that our communities are faced with today were not seen in the past. Many native people are 

seeking emotional, mental, and spiritual healing for past abuses and traumas; for the pain that they are 

carrying as a result of what generations of their families went through; and for a loss of identity because 

of separation from family and culture. Others are seeking help for physical illnesses such as diabetes and 

arthritis that affect native people in disproportionately large numbers. 

“Native people know that everything in Creation—the plants, trees, the water, wind, rocks and the 

mountains—have spirit. As part of Creation, we also are sacred and have spirit. Healing is understood in 

terms of the spiritual basis of everything. Our approach to healing is through ceremony. When we put 

our tobacco down as an offering to these things we call Creation, our spirit is making that connection 

so that we will be able to get that life source from them. Our healing ways are referred to as Traditional 

Healing. This way of healing is holistic, based on an understanding of the interconnectedness of all life 

and the importance of balance and harmony in Creation. Just as in Creation all things are connected but 

have different functions, so our mind, body, spirit, and emotions are part of the sacred circle of life and are 

interconnected. When one of them is out of balance, it affects the others. If you have a physical problem, it 

is connected to your spirit. If your mental state is out of balance, it will cause emotional turmoil. Traditional 

Healing is the restoring of balance to the mind, body, spirit and emotions. There needs to be harmony 

and balance in us just as there is in all of Creation. When that harmony and balance is lacking, sickness 

ensues. It is said that a great deal of healing comes from ourselves because we want to be healed. In taking 

responsibility for our own healing, we may participate in ceremonies. This can include our daily ceremony 

of offering tobacco. It can also include other healing ceremonies that we participate in under the guidance 

of Healers and conductors, such as the sweat lodge, the shaking tent, the Sundance, the fast, and the vision 

quest. When you start on a healing journey, you are making a commitment to help yourself, your family and 

your community. Although ceremonies differ from First Nation to First Nation, basic beliefs are similar. We 

have all come to take care of the spirit. Use of sacred items such as the pipe, the drum and the eagle feather 

can help us make the connection with Creation. It is said that all of Creation can give us teachings, that our 

way is a loving way that teaches us about kindness, caring, sharing, honesty and respect. When we pray, 

the spirits that travel with us hear our prayers. They recognize us clearly when we let them know our spirit 

name. In this way, our spirit name is said to be ffty percent of our healing and balance and also, because 

with it, we know who we are, we know where we belong, we know where we are going, and we know where 

we came from.” 

Source: Anishnawbe Health Toronto, 2000, p. 1. 

Chapter 2 73 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Vignette 1—Vicki: Establishing Relationships, Acknowledging the 

Past, and Choosing Treatment 

Overview 

This story illustrates how providers can engage 

clients to begin developing a therapeutic relationship and guide them to make a commitment 

to treatment and to well-being. The story begins 

when Vicki attends an intake interview at a residential treatment center to which she has been 

referred as a result of a court order. This treatment 

center is located in a small town in a rural area near 

two reservations and has a reputation of working 

well with American Indian and Alaska Native 

clients, who represent about 20 percent of the 

program’s population. Vicki has attended another 

treatment center in the region twice before. 

Vicki frst meets Karen, who facilitates the intake 

interview and will be her primary provider if she 

attends the program at the new facility. Karen, 

who has some native blood in her mixed-race 

background, was raised in a predominantly White 

neighborhood of a suburban community. She 

was raised with a mix of cultures represented in 

her family’s traditions, although she wasn’t particularly aware of that. After college, she served 

with Volunteers in Service to America (VISTA) and 

developed a preference for rural living. Building 

on her undergraduate work in psychology and 

her personal interest in counseling people with 

substance use disorders, she became a licensed 

alcohol and drug treatment provider. 

Karen has been working at this treatment center 

for 3 years, and she is learning that there is more 

to her job than treating drug and alcohol dependence. She has come to look at her work as helping 

people make decisions and changes that restore 

balance in their lives. She knows that fnding out 

what the vision of a balanced life means to each of 

her clients is important. For her American Indian 

and Alaska Native clients, she has found that 

this vision is infuenced by their life experiences, 

historical trauma, cultural identity, and beliefs. It is 

important to her to understand her clients individually and to provide a welcoming environment 

where they can make their own choices. 

She also knows that trust in non-natives and in 

mainstream services does not come easily for 

many American Indians and Alaska Natives. She 

has come to understand that her relationships with 

clients are paramount and that relationships are 

built through time, investment in the individual 

and community, and active listening. She also 

recognizes that many presenting problems among 

American Indian and Alaska Native clients are a 

consequence of historical trauma, discrimination, 

and poverty. Karen has learned to appreciate 

the fortitude and resilience of native people and 

believes that MI and other strengths-based 

approaches in assessment and counseling are 

more suitable than others. 

For additional guidance in using MI, 

refer to Native American Motivational 

Interviewing: Weaving Native 

American and Western Practices—A 

Manual for Counselors in Native 

American Communities (Venner, 

Feldstein, & Tafoya, 2006). 

Vicki’s Case History 

Vicki is a 50-year-old American Indian woman who 

lives on a small reservation in the Midwest. She was 

referred by the tribal court for inpatient drug and 

alcohol treatment. Vicki currently lives with her two 

nieces, ages 5 and 7, as their guardian. Vicki’s sister 

is drug dependent and lives in a nearby town. She 

has little to do with her children. Vicki is single and 

reports that she has had unhealthy relationships 

with men, previously choosing abusive men with 

alcohol use disorders. 

Vicki has lived on the reservation all her life, except 

for 4 years in boarding school. Her parents were 

from different tribes, and she is enrolled in her 

father’s tribe but lives on her mother’s reservation. 

She feels some prejudice because she is not 

enrolled in the tribe on whose reservation she is 

living. Both her grandparents and parents raised her. 

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Vicki’s grandparents and father were very traditional 

in their spirituality, but her mother was Catholic. 

Vicki was sent to boarding school in a neighboring 

state between the ages of 8 and 12. She has painful 

memories of boarding school and disclosed that she 

suffered emotional, physical, and sexual abuse. Her 

parents died before Vicki was 25 years old. Both 

Vicki’s parents had alcohol use disorders. 

Vicki believes that she has been depressed all her 

life and that she drinks to make her nightmares and 

memories go away. She has abstained from alcohol 

for signifcant periods. Seven months is the longest 

reported abstinence, and this occurred when she 

assumed the guardianship of her nieces. When she 

is healthy and abstinent, Vicki likes to practice the 

traditions she learned from her grandmother. She 

considers herself traditional and feels guilty that 

she does not practice consistently. 

Vicki has a GED. She is not working now because 

of her drinking and legal problems; however, she 

has worked on several occasions at the casino and 

other places during her periods of abstinence. In 

terms of physical health, Vicki has diabetes. She is 

overweight but not obese. 

Vicki was arrested and convicted for a DUI 5 years 

ago. Recently, she was arrested and charged with 

a second DUI, along with child endangerment. Her 

nieces were in the car when she was stopped by 

police, and they were subsequently placed in the 

tribal group home. Vicki’s license is now suspended 

and she has spent several days in jail. She is 

involved with the tribal court. During the assessment, Vicki was quite distraught over her nieces’ 

placement and began talking about her boarding 

school experiences. Vicki stated that she is quite 

upset with herself for allowing this to happen to 

her nieces. 

Vicki’s court assessment recommended inpatient 

treatment. The evaluator suggested in the report 

that Vicki may have traumatic stress based on 

her history of abuse at the boarding school and 

in relationships with men. Therefore, it is likely 

that Vicki will experience some retraumatization 

in being mandated to residential treatment. The 

evaluator suspects that this may have contributed 

to her poor outcome in prior treatments. The 

report stressed the importance of anticipating 

retraumatization and investing in building a safe 

environment for Vicki’s success in the program. 

Objectives for Vignette 1 

The objectives are: 

1. To illustrate how to begin building a trusting 

relationship with Vicki, using culturally responsive 

interviewing skills. 

2. To demonstrate approaches that will help Vicki 

look at her situation, including the roles that 

historical trauma, traumatic stress, and alcohol 

play in her current diffculties. 

3. To highlight how to help Vicki make her own individual decision about treatment, even though 

she was mandated to treatment by the court. 

4. To illustrate the importance of identifying Vicki’s 

motivations and strengths, including cultural 

strengths, that may help her in maintaining 

recovery. 

Some strategies embedded in the dialog include 

active listening skills (such as refections, summarizations, and open-ended questions), self-disclosure, 

scaling, and decisional analysis (weighing pros 

and cons). Beyond specifc techniques, the most 

important provider characteristics are genuineness 

(where your words match your actions and beliefs) 

and empathy (the ability to perceive another’s 

experience and communicate this perception back 

to the client verbally or nonverbally). 

This vignette uses MI, as well as overlapping strategies from other theories or approaches, including 

cognitive–behavioral therapy (CBT), self-effcacy 

theory, a person-centered approach, and culturally 

responsive treatment. 

Client–Provider Dialog 

PROVIDER: Hello, Vicki. Thank you for coming in. 

My name is Karen. I will be your provider if you 

decide to come into treatment, and that’s what I’d 

like to talk with you about. Please, have a seat. May 

I get you a glass of water or a cup of coffee or tea? 

VICKI: Yes, thank you. Tea, please. [As the provider 

gets tea, Vicki looks around the offce. She sees an 

interesting mix of art, including a basket in the traditional style of her tribe. She also spots an abalone 

shell, a package of sage, and a box of matches.] 

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MASTER PROVIDER NOTE 

The offce is arranged for provider and client to 

sit at a slight angle to each other, rather than 

directly face-to-face. The provider and Vicki 

move away from the desk to remove the physical 

barrier to conversation. 

THE SMUDGING CEREMONY 

The abalone shell (or in some traditions, a 

clay bowl or fat stone), sage, and matches are 

materials used for smudging. A non-native 

provider might make these materials available 

for use by clients, although it is best to let clients 

perform the smudge. It involves prayer, burning a 

small amount of an offering (typically sage, cedar, 

or sweetgrass), and using the smoke to purify 

the people and space. The holder of the shell or 

bowl approaches each person present, who may 

choose to draw the smoke toward his or her body, 

his or her heart, and over his or her head. The 

purpose is to clear away bad spirits and energies 

and dedicate what happens in the space to the 

Creator. Smudging is a ceremony that must be 

done with care, as participants are entering into 

a relationship with the unseen powers of these 

plants and with the spirits of the ceremony. 

PROVIDER: [Karen returns with their tea.] Oh, I 

see you’ve noticed the shell. I’ve found that some 

people who meet with me feel better if they begin 

with a smudge to clear the energy in here and 

bless what happens in this room. Is that something 

you would like to do for us? 

VICKI: Okay. That would be good. [She performs 

the ritual, which takes about 5 minutes.] 

MASTER PROVIDER NOTE 

Karen only mentions the smudge ritual when 

she sees that her client is interested in the shell. 

For some clients, this is a comforting offer. 

Others are not comfortable sharing it in this 

interview situation. Smudging can be a powerful 

ceremony. 

PROVIDER: Thank you. We have time together to 

talk about if you want to come into treatment and 

how we might work together, if that’s what you 

choose. I’d like to get to know you a little today, 

and I’m going to ask you to share about yourself, 

so I want to share a bit about myself, too. I grew up 

south of here, and my heritage is English, Cajun, 

African American, and (names a southeastern 

tribe). I’ve been counseling here for almost 3 

years, and before that I worked with VISTA in a 

community west of here. I really liked the area. I am 

in a relationship, and he works for a local company. 

We both like our work, so we plan on staying and 

making our home here. 

MASTER PROVIDER NOTE 

Typically, providers are trained not to share 

personal information with clients. With 

indigenous cultures, it is very important to 

tell your client who you are. If you are native, 

mention your tribal affliations; if you are not 

native, say a bit about where you come from. 

VICKI: Are you enrolled? 

PROVIDER: No. I don’t qualify. I grew up away 

from that culture and reservation. I have lived 

closer to cities most of my life, but I wish I was 

more connected. 

VICKI: I’m not enrolled here, either. 

PROVIDER: That’s got to be a bit diffcult, I would 

think. 

VICKI: I’ve been here a long time, though, and I 

live in my grandmother’s house. She was a tribal 

member, and people liked her. They’re pretty good 

to me, but I feel the difference. I’m still an outsider 

in some ways. Especially at election time, when I 

can’t vote for tribal council. Mostly, it’s okay. I have 

close friends. 

PROVIDER: It sounds like you’ve made a home 

here. So, tell me, what are some things that led you 

here? 

VICKI: I got a DUI, and the court said I have to go 

to treatment. 

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PROVIDER: You’re here mainly because the court 

sent you because of your DUI. The court believes 

you need treatment in order to stop drinking. Is 

that right? 

VICKI: The court says I need to go to inpatient 

treatment; that’s why I’m here. 

REFLECTIVE LISTENING SKILLS 

Refective listening skills take considerable time to develop. This skill set needs intentional practice even 

after years as a provider. Yet, all too often, providers perceive refective listening as a very basic clinical skill 

and assume that they use it well. 

Refective listening, also known as active listening, involves more than simply paraphrasing what the person 

has stated. It moves beyond focusing solely on content or action-oriented responses (immediately giving 

advice or suggesting a plan of action). 

Refective listening begins with repeating or paraphrasing in your own words the words of your client. 

However, this is the basic form of refective listening. There are different and more skillful levels of refective 

listening, and each type of refection has a specifc intention—for example, signifying an understanding 

of the client’s concerns, identifying discrepancies in a nonthreatening and accepting manner, or evoking 

further client discussions. Refections may involve refecting back the client’s statements using empathic 

statements, attaching implied feelings, or making some interpretation while rephrasing the client’s statement. 

Refective listening requires active silence, attending to the story of the person sitting with you, listening for 

what is not being said but implied, checking out your refection to make sure it matches what your client is 

trying to say, and approaching every client with empathy—the ability to feel, imagine, and express what it 

may be like for your client. 

MASTER PROVIDER NOTE 

A common pitfall in counseling and during 

intake interviews is stacking questions. This is 

when you ask two or more questions in a row 

before your client responds. For example, “How 

are you feeling about being sent to treatment 

again? What was treatment like before?” Rather 

than sticking to one question, the provider 

stacks the questions often to solicit more 

discussion. Many providers do not realize that 

they are asking more than one question at a 

time. Unfortunately, most clients tend to focus 

on and respond to one question, or they become 

confused about what the provider is trying to 

ask. Stacking questions is commonplace, but it 

is more likely to happen if the provider is anxious 

or uncomfortable with silence or the pace of the 

session. 

PROVIDER: How do you feel about being here 

today? 

VICKI: I came in angry. The smudging helped, 

though. With the DUI, I only had a few sips, and 

the girls were okay. I think the cops were getting 

into my business. 

PROVIDER: So, you’re pretty upset about this. 

You think everything was under control, but then 

the cops got into your business. I imagine that it 

doesn’t seem fair to you that you got sent here. 

And still, you showed up. Even though you don’t 

like the idea, there’s something you care about a 

lot that brought you here. Am I getting that right? 

VICKI: I’m willing to go to treatment because I 

need to keep my nieces. I’ve been in treatment 

before—two times. 

MASTER PROVIDER NOTE 

Karen’s refection about “something you care 

about a lot that brought you here” invites Vicki 

to talk about what motivates her to come for the 

interview and to treatment. It also emphasizes 

that Vicki is making a choice, despite the fact 

that treatment is court mandated. 

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PROVIDER: Okay, so you’ve been in treatment 

before. And even though those treatments didn’t 

solve your problems, the court wants you to try 

it again. How are you feeling about being sent to 

treatment again? 

VICKI: The providers didn’t really take the time to 

get to know me or my history, but they sure could 

tell me how to run my life. 

PROVIDER: I hear you—that it will be very 

important if we work together that I listen closely 

to your story and get to know you. I really do want 

to, and I appreciate you telling me all of this. I’ll 

really need your help in telling me about yourself. 

VICKI: I don’t know. Why should I tell you my 

private stuff? At the other place, I didn’t tell them 

much. I saw how they used the information. One 

lady got her children taken away. 

PROVIDER: That would be horrible for you. Keeping 

your nieces is the reason you’re here. They are really 

important to you. [Vicki nods and says, “Yes.”] 

MASTER PROVIDER NOTE 

By adding an empathic response while stressing 

the importance of her nieces, Karen reinforces 

Vicki’s motivation in attending treatment and in 

addressing her alcohol use. It also refects Vicki’s 

concerns. Active listening skills are an important 

approach in building trust and imparting basic 

empathic responses. 

PROVIDER: So, no wonder you’re worried about 

sharing. Is it okay if I share a little with you about 

how it would work if I were your provider here? 

[Vicki nods.] First, I’ve already mentioned about 

confdentiality and the few situations that would 

require me to share your information. I don’t anticipate that this will happen. Next, we have individual 

and group counseling here. You would talk about 

your private issues with me here in my offce, or 

we might take a walk sometimes and talk—but just 

you and me. You are the one who will decide what 

you want to bring up in group—things you want to 

talk about and maybe ask some advice about. It’s 

your choice. The rest of the activities are focused 

on learning about your addiction problem, ways 

to walk a recovery path, and how to have a social 

life without alcohol and drugs. I will not make you 

hang out your laundry for everyone to see. You’re 

the one who decides what to say and who to talk 

with about those things. Does that help? 

VICKI: Yes, but I don’t know you. How can you 

understand my life, when you’re not even native? 

MASTER PROVIDER NOTE 

One of the qualities most valued in providers 

is authenticity. Many American Indian and 

Alaska Native clients see authenticity as a 

primary characteristic in selecting providers. 

Whether you are a provider with or without 

native heritage, it is important to respect your 

own cultural heritage, life experiences, and 

upbringing and to be willing to talk about 

them from the outset. As expressed in Part 1, 

Chapter 1, it is not a good idea to try to act in a 

preconceived way that fts your views of how 

American Indians and Alaska Natives behave, 

making biased assumptions that all native 

people or a particular tribe has a prescribed way 

of being. In other words, don’t try to be native 

when you are not or misrepresent yourself as 

traditional when this has not been a part of your 

history as a native person. 

PROVIDER: True. Hmm. Well, I understand your 

concern about my not getting it because I’m not 

native. I can’t deny that it gives us a challenge. I 

hope to learn as much as I can from you and listen 

to hear what it has been like for you. What I can say 

is that I’m learning from other native people here. 

But we—you and I—are not alone. We have native 

staff, peer specialists, and elders who are very 

much a part of this program, and we will all work 

together to help you determine your path through 

your current situation. I also personally believe 

that someone only knows me as much as he or she 

listens to me, and it takes time. So, that’s what I try 

to do here as a provider. 

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VICKI: That makes me feel a little better. I never 

had an outsider listen to me. Got any kids? 

PROVIDER: No, and my nieces and nephews live 

a long way from here. Are we good for now? [Vicki 

nods.] I think from what you’ve said that the main 

reason you’re here now is that you really care a lot 

about your nieces, and you want to get them back 

with you. 

VICKI: I love them. I’ve raised them since they were 

babies. It’s hurting me that they’re in placement. 

I don’t want them to go through what I went 

through in boarding school. It’s driving me crazy, 

just the thought that they’re not with me. 

MASTER PROVIDER NOTE 

Over the course of treatment, Vicki will learn 

about trauma, traumatic stress reactions, 

historical trauma, and healing. Further 

assessment will occur in later sessions. 

PROVIDER: Your nieces are very important to you. 

You don’t want them to be away from family or 

experience the things that you went through. So, 

you’re here today so that you can continue to take 

care of them. [Vicki nods.] Can I ask you when you 

say the word, “crazy,” what does crazy feel like for 

you? 

VICKI: Crazy means that I’m anxious. When I feel 

crazy, I keep thinking about something over and 

over again. I can’t seem to concentrate on anything 

else but my nieces. What are they doing? I want 

their lives to be different from mine. I have to do 

something about them. 

PROVIDER: So sometimes feeling “crazy” is a 

sign—a sign that you need to make a move or do 

something different? 

VICKI: Yes, and that’s what the court says, too. If I 

go to inpatient, then everything will be okay. 

PROVIDER: So, you’ve decided you will do what it 

takes to get the girls back. And here you are. That’s 

a big decision to make, and it shows real strength, 

respect, and care on your part. If you decide to 

come in to this program, hopefully we can work 

together to make this experience good for you. 

Would it be okay with you, considering the DUI, if 

I can learn more about your drinking history? I’d 

like to hear about how you got started with your 

drinking. 

VICKI: [Initial silence.] I started when I was 11 and 

would sneak sips from my parents’ beer. I started 

drinking and smoking weed [marijuana] when I was 

13. 

PROVIDER: [Nods.] And recently? 

VICKI: Mostly it’s been alcohol. I don’t drink all the 

time, but sometimes I have had too many drinks. 

LISTEN FOR THE MEANING: 

COGNITIVE–BEHAVIORAL 

STRATEGIES 

A key strategy in CBT is helping people explore 

the meaning of their experiences, diffculties, 

or verbal expressions. In other words, it is not 

what is said, but rather the meaning that is 

attached to the word, statement, or experience. 

CBT and other approaches call this “idiosyncratic 

meaning,” or in simpler terminology, “individual 

meaning.” As a provider, you are accustomed 

to, and often desensitized to, hearing common 

client expressions when they relate to a feeling 

or experience. Yet, the heart of treatment is 

taking the time to look and explore the individual 

meaning behind the word, statement, or 

experience. How often have you heard a client 

say that they feel crazy, blue, frustrated, or upset, 

just to name a few? It is easy to overlook these 

terms in a discussion and assume you know the 

meaning the client is trying to express. Instead, 

take the time to ask about these generic words. 

“When you say you feel crazy, what does crazy 

mean to you? What does crazy feel like for you?” 

By taking the time to ask these simple questions, 

the conversation moves from the surface of the 

experience closer to the core. 

MASTER PROVIDER NOTE

Karen affrms and strengthens Vicki’s decision to 

come to treatment and lets Vicki know it will be 

geared toward her individual needs. 

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I’ve stopped from time to time, once for 7 months 

when I frst began caring for my nieces. I don’t see 

myself as having a problem, although I probably 

drank too much when the cops pulled me over. 

MASTER PROVIDER NOTE 

Be mindful of how you ask questions. A core 

counseling skill is choosing questions that are 

mostly open-ended, or questions that require 

more than a one-word or one-phrase response, 

such as: 

• “What brings you here?” 

• “Describe the situation that led you to come to 

this appointment.” 

• “What is your theory about what is going on?” 

• “When you look back on that given situation, 

can you describe how you reacted when it frst 

happened?” 

• “How would you know that you have healed 

from this emotional pain?” 

Do not quickly fll the relational space with 

chatter. Allow silence. Some providers get 

anxious with silence in sessions. Thus, they are 

more likely to bombard clients with closedended questions to get responses or complete 

intake interviews. 

PROVIDER: Sometimes there are periods when you 

feel good and you don’t drink at all, and then there 

are times when you drink too much. 

VICKI: [Vicki nods, then some silence.] I can go 2 to 

4 days a week until the booze runs out, and then 

I’ll stop. Sometimes it depends on what’s going on. 

I might not drink for a week or month at a time. 

When I’m feeling down, I’ll get drunk. [Silence.] I 

try to control it around my nieces. I guess I didn’t 

do that when I was drinking and driving with them 

in the car. 

PROVIDER: On one hand, you see yourself having 

control because you don’t drink all the time, but 

on the other hand, you notice it’s getting out of 

control because it’s directly affecting your nieces. 

MASTER PROVIDER NOTE 

A double-sided refection, commonly used in MI, 

is used when the client has mixed feelings about 

a behavior or making a decision. It emphasizes 

the client’s own pro and con statements. For 

example, you say, “So, on the one hand ... but 

on the other hand ....” Using double-sided 

refections helps the client see both sides of the 

situation from his or her experience. It is also a 

more palatable way of highlighting the not-sogood things without creating resistance. 

Have I said that correctly? [Vicki nods.] Sometimes 

you reach out to drinking when there are other 

things going on. People usually do things that 

make sense to them. How does your drinking make 

sense to you? 

VICKI: When I start drinking, it’s like walking into 

peaceful woods. I don’t think about things as 

much. It helps until the alcohol runs out. Then, I 

don’t feel so good. Sometimes my past comes 

back after I’ve been drinking for a few days. Then, I 

feel as if there is a storm in my head; I can’t turn off 

my worries, past, or thoughts about my nieces. It 

messes with my diabetes. 

PROVIDER: At frst, drinking feels like a safe 

place you can retreat into. After a few days of 

the drinking, you’re not feeling good and your 

diabetes is not controlled. The things that are 

bugging you come back into your mind. Maybe 

you’re almost glad when you run out because you 

feel pretty bad by that time. What else? Sounds 

like there’s more to the story. 

MASTER PROVIDER NOTE 

The provider summarizes Vicki’s negative 

effects from drinking and introduces the idea 

that stopping a binge is a relief. Tagging a new 

perspective onto a refection of the client’s 

statement is an approach used in MI. Karen’s 

last refection offers Vicki an open-ended 

opportunity to say more about this. 

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USING METAPHOR IN COUNSELING 

Metaphors are fgures of speech that liken one seemingly unrelated thing to another (e.g., “I am drowning 

in my sorrow”). Metaphor often symbolizes a feeling, behavior, characteristic, or an experience. Here, Vicki 

uses metaphor to compare her agitation to a storm. 

American Indians and Alaska Natives have a long oral tradition that includes metaphors and images 

embedded within stories. Although you, as the provider, may introduce or use metaphor in counseling 

(e.g., having people visualize something that represents their strengths), make sure to track the metaphors 

that your clients introduce in discussions. It is far more powerful to use the language and images of your 

client than to create ones that may not match their experiences. You could carry Vicki’s metaphor further 

by asking, “How long does the storm last?” “When do you know that the storm is over?” “In what ways have 

you tried to weather the storm?” Later, you can work with the same image to discuss how she could protect 

herself in a storm. 

Metaphors typically involve a combination of visual images and words. Used in counseling, they can be 

quite grounding for some clients; they use the metaphor as a cue to be, to act, or to remember something. 

Metaphors can become powerful reminders. Take, for example, a client who had diffculty refusing to drink 

alcohol when her cousin would show up at her home. At some point in counseling, she had talked about 

how much she loved her old car with the designer stainless steel brake pedal shaped like a foot. Later 

in treatment, the image of the foot pedal came back as a reminder for her to take it slow, avoid making 

decisions quickly, and set limits when needed to avoid drinking. Using the image of the brake pedal, she 

coined the expression, “braking old habits.” 

VICKI: I worry about the girls. They don’t get off to 

school on time when I’m drinking. I take good care 

of the girls. They’re not abused. They love their 

auntie. 

PROVIDER: What other worries do you have about 

your drinking and your girls? 

MASTER PROVIDER NOTE 

Vicki’s love for the girls is her strongest motivation 

for complying with the court order for treatment. 

MI calls this strong personal interest Vicki’s 

intrinsic motivation. By asking Vicki to talk more 

about her worries regarding the effects of her 

drinking on the girls, Karen hopes to strengthen 

Vicki’s interest in addressing her alcohol use. 

VICKI: Well, they like it better when I’m not 

drinking. We have fun together. They get real 

quiet and want to stay at home when I’m drinking. 

They’re good girls. 

PROVIDER: Maybe they get a little worried about 

you when you’re drinking, and then they want to 

stay close. Perhaps they want to keep you safe, or 

they miss their auntie when you drink? 

VICKI: I never thought of that. They don’t say 

anything about it. I’ll have to think about that. 

PROVIDER: Okay. What are some other not-sogood things that happen when you do drink? 

VICKI: I kept a job for 8 months and then went out 

drinking for a few days. They fred me. I’ve had a 

few good jobs, but they all end like this. 

MASTER PROVIDER NOTE 

Common counseling mishaps include trying 

to solve a problem quickly before listening 

in depth or using real or potential negative 

consequences as a reason to change behavior. 

These can be ill-timed counseling habits when 

working with most individuals and populations, 

but they are particularly problematic and culturally 

insensitive to many American Indian and Alaska 

Native clients. Remember that some may see the 

discussion about consequences as foretelling and 

“quick advice” as the inability to listen or to be 

present. Instead, providers should focus on clients’ 

current concerns and the history of the presenting 

circumstances in the beginning of the relationship. 

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PROVIDER: Sounds like if you took care of this 

drinking, you’d be able to work more steadily. 

VICKI: I’m thinking maybe I should stop. It would 

be better for me and the girls. 

PROVIDER: You have some good reasons of your 

own for stopping. How far have you gotten with 

the idea of stopping? 

MASTER PROVIDER NOTE 

Karen wants to evoke more of Vicki’s personally 

motivating reasons for stopping drinking while 

letting her know she sees the effort Vicki is 

already putting into changing. 

VICKI: I’ve been thinking and praying on it. I’ve 

been to church. I’ve cut down on my drinking in the 

last couple of months. I don’t drink nearly as much 

as I used to or as often. 

PROVIDER: More than thinking, even. It sounds 

like you’ve already done some things about it. 

You’ve even had some success—not drinking for 

several months—and you’re now using alcohol 

less. You’ve already proven to yourself that you can 

make diffcult choices and changes. 

MASTER PROVIDER NOTE 

Karen affrms Vicki’s thinking and points out 

that she is already taking action for change. She 

is not just contemplating; she is acting. She is 

building Vicki’s confdence that she can make 

more changes. 

VICKI: I’ve been working on it. Sometimes I go 

to church like my Mom. She taught me Catholic 

ways. Yet, I am more traditional like my grandma 

and grandpa. They taught me, and I’ve been to 

drum ceremonies to celebrate the season. We 

would go to naming ceremonies. They prayed 

every morning. I do, too, when I’m not drinking 

or hungover. I always feel good when I do pray. 

I feel connected. But sometimes I feel conficted 

because my mom was Catholic, and I prefer more 

traditional ways. And then sometimes, I read the 

Alcoholic Anonymous “Big Book” that I got in my 

frst treatment. It’s confusing sometimes. 

PROVIDER: There are many ways to think about 

spirituality and the paths to healing. You already 

seem to get some strength and help from your 

spiritual practices. [Vicki nods, and the provider 

waits before speaking again.] We have people 

available to you to help with your spirituality 

and fnding the path that fts for you. We have 

a traditional elder who works with us here as a 

spiritual advisor to help our clients who want some 

guidance or would like to use traditional healers. 

You should also know that we have a chaplain, 

some AA people in recovery, and other native and 

non-native peer specialists in the program. 

VICKI: Okay. I’ve been thinking about seeing a 

traditional healer for some time, but I’m not sure 

yet. [Provider nods.] 

PROVIDER: Maybe now’s a good time to 

summarize what I’ve heard so far, to make sure I’m 

understanding. We talked about the court order 

and how it’s a threat to your life with the girls 

unless you get treatment and quit drinking. You 

told me how your drinking started and got you 

here. You began drinking very young, starting with 

sneaking sips from your parents when you were 

11, and then at 13 starting to use on your own. It 

seemed pretty normal to you because your parents 

drank a lot, too. You have drinking episodes now. 

You like the beginning of each episode more than 

the end; by the time you’ve fnished the alcohol 

you have, you feel pretty bad. It interferes with 

your health. It contributes to the girls missing 

school, and they change a little when you are 

drinking. We don’t know what they’re thinking and 

feeling at those times when you’re drinking. It’s 

hard for you to keep a job. The court order got you 

here but being able to keep a job and, especially, 

to take care of the girls are your biggest reasons 

for wanting to quit. You’re also looking for some 

spiritual ways that might help you feel stronger and 

more peaceful about life. Have I got that right? 

[Vicki nods; then there is silence.] 

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MASTER PROVIDER NOTE 

Summaries like this one serve several purposes. 

They are a good barometer for an accurate 

understanding between the client and the 

provider. Second, the important elements of the 

client’s problem come together for the client 

to hear. In turn, this helps the client clarify her 

experience by allowing her to hear her own 

thoughts and experiences from someone else— 

in essence, hearing herself more clearly. 

VICKI: Right now, I worry about my nieces. I don’t 

want them to have the same experiences that I had 

in boarding school, now that they’re in placement. 

It’s driving me crazy and making me very sad. 

This is not something I want to talk about, but it’s 

important for me to get my nieces out of the group 

home. I don’t want them to be harmed. I don’t 

want them to go through what I went through. I 

don’t want them to have the nightmares or feel 

depressed. I don’t want to lose them, and I don’t 

want them drinking, like I do, to deal with it. It’s 

important for me to get over this court thing that’s 

going on. 

COURT ORDERS AND 

MANDATES FOR TREATMENT 

You need to know the relationships among local 

tribal, county, state, and federal courts. These 

relationships and jurisdictional issues vary from 

tribe to tribe. Learn tribal codes; there is often an 

opportunity to make recommendations in tribal 

courts, sometimes called wellness courts. 

PROVIDER: So, knowing what you feel right now 

and knowing what alcohol has done for you, you 

know how important it is to change your drinking 

right now. Say, on a scale of 1 to 10 where 1 means 

that change is least important and 10 is most 

important, what number are you at? 

VICKI: I’d say a 9. It’s important for me to get my 

nieces out of placement, and I need to change how 

things are going. 

PROVIDER: So why a 9 and not an 8 or a 7? 

VICKI: I have to show my nieces that there is 

another way to handle things. I have to show them 

that I can do it. I want to get done with the courts, 

get a job, and get them back. I want them to 

know about traditional ways. I want them to have 

something to hang on to besides me. And I don’t 

want them to use alcohol like I do. 

PROVIDER: So, on the same scale, how ready are 

you to make a decision about your drinking? 

VICKI: That’s an 8. It’s time. I have been sensing 

this for some time that I need to stop drinking and 

go back to treatment. I just don’t know if I can stop 

drinking for any length of time. I just get worried 

that I won’t know what to do if I feel low, get an 

urge, or see my friends. 

PROVIDER: [Karen nods.] You’re ready, but you 

need to fnd ways to manage your mood and deal 

with situations around alcohol. [Vicki nods.] You 

have some big decisions to make right now. How 

confdent, on a scale of 1 to 10, are you that you 

can make these changes right now? 

VICKI: I can do treatment, but I’d say a 6 about 

quitting drinking. I have my doubts that it will stick 

just because of my history, and that’s why it’s a 6 

and not higher. However, I have done it before, and 

I have gotten something out of each treatment. 

It’s not lower than a 6. Everything is slowly getting 

worse every time I drink, and trouble seems to fnd 

me more often. I’m hoping this time it sticks. 

MASTER PROVIDER NOTE 

Karen has learned that although Vicki rates her 

importance for quitting drinking at 9 on a scale 

of 1 to 10, her confdence is somewhat lower. 

Vicki fears that she will not be able to cope with 

her past or deal with the urge or pressure to 

drink. Working on Vicki’s confdence in walking 

a new path will be very important in treatment. 

Helping her learn and practice ways to cope with 

other challenges will also be important. 

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TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

USING SCALES IN COUNSELING 

Several therapies use scales to assess, intervene, and evoke further discussions. For example, behavioral 

therapy and CBT for traumatic stress use the Subjective Units of Distress Scale (SUDS; Wolpe & Abrams, 

1991; a scale from 0 to 10, in which 0 means feeling no stress and 10 means feeling exceptionally distressed 

or overwhelmed) to assess the client’s level of stress from one session to the next. The SUDS serves as 

a quick gauge of the client’s current stress level when retelling or reexperiencing a traumatic memory. 

Behavioral approaches use the client’s SUDS level to identify the appropriate starting place for traumaspecifc interventions. 

CBT also uses percentages to help access the strength of a client’s belief. This form of scaling can be artfully 

used to challenge a belief that may be interfering with the client’s well-being. For example, how strong is 

the client’s belief that he or she is not able to get sober (where 100 percent represents a defnite belief that 

he or she will not stop drinking)? If a client states that he or she is 99 percent sure that he or she can’t 

stop, the provider can ask why he or she didn’t give it 100 percent or what would 

need to happen to bring the number down. Or the provider may ask if there was 

ever a time that this number was lower. Again, the importance of scaling extends 

far beyond the number that the client reports. When used prudently, it can be a 

powerful tool to challenge absolute or catastrophic thinking, often referred to as 

“all-or-nothing” thinking. To demonstrate these questions visually, the provider can 

use a circle and ask the person to draw a slice that demonstrates the strength of 

his or her belief. From this starting place, you can then have the person redraw and 

experiment with what it feels like to make the slice smaller or larger. 

In this vignette between Karen and Vicki, Karen uses the importance, readiness, and confdence scales 

from MI (Miller & Rollnick, 2013). Each question asks for the client’s perception about change using a scale 

from 1 to 10. For example, “How important is it for you to make this change? How ready are you to make this 

change now? How confdent are you that you can do it?” As with any scaling, the initial numerical answer 

is not as important as the subsequent questions. For instance, “Why did you give it a 9 and not an 8? What 

makes it a 7 and not a 9? What would need to happen to have a higher or lower number?” These follow-up 

questions promote a more indepth conversation and elicit talk about change. 

PROVIDER: So, coming into treatment and not 

drinking are pretty important for you. What do 

you think it would take for you to have even more 

confdence in these changes you want to make? 

VICKI: I want to participate in traditional ways and 

get back to living some of the ways of my grandpa 

and grandma. I want to be that person for my 

nieces that my grandma was for me. [Vicki starts 

crying.] I feel my grandmother with me. [Silence for 

a minute or more.] 

PROVIDER: [Silence initially.] It’s very important to 

you to give to your nieces what you received from 

your grandma. Your grandma loved you a lot. What 

would your grandma want for you today? 

VICKI: She’d want me to live my life and raise the 

girls in a good way. She is saying to me to stay 

close to her. When I think about it, I don’t feel 

MASTER PROVIDER NOTE 

Talking about grandma provides some comfort 

after thinking about her painful past, need for 

treatment, decision to not drink, and relationship 

with her nieces. For American Indians and Alaska 

Natives, thinking of deceased relatives is often 

a way to connect with strength and spirituality. 

What have always brought native people 

through hard times are relationships with their 

Creator and their relatives. 

connected to her when I drink. I need to rely on her 

more, and I need her help and guidance. 

PROVIDER: Maybe your grandmother is guiding 

you today. Perhaps she guided you here today. 

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MASTER PROVIDER NOTE 

Because Vicki brought her grandmother into 

the conversation, and she had clearly been a 

positive infuence and role model, Karen ended 

the session by invoking her infuence and value 

system. 

VICKI: She is important to me. I don’t want 

anything to get in the way of feeling her in my life. 

PROVIDER: Vicki, I appreciate you letting me talk 

to you about this. Have you thought about what 

your grandma might be saying right now about 

your decisions on treatment and drinking? 

VICKI: She’d be happy. She would be proud that 

I am honoring my nieces and community by not 

drinking and going to treatment. And that’s what 

I’m going to do. 

Summary 

Vicki came to the treatment center for her intake 

interview. She was court-ordered to treatment 

because of a DUI that also endangered the children 

she is raising. The provider introduced herself appropriately for Vicki’s culture and assured Vicki that 

the conversation was confdential, which helped 

ease Vicki’s initial distrust. She also took time to 

invite Vicki to smudge, a way of honoring Vicki’s 

traditional customs and introducing a spiritual 

dimension to the interview experience. Vicki’s 

agreement to perform the smudge reminded 

her of her values and infuenced the tone of the 

meeting. Rather than conducting a highly structured interview, Karen, the provider, asked Vicki 

to tell her story about what happened and guided 

a conversational interview using an MI orientation with cross-sectional strategies from other 

approaches. As she talked about the areas of her 

life, Vicki began identifying the consequences of 

her drinking. Vicki’s interest in ways that treatment 

could help her increased during the interview, and 

Vicki made a commitment to treatment that was 

motivated by her relationships and concerns rather 

than the court order that initiated this process. 

WELLNESS COURTS 

According to the National Drug Court Resource 

Center (2012) website, “a Tribal Healing to 

Wellness Court is not simply a tribal court that 

handles alcohol or other drug abuse cases. It is, 

rather, a component of the tribal justice system 

that incorporates and adapts the wellness 

concept to meet the specifc substance abuse 

needs of each tribal community. It provides an 

opportunity for each American Indian and Alaska 

Native community to address the devastation of 

alcohol or other drug abuse by establishing more 

structure and a higher level of accountability for 

these cases through a system of comprehensive 

supervision, drug testing, treatment services, 

immediate sanctions and incentives, teambased case management, and community 

support. The team includes not only tribal 

judges, advocates, prosecutors, police offcers, 

educators, and substance abuse and mental 

health professionals, but also tribal elders and 

traditional healers. The concept borrows from 

traditional problem-solving methods used since 

time immemorial and restores the person to his 

or her rightful place as a contributing member 

of the tribal community. The programs utilize 

the unique strengths and history of each tribe 

and realign existing resources available to the 

community in an atmosphere of communication, 

cooperation and collaboration.” 

For more information about wellness courts, 

see Tribal Healing to Wellness Courts: The 

Key Components (Flies-Away, Garrow, & 

Sekaquaptewa, 2014). 

The above resource is also available online 

(www.wellnesscourts.org/fles/Tribal%20Healing 

%20to%20Wellness%20Courts%20The%20Key%20 

Components.pdf). 

Chapter 2 85 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Vignette 2—Joe: Addressing Methamphetamine Dependence, 

Reconnecting With Family, and Recovering on the Reservation 

Overview 

This vignette illustrates the importance of establishing a good provider–client relationship starting 

with the frst pretreatment session. The dialog 

begins with the treatment provider, Mike, meeting 

Joe during his incarceration. The second session 

takes place after his transfer to a court-mandated 

treatment program. The pretreatment and 

treatment sessions focus on how to address 

treatment issues using experiential exercises in 

a culturally responsive way, such as highlighting 

strengths, addressing dreams, connecting with 

relatives, and identifying readiness for change. 

Joe’s Case History 

Joe is a 28-year-old, single American Indian man 

living on a reservation in the Southwest. He is an 

enrolled member of the tribe. He grew up on the 

reservation with his parents and grandparents. 

His grandparents are traditional and practice their 

native spirituality. Joe is bilingual, speaking both 

his tribal language and English. He returned to live 

on the reservation 5 months ago after living in an 

urban area for 10 years. He had frequently visited 

and stayed for weeks at a time with extended 

family on the reservation during those years. 

He is the oldest of seven siblings. When Joe was 

growing up, his parents drank alcohol and smoked 

marijuana. Joe started drinking alcohol when he 

was 11 years old and smoking marijuana when 

he was 12. He developed a pattern of drinking 

to intoxication by the time he was 13, and by 

age 14 he was binge drinking. Joe frst got into 

trouble with the law as a teenager and was sent to 

detention, then to boarding school from ages 14 

to 17. At boarding school, he was introduced to 

methamphetamine. He quickly became dependent, 

with methamphetamine being his drug of choice. 

He dropped out of school before graduating, left 

home, and moved to the city, where he continued 

to use methamphetamine. 

During his evaluation, Joe said that he spent a lot 

of time “on the street,” homeless. He reported 

that he never felt comfortable in the city, that he 

always felt like a stranger. He said he was ashamed 

to return home with nothing to show for himself. 

He fnally did return to the reservation because he 

ran out of resources and was scared that something 

would happen to him on the streets. Recently, Joe 

has been exhibiting some signs of paranoia and 

confused thinking. 

With his 11th-grade education, Joe was able 

to work from time to time in construction and 

as an artist. Over the years, his dependence on 

methamphetamine became stronger until he was 

unable to work because he would not show up. He 

would stay awake for 4 to 6 days at a time. When 

he was fnally able to “crash,” he would sleep for 

days, miss work, and lose his job. When Joe was 

not working, he would steal, deal drugs, and do 

whatever he needed to do to continue his habit, 

hence his involvement with the law. 

Joe has spent a total of 4 years in jail for various 

alcohol- and drug-related charges. Joe was 

court-ordered to receive an alcohol and drug 

evaluation and subsequently mandated to attend 

treatment. He has spent 3 months in jail and is now 

entering treatment to serve the remainder of his 

time. Joe says that he wants to go to treatment 

and that he knows he can change his life. 

Objectives for Vignette 2 

This vignette includes two sessions. The frst 

session takes place during Joe’s incarceration, 

and the second occurs upon his transfer to the 

tribal treatment center. Treatment attendance is 

more likely to improve if you begin building the 

provider–client relationship before admission. 

Likewise, clients will more likely follow through 

with the next level of care if you physically 

introduce them to the new group or service. 

Making connections is essential. In this vignette, 

Joe meets his provider before leaving jail. In 

other scenarios, you, as the provider, may need 

to facilitate a client’s transition from one service 

to the next (e.g., assist a client moving to a 

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continuing care group after attending an intensive 

outpatient program). To improve the likelihood of 

follow-through and to increase the client’s feeling 

of connection, you may consider attending the frst 

meeting at the new program with your client or 

introducing your client to the new provider before 

transferring him or her to the new service, even if 

the service is not located within the same facility. 

The objectives are: 

1. To review common symptoms of methamphetamine use. 

2. To introduce the use of a pretreatment session 

to establish a connection and supportive 

relationship with Joe prior to his admission into 

treatment. 

3. To illustrate some ways to discuss cultural 

identity, traditional practices, and language 

needs and preferences in treatment. 

4. To provide general cultural guidelines for using 

strengths-based practice. 

5. To use a culturally adapted Stages of Change 

model as an experiential exercise that honors 

traditional ways, culture, and connection to 

promote healing. 

Client–Provider Dialog 

Pretreatment session: Session one 

We meet Joe at two points in his recovery: early 

in his incarceration, and 3 months later, after his 

transfer to serve out his sentence in treatment. 

In the frst session, the provider meets Joe in jail, 

where he has been incarcerated for a couple of 

weeks. The tribal treatment program provides 

an initial meeting to help with the transition to 

treatment, if Joe continues to choose treatment. 

Mike, a provider from the tribe’s treatment center, 

meets Joe during his withdrawal from methamphetamine. Joe has nightmares and exhibits some 

mild involuntary twitching in his face during the 

frst meeting, although he says that most symptoms 

have signifcantly lessened. During the frst session, 

he appears restless, reports feeling very depressed, 

and shows some paranoid thoughts. Joe wants 

to go to treatment, and he reported to the court 

evaluator that he is likely to relapse without it. 

PROVIDER: Hello, Mr. ——. I’m Mike, one of the 

providers at the treatment center. I grew up in this 

area, although I spent my twenties in Los Angeles. 

[Mike tells Joe his lineage.] I think during that time, 

I spent more time traveling back to the reservation 

than being away. After I got into recovery, I wanted 

to work on the rez and help others. It fnally 

happened about 4 years ago. How are you feeling 

about being here? 

MASTER PROVIDER NOTE 

Ask your client how he or she would like to 

be addressed. This is a core counseling and 

relationship-building skill. As with any client, 

native or non-native, using more formal 

introductions before determining a preference 

shows respect. Honoring the importance of 

names is fundamental, particularly within 

American Indian and Alaska Native cultures. 

Sometimes, a client will want to be addressed 

by his or her Indian name. As discussed in the 

frst chapter, the use of diagnostic labels during 

sessions can also be quite disquieting to your 

client—it is another way of naming. 

JOE: You can call me Joe. I’m all right. Just nervous. 

PROVIDER: You’re in a tough situation. [Mike gives 

time for silence.] What can you tell me about your 

nervousness? 

JOE: What? 

PROVIDER: Joe, where do you feel this 

nervousness? 

JOE: Yeah, it’s hard to stay still and then be put in a 

six by eight. It’s tough being here. I could jump out 

of my skin. At least, I don’t have to worry right now 

about using. [Joe becomes silent for a while.] I’m 

not much of a talker. 

Chapter 2 87 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

MASTER PROVIDER NOTE 

The provider notices that Joe is cooperative but 

having a hard time answering questions because 

of decreased ability to concentrate (likely a 

withdrawal symptom from methamphetamine). 

He changes his style so that he does more of the 

talking, soothing and reassuring Joe, and asks 

questions using a slower pace to give him time 

for thinking and to keep him engaged in the 

conversation. Mike, the provider, is uncertain still 

about language preferences and assumes that 

Joe is translating from his native language to 

English. 

PROVIDER: I know some of the things you’ve 

been going through. I also know coming down off 

meth is tough. I admire you for working through it. 

[Silence for a minute or more; Joe nods.] 

PROVIDER: Joe, I know from your evaluation that 

you were brought up traditional. I understand 

you’re bilingual. I’m not good with our language 

myself. Would you feel more comfortable with a 

translator? 

MASTER PROVIDER NOTE 

On Joe’s reservation, as on many others, 

traditional people may speak their native 

language in daily life. Because Joe grew up in a 

traditional family, the provider offers to provide a 

translator. 

JOE: No. My English is good. I used to speak my 

language more when I lived at home, but in the 

city, I speak English. I’ve never felt at home in the 

city, and my traditional ways always call me back. 

For me, I don’t belong there. I don’t trust the city; 

it’s treated me badly. 

PROVIDER: [Nods.] So, you are coming home. 

I’m glad that you are. Welcome home, Joe. [Joe 

begins to tear up, and Mike gives space and time 

in the session for him to be with his feelings.] Joe, 

if you’re ready to hear, let me take a minute to 

THE LOSS OF LANGUAGE 

According to Manatowa-Bailey (2007), “When a 

language dies, the loss to a tribal community— 

and to the world—is beyond measure. Entire 

systems of thought, belief, and practice become 

permanently removed from the storehouse 

of human knowledge.... The harm caused to 

indigenous communities by language loss is 

undeniable. When you remove a people from 

their language, you cut out the heart of their 

identity. When a language dies, everything that 

is attached to it—prayer, song, stories, dances, 

ceremonies, and every other aspect of a tribal 

system—becomes more diffcult to sustain.... The 

challenge is great. Of the estimated 154 tribal 

languages that still exist, 56 percent have only a 

few elderly speakers. The Indigenous Language 

Institute reports that 89 percent of all North 

American languages are in danger of extinction. 

Of 2 million American Indians, only 18 percent still 

speak their tribal language, and the vast majority 

of these are elderly. Moreover, almost half of 

the 18 percent belong to a single tribe: the Diné 

(Navajo) Nation.” 

talk about why I’m here, what you can expect if 

you come to treatment, and then talk about some 

common, but passing, symptoms of methamphetamine withdrawal. [Joe nods.] The most important 

thing I want to say, though, is that I’m here to help 

make the transition from jail to treatment a little 

easier. I also want you to have a sense about me 

before coming to treatment, because we will be 

working together. [Mike proceeds to talk about 

the logistics of admissions and the early phase of 

treatment.] 

JOE: I need help. I’m having a rough time, and I 

don’t like what is happening. I feel low. I can’t stop 

thinking, and I have lots of dreams. Some of them 

don’t feel right. 

PROVIDER: Joe, before I talk about the common 

signs of meth withdrawal, what do you think is 

going on with your dreams? 

JOE: I don’t know if I want to talk about it. 

PROVIDER: [Nods.] Okay, you don’t need to 

tell me. 

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JOE: I keep seeing so many things that I can’t 

focus on any one thing to tell you, but I keep 

seeing myself repeatedly walking into this room 

flled with people and empty baskets and a bird 

standing in the corner. I feel compassion coming 

from the bird, but I don’t know what it means right 

now. Let’s drop it. [Mike nods. Joe’s response 

indicates to the provider that he likely sees his 

dreams as spiritual messages.] 

MASTER PROVIDER NOTE 

There is no universal belief about dreams across 

American Indian and Alaska Native cultures. 

In some native languages, the word for “sleep” 

translates as “the time when the spirit travels.” 

In Joe’s culture, dreams, sometimes referred 

to as visions, are powerful spiritual messages. 

The provider is aware of this and is interested in 

considering if this is the case with Joe’s dreams 

or if they are related to methamphetamine 

withdrawal. 

PROVIDER: [Silence.] Joe, I want you to know that 

I’m here with you and want to help. At some point, 

you may want to talk about this reoccurring dream 

or other dreams. Sometimes dreams become quite 

clear in their own time. But it doesn’t have to be 

with me. In our program, we have providers, peer 

specialists, elders, and access to traditional healers. 

JOE: [Nods.] I don’t know, can’t think about it right 

now. 

PROVIDER: It’s hard thinking about things right 

now. I know it’s tough, and you’re going through 

the worst of the withdrawal while in jail without 

much support. But what I do know is that you have 

many relatives who care about you. 

JOE: I’d like to be with my grandfather. [His grandfather is living; he has come to visit Joe.] 

PROVIDER: Where would you like to be with him? 

JOE: [Quickly responds.] Well, not here. Besides, 

there is not enough furniture or food. [He starts 

laughing.] It feels good to laugh! Haven’t done that 

for a while. 

STRENGTHS-BASED PRACTICE: ALL CLIENTS HAVE STRENGTHS THAT 

HAVE BROUGHT THEM THIS FAR 

The experience and effects of historical trauma, institutional racism, prejudice, and disparities can 

easily undermine people’s perception of personal strengths. Coupled with the negative changes in selfperception and self-talk that can easily occur with addiction and psychological distress, individuals can 

begin to believe that their lives are worthless, their futures are hopeless, and their contributions to the 

community are insignifcant. 

Working from a strengths-based perspective is typically a good ft when developing and implementing 

American Indian and Alaska Native prevention and treatment programs and approaches. Among many 

native people, and particularly those who are more traditional, there is a belief that what you attend to 

becomes your reality, so emphasizing and safeguarding the clients’ strengths—including individual, 

family, community, cultural, spiritual, and environmental strengths—is essential in healing and recovery. 

In culturally adapting strengths-based practice, American Indians and Alaska Natives may be reluctant 

to talk about their strengths; this can be seen as boasting. Strengths-based practice is much more than 

having a superfcial conversation in which you ask clients to name their strengths. Strengths-based 

practice acknowledges how people fortify themselves and use strengths and resources they have been 

given or received. It draws on strengths passed from previous generations and from tribal or cultural 

heritage. What can people depend on? What are their resources? As a provider, it is important to promote 

this understanding of strengths-based practice. 

Continued on next page 

Chapter 2 89 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

STRENGTHS-BASED PRACTICE: ALL CLIENTS HAVE STRENGTHS THAT 

HAVE BROUGHT THEM THIS FAR (CONTINUED) 

Below are a few core values and beliefs of strengths-based approaches that you may want to convey to your 

clients and integrate into your practice (Hammond, 2010): 

1. Everyone has strengths and resources from varied origins, including individual, community, family/ 

intergenerational, elder, cultural and tribal, spiritual, traditional healing practices, and environmental. 

2. What you say to yourself or attend to becomes your reality. If you always tell yourself that you can’t 

get sober, then what are the chances that you will? The focus on strengths-based practice requires 

changing the script, internal dialog, or focus to match your vision of recovery. 

3. It is helpful to focus on your strengths, skills, traditions, beliefs, and support when tackling problems. 

You can draw on wisdom from the past with your elders, family, community, and traditions. 

4. Change is possible, but more likely if it occurs with support, care, and guidance from others. Change is 

more feasible when you make connections. 

5. Ask yourself what has gone well so far (no matter how insignifcant it may seem), then recreate it, 

and build on it. For example, in this vignette, Joe shows several strengths, including his traditional 

upbringing, artwork, connection with his grandfather, family and community support, prior success in 

withdrawing from methamphetamine, and willingness to enter treatment. 

6. Start with what you know. Start with your story. You are the expert. Change only happens if you see it as 

an important part of your story. 

Group Exercises: Gathering of Strengths and Storytelling. These exercises can be easily adapted for 

individual sessions. As a provider, remember to approach these exercises appropriately. They provide an 

opportunity for individuals to gather strengths and resources both inside and outside of themselves. 

Although some providers have used boasting sessions, this is typically inappropriate in American Indian 

and Alaska Native cultures and promotes a very limited perspective of strengths-based practice. 

Gathering of Strengths. This activity begins with a discussion about strengths. What are they? Use the 

group to generate a sample list of strengths. The list could include strengths from many different sources, 

such as participation in seasonal activities, ceremonies, and rituals; skills with crafts or art; involvement 

and participation in traditional healing and other traditional practices; family, community, and individual 

attributes; intergenerational and ancestral strengths; stories remembered and told; sports participation; 

and beliefs in connectedness, as well as other spiritual beliefs. Once the group creates a list of strengths, 

break up the group for 15–30 minutes so that each member can select and gather two or three items that 

symbolize a strength that he or she has received in their life. The items may come from nature or items 

within the program. Make sure you set appropriate boundaries as to where they can go and what they 

can use in the program. (As with any population in treatment, if you do not set guidelines, it could on 

occasion cause problems, such as someone’s going into someone else’s room and using a personal item.) 

Creating a sense of safety is a primary role for a provider. Upon their return to the group, use a talking circle 

format. Have everyone take a turn and talk about the items that they chose and what the items personally 

represent. The group facilitator helps process the stories with the group at the end of the session. 

Storytelling: Stories of Strengths. This activity follows the same format as above. It begins with a 

discussion about strengths; then, everyone individually takes 15–30 minutes to create a story that shows 

or represents strengths that will help them in their recovery. When they return to the group, use a talking 

circle format. Have people take turns and tell their story. They can be as creative as they would like, and 

the storytelling exercise may extend to the next session or to activities outside the group. For example, 

a client may want to draw the story between sessions or create a collage. The group may have access to 

materials so that they can create a group banner using beads, ribbons, and other materials. An alternative 

is to introduce the topic of strengths prior to the end of a group session to avoid the time limit for creating 

stories. Then ask group members to create a story of strength before the next session. The group facilitator 

helps process the stories with the group in the session. Another alternative is to use this exercise in multiple 

family treatment groups; the family comes together, creates a story, engages in a medium to represent the 

story, and presents it in a family talking circle format. 

90 Chapter 2 
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Across American Indian and Alaska 

Native cultures, people often insert 

joking and laughter into their 

conversations, knowing that laughter 

is good medicine and strengthens the 

connections between people. 

PROVIDER: Yeah, laughter is good medicine. 

JOE: [Nods and becomes quiet. After a minute 

of silence to think about whether he wants to say 

more about his grandfather or how to talk about 

his visits with his grandfather, he continues.] My 

grandfather is an artist. 

PROVIDER: [Nods.] And you? 

JOE: I haven’t done anything in a year or so. I can’t 

seem to be quiet enough to draw. I feel trapped. 

Drawing makes me focused, but I can’t seem to get 

into it right now. But it is something I have always 

hung on to. I carry memories of my grandfather 

spending hours drawing with me. 

PROVIDER: It sounds like your artwork brings you 

strength and connects you to your grandfather. It 

sounds as if this is a good path. 

JOE: Yeah, I know. I just don’t feel still enough in 

my own skin to do it now. 

PROVIDER: It will pass, your shakiness. But maybe 

you don’t have to wait till you are back comfortably 

in your own skin. [Mike will reassess this once 

Joe transitions to treatment. Some mindfulness 

strategies may help Joe become more comfortable 

with his current experience so that he can return to 

drawing.] Joe, you may be through the worst part 

of the physical withdrawal from meth—but would 

it be okay with you if I spent time talking to you 

about some of the normal withdrawal symptoms of 

meth? I know you’ve gone through this a few times. 

[Joe nods, and a portion of the session is devoted 

to normalizing the symptoms of withdrawal.] 

PROVIDER: [The session ends with this last 

exchange and a promise to reconnect in the 

treatment program.] Well, hang in there. You’re 

going through withdrawal right now, and it 

will pass in time. You know already that some 

withdrawal symptoms have lessened, but it’s not 

easy. You’ve told me you want to get treatment 

and make changes in your life, so I would like to 

check back with you again before you come to 

treatment. Is that okay with you? 

JOE: Yeah. 

PROVIDER: I look forward to seeing you again. 

MASTER PROVIDER NOTE 

Recognize that talking about consequences or 

the potential effects of drugs and alcohol can be 

perceived, by some American Indian and Alaska 

Native clients, as an omen. Mike is sensitive in 

asking for permission to talk about the effects of 

withdrawal. 

Pretreatment session discussion 

The session focused on compassion and connection—creating a connection prior to treatment. The 

provider guided the discussion toward strengths, 

including Joe’s artwork and relationships with 

others. The provider was supportive and presented 

information about treatment; even though Joe 

had considerable knowledge and experience in 

withdrawing from methamphetamine, the provider 

offered information about withdrawal to normalize 

Joe’s current symptoms. 

Early treatment session: Session two 

Three months have passed, and Joe has been 

admitted to the treatment program. After his 

intake interview and assessment, he reconnects 

with Mike and reports very little discomfort 

and few withdrawal symptoms. Upon entering 

treatment, he did not feel that people were out to 

get him as he had when he was in jail. He quickly 

began to participate in all program activities, and 

he recognized the importance of returning to his 

traditions. Joe wants change and has initiated it 

through his active participation within the program. 

Yet, he frequently states that he is anxious about 

having cravings and fears that he may relapse as he 

had before. He wants to honor his family by staying 

sober and clean. He does not want to return to that 

place of shame where he promised himself every 

Chapter 2 91 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

day that it would be different, only to go back and 

do the same thing again. 

Grounded in traditional culture, Joe’s treatment 

program is tribally run and located on the reservation. The program uses a holistic model expressed 

with traditional teachings about the sacred circle 

and uses the Red Road format—an American 

Indian and Alaska Native worldview of the 12-Step 

program. A smudging ceremony opens the 

morning meetings, and clients within the program 

have personal options to participate in sacred 

ceremonies, including sweat lodge, pipe ceremony, 

and healing ceremonies. The program’s philosophy is to incorporate teaching of tribal culture 

wherever possible and to allow clients to decide 

for themselves about participating in the spiritual 

ceremonies. Participation in these ceremonies is 

chosen rather than required. 

During the early phase of treatment, Joe initially 

learned more about the addiction and withdrawal 

processes he had been through and the chronic 

nature of his use that makes abstinence a goal 

of recovery. He began attending native 12-Step 

meetings and, with the help of treatment staff and 

his peers, began to experience how traditional 

practices and the 12-Step program could provide 

healing. 

PROVIDER: It’s been a while since I saw you last. 

You look better. How do you feel? 

JOE: The jumpiness is better. But I still hit the 

ceiling if a door slams. 

PROVIDER: To be where you are is a good thing 

right now. 

JOE: People don’t understand how hard it is to get 

off meth. I am feeling better, but I’m struggling. I 

keep thinking I have to do things differently, but 

it feels like it would be too much. Everyone keeps 

telling me I’m going to get through this. 

PROVIDER: What do you think? 

JOE: I’ve done it before, but I always start using 

again. I feel stuck; I know what I have to do, but I 

don’t seem to do it for long. Then I walk away and 

feel pretty bad. 

PROVIDER: Joe, would you be willing to look at 

how you’re stuck? I have an exercise that might 

help you sort some of this out. You don’t have to 

know what to do; I will guide you. The exercise is 

looking at where you are in the circle of change. 

Are you willing to give it try? 

[Joe nods, and Mike proceeds to review the Stages 

of Change model, adapted culturally for this 

session (Exhibit 1.2-2). Then Mike uses string to 

form a large circle on the foor in the middle of the 

room. He then introduces each stage of change 

directionally along the circle before asking Joe to 

stand up. Mike asks Joe to think about where he 

would place himself along the circle and then stand 

on that spot.] 

JOE: [Joe places himself between preparation and 

action.] I stand here because I’ve decided to come 

to treatment, so I’m taking action. But I’m also in 

preparation, thinking about how I’m going to stay 

away from meth and alcohol. 

PROVIDER: What does it feel like to stand where 

you positioned yourself? 

JOE: It still doesn’t feel right. I think this is as far 

as I get when I’ve been in treatment before. I get 

stuck on this section of the path. 

PROVIDER: Would you be willing to try other 

parts of the circle? Maybe if we stand at different 

places [stages] along the circle, you will begin to 

understand the how’s and why’s about getting 

trapped here. [Joe nods in agreement.] So, Joe, 

you’re standing in between preparation and action. 

Let’s move back to contemplation and stand in this 

space. What is this like for you? 

JOE: It’s a miserable place. I spend most of my 

time here, thinking that today is the day to stop 

using, only to go back again. I don’t like it here. 

In this place, I know that things are not good, but 

I feel like I can’t move, and I am holding a bag of 

bad feelings: that I’m disappointing my family and 

bringing shame to my tribe. There’s no hope here. 

PROVIDER: Joe, let’s bypass the preparation phase 

and stand frmly on action so you can compare 

what it might feel like to stand here versus in contemplation. What does it feel like to stand here? 

92 Chapter 2 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

EXHIBIT 1.2-2. The Stages of Change Model 

The Stages of Change model was never meant 

to be a linear model of change behavior. Change 

does not typically occur at one time, but rather, it 

is a journey. In this model, individuals can move 

back and forth from different places along the 

cycle of change or stay in one place. For example, 

individuals can be painfully aware of needing 

to make a change, so they quickly move from 

thinking about it (contemplation) to action. At 

that moment, they might become so 

overwhelmed with their new decision that it 

compels them back to contemplation. Others 

may prepare or take small steps toward a decision 

for some time after knowing that they need 

to change. Still others may deny that change 

is needed. Decisions and change behavior are 

never static. In the Stages of Change graphic, you 

will notice arrows facing both directions on the 

outer concentric circle. These arrows represent 

an individual’s ability to move in either direction. 

You will also notice three of the arrows pointing 

away from the inner concentric circle, Change. 

These arrows emphasize that individuals can 

move away from change and revert to previous 

behaviors, beliefs, or ambivalence about making 

a decision to change. They may even return to 

precontemplation, where they deny that change is 

needed. 

< > < >

<

> 

< 

> < 

> 

<

>

<

> < > < > < >

<

> 

< 

> 

< 

> 

<

>

< > < > 

Action

Preparation Change

Contemplation

Precontemplation

Precontemplation. Individuals in this part of 

the cycle do not see a need to do anything 

different or to make changes. They are unaware 

that their current behavior is producing 

negative consequences. When others address 

their behavior, they are more likely to place 

the responsibility on circumstances outside 

of themselves and report that others are 

overreacting or overly concerned about the 

problem behavior. They do not see a need to make 

a different decision or to make any changes. 

Contemplation. Individuals standing in this 

place think about changing a particular behavior 

or want to make some change, but they have 

mixed feelings about it. This can be a painful 

place—knowing that you need to make a change, 

promising yourself you are going to follow through 

with it, and then not doing it. Individuals are aware 

that their behavior is problematic, but they may 

feel stuck, ambivalent, or overwhelmed with the 

idea of doing something about it. 

Preparation. In this place within the cycle, 

individuals are preparing to make a change. They 

are taking small steps toward changing behavior 

or making a decision. They are likely to gather 

some information about the particular change— 

for example, talking with someone about it, 

cutting down use, or changing some behaviors 

around it. They are standing at the doorstep. 

Action. Individuals within this part of the cycle are 

committed and have decided to change. They are 

working on obstacles that may lead them back 

to old behaviors and engaging in activities that 

help support their change. Within this model, 

individuals who have sustained change for 6 

months are considered to be in maintenance. 

The Stages of Change model was culturally 

adapted to highlight the importance of cycles in 

native culture. 

Source: Prochaska, DiClemente, & Norcross, 1992. 

Adapted with permission. 

Chapter 2 93 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

JOE: I have this mental picture that I’m home—that 

my family (at least some relatives) is proud of me. I 

feel like I can stand tall here—that I’m not carrying 

such weight or shame. I have this image of walking 

into our community center and people greeting 

me. I feel connected to my traditions. But then I 

get nervous when I’m here for any length of time. 

I feel like I might not do it right, and then I start 

getting cravings. 

PROVIDER: Let me just check this out with you. 

When you stand in action, you feel as if you are 

standing with others. [Joe nods.] But then you start 

getting nervous, or maybe even experience some 

urges to use, and it feels like too much. Then what 

happens? 

JOE: I start pulling back from relatives, and I start 

using again and go back to the streets. 

PROVIDER: Your frst signs of using are feeling 

nervous, as if it’s too much, and dealing with it 

alone? 

JOE: Yes. 

PROVIDER: Let’s just experiment a little bit more. 

What might you say or visualize to yourself when 

you’re feeling nervous or when it feels like it’s too 

much standing in action? 

JOE: I picture in my mind that people are 

welcoming me at the community center—that I 

don’t have to do it alone. My relatives are here, 

and my grandfather is standing, waiting for me to 

walk down the path. 

PROVIDER: I want you to hold this image and 

words, but for a moment, I want you to walk back 

to contemplation. What is this like, again? 

JOE: I really don’t want to be here. It’s like a 

waiting place. You know where you want to be, 

but you can’t get there. And you are the only one 

waiting, waiting alone. [Mike acknowledges Joe’s 

pain.] 

PROVIDER: Joe, let’s walk back up to action. 

What’s it like to return here? 

JOE: This is where I belong. I belong back here. 

I’ve just got to remember that no matter what I’m 

feeling that there are people I can go to—that I 

don’t have to leave this place alone or do it by 

myself. 

PROVIDER: Are you willing to hold onto the image 

of being welcomed back in the community as a 

reminder? [Joe nods.] 

JOE: I got it. I want to stay here. I think this picture 

will keep me on a good path. 

[Both continue to discuss some ways to gain 

support and to avoid isolation using traditional 

healing practices and connecting with a peer 

specialist at the center.] 

MASTER PROVIDER NOTE 

Participation in traditional ways, including 

sacred ceremonies, should be more than an addon to the treatment program. Native spirituality 

is central to American Indian and Alaska Native 

health and recovery for those who practice; 

living native traditions is much more inclusive 

and grounding than a treatment plan targeting 

a specifc problem, such as substance abuse 

or a mental health issue. Actively involving 

traditional healers to assist in the healing 

process can be extremely powerful in promoting 

recovery. Using traditional peer specialists for 

individuals who want to walk the recovery path 

in traditional ways can be a very compassionate 

and supportive approach. 

Summary 

The results of Joe’s court assessment suggested 

he would beneft from residential treatment. He 

agreed to attend the alcohol and drug treatment 

program at the tribal center and expressed that 

he wanted treatment. Joe underwent the most 

acute part of withdrawal in jail. The pretreatment 

session within the correctional facility provided Joe 

94 Chapter 2 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

an initial connection right at the time when he was 

ready to make signifcant changes. Treatment gave 

him an opportunity to structure his recovery in a 

safe place to begin his journey. In the early phase 

of treatment, Joe began to see the connection 

between his drug use and his feelings of isolation 

and shame. He felt that he had disappointed 

his family and community. Using an experiential 

exercise based on the Stages of Change model, 

Joe was able to identify major barriers in recovery. 

He recognized that walking his path meant walking 

with others, asking for help, and engaging in 

traditional practices. The community has become a 

symbol for recovery and healing. 

CULTURALLY RESPONSIVE COUNSELING WITH AMERICAN INDIANS 

AND ALASKA NATIVES 

Take cultural cues from clients. Until you learn otherwise, it is best to assume that your clients may be 

culturally traditional. You can assess specifcally for this as the session progresses. 

Welcome your clients. The American Indian and Alaska Native way is to offer food, water, and a place to be 

comfortable. The consensus panel suggests that you treat your American Indian and Alaska Native clients 

like relatives. 

Introduce yourself. It’s important to share a bit about your family background and where you come from, 

as well as what your role is in this meeting. 

Use an open-ended style. The provider sets the tone for the relationship. The consensus panel suggests 

conducting sessions and assessments in an open-ended, relational style to encourage an engaging 

connection between providers and clients. Encourage clients to tell their stories, listening for personal 

values that might motivate clients for recovery and strengths that might assist them. Ask questions to fll in 

missing information. 

Build on people’s values. Values are the motivators for change. Simply looking at a problem is not enough 

for clients to make a diffcult change. It is how the problem interferes with people’s well-being—the way it 

stops clients from living their values—that motivates change. 

Honor the importance of family, community, and connectedness. American Indians and Alaska Natives 

often relate strongly with their family, community, and environment. When working with individuals, 

remember to involve other support individuals in the family and community to help support recovery. 

Make room for silence. Remember that many American Indians and Alaska Natives speak carefully, 

thinking about their words before talking. This is especially true when your clients are bilingual and perhaps 

speak their native language at home. 

Chapter 2 95 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Vignette 3—Marlene: Facilitating Support, Creating Family 

Connections, Honoring Traditional Ways, and Recovering in Remote 

Alaska Villages 

Overview 

This vignette begins with a counseling session 

to help Marlene prepare for a session with her 

family. The vignette covers considerable ground in 

highlighting the challenges of remote village life in 

Alaska, assessing the role of traditional ways and 

subsistence in recovery, and promoting the importance of intergenerational healing. The second 

session is a family session that allows all members 

to talk about the effects of and their relationship 

with alcohol, to connect family members who 

are more likely be supportive of recovery, and to 

provide opportunities for the family to tell their 

story so they can heal, gain strength, and be 

guided in recovery. 

Marlene’s treatment provider is Nolee, an Alaska 

Native who left her remote village to obtain 

her education and training. From her life experiences as an Alaska Native who grew up in a 

remote village and through her internship as a 

village-based provider, Nolee brings a wealth of 

cultural knowledge to the relationship. When she 

meets Marlene, she has several years’ experience 

in counseling Alaska Natives and a vibrant referral 

network, as well as skills in using technology for 

long-distance services. Nolee works with Marlene 

throughout her stay to secure support from her 

family and community. 

Although this vignette focuses on family connections, Nolee also reinforces participation in 

traditional practices to help maintain abstinence; 

provides psychoeducation about the binge 

pattern of alcohol use; introduces the concept 

and normalizes the symptoms of traumatic stress; 

and emphasizes the importance of support 

throughout her treatment stay during individual, 

group, and community meetings. Nolee identifed 

a key objective in preparation for continuing 

care planning: to develop Marlene’s interest and 

comfort in using technology at her village’s health 

clinic as a recovery tool upon discharge. This 

included online participation in native recovery 

support groups, regular email communication with 

a peer specialist, and follow-up videoconferencing 

or phone calls. Nolee believes that comfort with 

a skill comes through practice, so she arranged to 

have Marlene participate in a few online support 

meetings and facilitated a couple of phone calls 

to her peer support specialist. This helped her 

become more accustomed to using the technology before she was discharged from inpatient 

treatment. 

Marlene’s Case History 

Marlene is a 30-year-old Alaska Native who lives 

in her native village in western Alaska. She was 

referred to residential treatment by an outpatient 

program after she had repeated returns to use 

during treatment. This is her frst inpatient 

treatment experience. 

Marlene was raised in her tribe’s traditional culture. 

English is her second language; she speaks her 

native language in her daily life. Marlene declined 

to have an interpreter during her initial interview 

and treatment. She communicates well in English, 

although she spends time gathering her thoughts 

before speaking. 

Marlene is married and lives with her husband 

and their two children in the village. The Offce of 

Children’s Services became involved with Marlene’s 

family after repeated reports of neglect. Currently, 

both children are staying with her mother. She needs 

to complete treatment successfully and maintain 

abstinence to ensure that she remains their primary 

caregiver. In outpatient treatment, Marlene was 

diagnosed with alcohol dependence and depression. She reports unresolved issues stemming from 

the suicide of a cousin 15 years ago. She blames his 

death on his drinking and expressed anger toward 

her mother for not attending his funeral. 

96 Chapter 2 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

ALASKA NATIVE VILLAGES: CURRENT CHALLENGES 

Villages range in size from populations of fewer than 100 to nearly 1,000, which is considered a large village. 

Communities are close, and tribal councils are elected from among the villagers, so leadership refects 

the village’s social culture. In remote villages, there’s a high reliance on government funding, and the cost 

of living is much higher. Many communities lack economic vigor, thus impeding suffcient employment; 

adequate utilities; and safety protection, including police, housing, and fre departments. Many jobs are 

part time to employ more people in the community. A signifcantly higher percentage of families who live 

in remote villages are economically poorer (Martin & Hill, 2009) than families who live closer to larger towns 

or cities; they also tend to be poorer than non-natives who live in Alaska. 

Villages rely primarily on seasonal work and subsistence practices, including hunting and fshing. For native 

people, subsistence is a way of life, culture, self-determination, and identity, but there are many external 

challenges facing subsistence among native people, particularly the effects of commercial fshing and 

policies. According to the Alaska Department of Fish and Game, only 2 percent of consumption occurs 

through subsistence harvesting, whereas nearly 97 percent of resource consumption occurs through 

commercial entities (Alaska Department of Fish and Game, n.d.). 

Many villages have limited services, including health care, courts, and police departments. Communities 

that do not have road access depend on small planes, snowmobiles (commonly referred to as snow 

machines in Alaska), or boat transportation when weather permits. Villages often rely on state police 

stationed hundreds of miles away; response times refect availability, situation severity, weather, and 

transportation. Some villages have assigned village public safety offcers, who have limited responsibilities 

and abilities to protect. Many Alaska Native communities experience some of the highest rates of family 

violence, alcohol abuse, sexual assault, and suicide in the United States. Women in native communities are 

12 times more likely to be physically assaulted and three times more likely to be sexually assaulted than the 

national average. Suicide rates among Alaska Natives are almost four times greater as well (Indian Law & 

Order Commission, 2013). 

Leadership, resources, and funding capacity of tribal health organizations determine the types and level 

of behavioral health services in each region. The Alaska Area Native Health Service provides fnancial and 

personnel support to the Alaska Native Tribal Health Consortium and other Alaska Native healthcare 

providers servicing remote villages and rural and urban areas (Indian Health Service, n.d.). Through selfgovernance, Alaska Native organizations and corporations oversee most funds designated for health care. 

At the village level, the community often relies on community health aides at the clinic, who are frst 

responders in managing emergencies, administering frst aid, assessing injuries and illness, prescribing 

medication (under physicians’ licenses), conducting preventive services, and facilitating telehealth, where 

available. Village-based providers may also be available to provide and broker further assessments and 

referrals for more severe behavioral health conditions. Other healthcare professionals may visit the village 

on regular schedules, but this depends considerably on geographic barriers, weather, and funding. 

Approximately 80 percent of primary care and nearly all specialty physicians reside near Anchorage 

(Alaska Federal Health Care Partnership, 2015). The challenges in accessing care in remote villages can lead 

to limited, delayed, or inconsistent care across modalities, including mental health, addictions, general 

medical, specialty health care, and prevention services. 

Marlene shows respect toward her mother and is 

submissive toward her, honoring her traditional 

upbringing. Marlene reported earlier childhood 

memories of her mother and grandmother both 

being depressed, frequently telling stories of the 

“Great Death” (epidemics that decimated entire 

families, villages, and generations). Marlene’s 

depression also stems from a history of sexual 

abuse from her stepfather. Her mother thinks 

that Marlene should forgive her stepfather, yet 

her mother reported the sexual abuse that led to 

his incarceration. Marlene denies any diffculties 

stemming from the sexual abuse and says that she 

does not want to talk about it in treatment. She 

has no suicide history or current thoughts of 

harming herself. 

Chapter 2 97 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

She has been drinking homebrew to self-medicate 

and exhibits increased tolerance. Marlene binge 

drinks, consuming alcohol during the short periods 

when it is available. She attributes her past relapse 

episodes to her husband; she explained that she 

drank many times with him at home. When he left 

the house to drink somewhere else in the village, 

she often would attempt to fnd him and then 

would stay and drink with him. Thus, her use often 

mirrored her spouse’s use. She never thought it 

was much of a problem until recently, when he 

suddenly stopped drinking about a year ago. She 

maintains that her husband’s use was more serious. 

In the last 6 months, her husband has regularly left 

the village for work. Last month, Marlene began 

binge drinking for a few days when her husband 

was not home. This led to a report that she had 

neglected her children. She does not recall the 

incident but is worried about the outcome if she 

does not fnish treatment or stop drinking when 

she is discharged. 

Homebrew is made with simple 

household ingredients. The practice 

of making homebrew is well known 

in native villages. Individuals make 

their own spirits for many reasons, 

including limited availability and 

accessibility, costs, prohibition, and 

a means of income. Homebrew can 

be particularly dangerous to drink 

depending on sanitation during 

processing, the ingredients selected 

to create fermentation, the additives to 

alter taste, and the chemical properties 

after production. Homebrew can be 

toxic, and its effects may be fast acting. 

Not all villages ban alcohol sales, but 

a signifcant number of villages have 

imposed local controls on alcohol, 

banning sales, importation, or 

possession. 

ADULT BINGE DRINKING 

In adults, binge drinking is defned as having fve 

or more drinks (for men) or four or more drinks 

(for women) on the same occasion at least once 

in the past 30 days. 

• Binge drinking among Alaska Native adults 

appears to have decreased by 22 percent since 

1992–1994. 

• One in fve (20.4 percent) Alaska Native adults 

report binge drinking. 

• The prevalence of binge drinking among 

Alaska Native adults is similar to that of Alaska 

White (19.8 percent) and U.S. White adults (18.9 

percent). 

• Alaska Native binge drinking rates vary by tribal 

health region, ranging from 11.7 to 29.5 percent. 

• Binge drinking can damage the body 

signifcantly. It exposes the body and its organs 

to higher blood alcohol concentration and 

longer exposure as it is being processed in the 

body. 

• Binge drinking is associated with unintentional 

and intentional injuries, alcohol poisoning, 

poor control of diabetes, high blood pressure, 

stroke, liver damage, and neurological damage, 

among other consequences. 

Sources: Alaska Native Epidemiology Center, 2014; 

Centers for Disease Control and Prevention, 2014. 

Marlene has a 10th-grade education. She is 

sporadically employed and has a work history that 

includes fsh processer, store clerk, and janitor. 

She prefers a subsistence lifestyle to holding a 

job. Marlene’s cultural strengths include hunting, 

tanning hides, trapping, fshing, beading, sewing, 

and berry picking. She does not use alcohol during 

her subsistence activities. 

Objectives for Vignette 3 

The objectives are: 

1. To demonstrate how to prepare the client for a 

family session. 

2. To reinforce how traditional ways, including 

subsistence activities, can be a pathway to 

prevention and recovery. 

3. To provide several activities that involve children 

inside and outside the family session to reinforce 

the strength of culture, family, and community. 

98 Chapter 2 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

4. To illustrate how to conduct a family session 

early in recovery to build support from relatives. 

5. To indicate how traumatic stress is embedded 

across generations among American Indian and 

Alaska Native cultures and that its effects can 

be felt through the incidence of depression, 

parenting diffculties, and self-medication. 

6. To anticipate the geographic challenges of 

remote villages in securing recovery support 

services and the challenges of developing and 

implementing a plan prior to discharge so that 

the client can practice skills, including those that 

involve technology, thus increasing comfort and 

the likelihood of follow-through. 

Client–Provider Dialog 

Marlene is in her second week of treatment. 

She arrived at a residential treatment center 

some distance from her home village. Marlene is 

worried about her children and what will happen 

to her relationship with her husband now that he 

has stopped drinking. During the frst 10 days, 

several other areas were identifed and addressed, 

including psychoeducation about the binge 

pattern of alcohol use among women, the main 

components of trauma-informed care (including 

the education and normalization of traumatic stress 

symptoms), the importance of safety, the need for 

support, and the role that subsistence can play in 

maintaining abstinence. The frst dialog includes a 

brief exchange between the client and the provider 

to prepare for their family session. The next dialog 

is a family session that includes Marlene's mother, 

spouse, great-uncle (elder), and two children (Ben, 

age 12, and Tanya, age 10). The great-uncle is an 

elder on the traditional tribal council. Marlene's 

provider, Nolee, is also an Alaska Native. She 

obtained her education and provider training in the 

Anchorage area and completed her internship as a 

village-based behavioral health service provider in 

a remote village north of Fairbanks, AK. 

MASTER PROVIDER NOTE 

In American Indian and Alaska Native 

communities, even in urban areas, it is common 

that a provider will have multiple connections 

or relationships with a client besides the 

professional relationship. The client and provider 

may be related or live in the same community 

or village. The client may be a store clerk, 

teacher, mechanic, or librarian with whom the 

provider has done business for years. They may 

participate in the same social or community 

groups, have family and friends in common, 

or have children who are friends. When this 

happens, it is important that the provider 

makes use of clinical supervision to discuss 

and clarify boundaries and assures the client of 

confdentiality. 

Preparation session prior to family session: 

Session one 

MARLENE: [Enters the offce.] My family is 

traveling tomorrow for the family session and 

family weekend. 

PROVIDER: You sound surprised. 

MARLENE: [Marlene appears tearful.] I don’t know 

what to say to them, especially my children, and my 

great-uncle. He is an elder and a member of our 

traditional tribal council. 

PROVIDER: Let’s take this session to think about 

this. 

[Marlene nods, and Nolee spends some time to 

ease into the conversation after talking about her 

family’s travel arrangements and checking in with 

Marlene about her week in treatment.] 

MARLENE: [Marlene sits in silence for some time.] 

I want my children to know our ways. I’m worried 

that I’ve shown them something different. I think 

my mother and great-uncle would agree. They’ve 

always maintained our ways. When I do participate 

in community events, including subsistence activities, I begin to feel that I’m on the right path. At 

the same time, the frst feeling that comes fooding 

into my mind is shame when I’m not drinking. 

I blame myself, and I feel it sometimes in the 

community. 

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MASTER PROVIDER NOTE 

Community, and one’s reputation in the 

community, are important American Indian and 

Alaska Native values. People generally want to 

be contributors and well thought of, bringing 

respect and honor to the family within the 

community. Providers should be particularly 

sensitive to honoring this value in discussions. 

PROVIDER: What happens when you feel this 

shame? Where does that feeling of shame frst 

begin in your body? 

MARLENE: I don’t know. [Time passes.] I don’t 

know what to do. I just want to run from this 

feeling. And I do. I run with alcohol. 

PROVIDER: Have you ever listened to what the 

shame has to say? 

MARLENE: I frst hear in my head that I’m not 

a good person or mom. I sometimes feel as if 

nothing will come of my life. The feeling is all about 

the bad things that have happened because of 

drinking. 

PROVIDER: When you listen to it, its message 

is about the past and not the present moment. 

[Marlene nods.] What do you think would happen if 

you didn’t run—if you stood in the feelings? 

MARLENE: I don’t think I could do that. Don’t think 

I ever have done that for long. 

PROVIDER: So many feelings meet you at the door 

when you frst stop drinking. Do you think it will 

pass, if you don’t go back and run with alcohol? 

MARLENE: It does pass, but not right away when 

I go to camp. Hunting and tanning make me focus 

on what needs to be done. I don’t drink when I 

hunt; animals can smell it. When I go out hunting, 

I don’t think of anything else. I am happy. It’s 

cleansing. 

PROVIDER: So, when you frst don’t use, initially 

bad feelings come. Then if you stay with it, it 

passes. When you live your traditional ways, the 

bad feelings leave you. 

MARLENE: [Marlene nods.] Being with others who 

are not drinking at the time helps and being with 

my mom and great-uncle at the camp makes a 

difference. I am home. 

MASTER PROVIDER NOTE 

Marlene has reported feelings of depression during her intake. As a standard of care, she would initially 

have a medical evaluation to rule out any specifc conditions. Depending on severity, she may also need 

a referral for a psychological evaluation to determine the most appropriate course of treatment using 

traditional and mainstream approaches. 

As a provider, it is important to recognize that depressive symptoms may be a consequence of her 

drinking, trauma (including historical trauma), or other environmental conditions. Although this does 

not preclude the need for additional treatment to address her depressive symptoms, you need to know 

that depressive symptoms can emerge from a number of causes. For example, traumatic stress can 

be displayed through depressive symptoms alone. In other words, the person will not have the classic 

symptoms of traumatic stress outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth 

Edition (American Psychiatric Association, 2013), but instead have depression as the main symptom of 

traumatic stress. Also, individuals with a history of trauma may use drugs and alcohol to self-medicate the 

effects of their experiences. Unfortunately, self-medication often leads to a vicious trauma cycle, whereby 

the use of alcohol or drugs increases the likelihood of trauma, and then the new trauma reinforces 

ongoing self-medication with substances. 

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PROVIDER: What might you need to say to your 

mom and your great-uncle during the family 

session? 

MARLENE: My mom had a rough time in her life, 

but she is better now. I know she wants me to be 

well. I want to show both of them respect. 

PROVIDER: Is that what you want to say? [Marlene 

nods.] How would you like to show them respect? 

MARLENE: Taking care of my kids. Seeking out 

people who don’t shame me or who don’t want me 

to drink for support. Traditional ways. 

PROVIDER: When you say, “Taking care of your 

kids,” what does that look like? 

MARLENE: Teaching them old ways but giving 

them chances to learn new ways as well. Our 

village is changing quickly. I want them to know 

that they can learn the old and that knowing our 

ways will help them with change. I worry that I’ve 

taught them, like I’ve been taught, to use alcohol 

to cope. 

[This dialog took some time in the session. Marlene 

paused frequently, collecting her words and 

thinking about how she wanted to say this.] 

PROVIDER: Marlene, I’m drawing a circle on this 

paper. Let’s fll this circle with traditional ways and 

beliefs, the values of community, the things that 

you would like to teach your children. [They spend 

additional time in the session as Marlene flls in the 

circle.] What would you like to name this circle? 

MARLENE: This circle is for my children. It’s how 

I want to be with them. Um, maybe the circle of 

gifts. 

[Nolee then asks Marlene what she would like to 

do with the “circle of gifts.” Marlene decides that 

she wants to share the circle with her children alone 

when they come for the session and program.] 

SUBSISTENCE: LIVING 

TRADITIONAL WAYS 

“Hunting and fshing links today’s skiffs and 

nylon nets with the willow fsh traps of the past.... 

‘Our belief system—the way our creator spoke to 

us was through his own creation—through the 

animals and the fsh,’ said the 49-year-old Yup’ik. 

‘We not only hunt and we eat. That’s the way he 

spoke to us was through nature. So, when we 

participate in subsistence it’s like reaffrming who 

we are’” (Thomson, 2000). 

“Traditional hunting and fshing benefts go 

far beyond nutritional value and benefts, they 

are central to maintaining cultural norms and 

language. They reinforce the deeply embedded 

value of a shared sense of community and 

responsibility for the welfare of others. By working 

together, Alaska Natives meet and overcome 

the challenges found in the Alaskan outdoors. 

In this region, it is common among native 

members who are better equipped to hunt 

and fsh, to distribute food to the less well-off 

in the community. Hunting and gathering are 

key components of traditional living. The act of 

hunting itself can be ceremonial. What is eaten, 

and what is left untouched are often life lessons 

retold from the elders to their young through 

the art of storytelling. Accordingly, traditional 

hunting, fshing, and gathering is more than 

what Alaska Natives do; it embodies who they 

are as a people as traditions are passed down 

from one generation to the next. This way of 

life provides for the cultural, spiritual, physical, 

emotional, social, and economic wellbeing of 

Alaska Natives” (Alliance for a Just Society & 

Council of Athabascan Tribal Governments, 2013, 

p. 5). 

Two projects in Alaska have evaluated the 

feasibility of a community intervention to prevent 

suicide and alcohol abuse among rural Yup’ik 

Alaska Native youth in two remote communities. 

The interventions, originating in an indigenous 

model of protection, were built around traditional 

and subsistence activities which were presented 

as a Qungasvikm—a toolbox containing 36 

activities or modules (Mohatt, Fok, Henry, People 

Awakening Team, & Allen, 2014). 

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MASTER PROVIDER NOTE 

The “circle of gifts” can be easily incorporated 

into family programming to help parents share 

stories with children about traditional ways and 

values. You can also use this circle to discuss how 

traditional ways provide lessons on how to cope 

with life circumstances. This exercise can easily 

be adapted as a group activity in treatment, 

whereby clients complete, share, and process 

their circle within the group or community. It 

provides an opportunity to use storytelling to 

express how traditional ways can guide recovery. 

PROVIDER: Marlene, I’m thinking about your 

husband attending the session. What would be 

helpful? 

MARLENE: I’ve known him my whole life. We’re on 

better ground since I got here. [Marlene begins to 

laugh.] You know, he’s shown me how to drink and 

how not to. I’m proud of him. For years, I thought I 

was going to lose him the same way as my cousin. 

He would get so down about not working all the 

time. 

PROVIDER: Is there anything you haven’t said that 

you need to say to him? 

MARLENE: He knows I’m proud of him for not 

drinking and for fnding work. He is walking the 

walk. Now he works more regularly, even though 

it’s still seasonal. People really respect him in the 

village. He turned things around. 

PROVIDER: Before we end this session, is there 

anything that you haven’t spoken here that may 

come up in the family session? [Marlene shakes 

her head, no.] Marlene, our next session will be 

the family session. It will be a time for listening, a 

time to share stories, and a time to heal. Is there 

anything else that you need to talk about in the 

family session? [Marlene says, “No.”] How would 

you like to close this session? 

MASTER PROVIDER NOTE 

When preparing your client for a family session, 

it is always wise to ask whether there is anything 

that he or she hasn’t said that might come 

up in the family session. This is not unique to 

American Indian and Alaska Native clients. 

Sometimes, the client or the family will use the 

session to make a surprising announcement 

(e.g., affairs, separations, custody). Although you 

surely cannot stop this from happening with 

the client or another family member, asking 

this question will at least alert the client that 

this is the time to talk about it: before the family 

session. The family sessions—at least the initial 

one—that may include extended relatives and 

children are not an appropriate place or a safe 

place to rid oneself of a secret or a surprise. As 

a provider, you want the initial session to build 

connections; to increase awareness of the effects 

of substance use or psychological problems on 

the family; and to bridge any gap of support to 

ensure recovery of the individual, family, and 

community. If the client does have a secret, then 

you both can talk about how and when it may be 

addressed. 

Family session: Session two 

Marlene’s mother, great-uncle, and two children 

arrived for the session. Her husband was not able 

to attend because of work. Prior to the session, 

Nolee made arrangements so that Marlene’s 

husband could call in during the session for at 

least part of the session. Nolee divided the family 

session into three segments. The frst portion, 

called the listening circle, involved everyone, 

including her two children. The second portion of 

the session only included her great-uncle, mother, 

and spouse, and the fnal portion involved the 

entire family in creating a family recovery crest. 

The frst segment of the family session: 

The listening circle 

[During the welcome, introductions, opening 

words, and format outline, Nolee asks the elder 

(great-uncle) if he wants to say anything or ask 

anything before the session starts. Then, Nolee 

asks the family a question to confrm that everyone 

knows why they are here.] 

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MASTER PROVIDER NOTE 

In family sessions, providers should not assume that everyone in the family was told why they were 

attending the session or why the client is in treatment. After introductions and opening words, the 

provider should deal with this assumption by beginning with a question about everyone’s understanding 

of why they were invited to attend the family session. This question helps guide the session, and it allows 

for a gentle approach. As a provider, you do not want to be the messenger. Instead, it is important that 

clients explain the reason in their own words if they have not done so prior to the session. If the client is 

struggling, you may ask if he or she would like you to say something about the purpose of the session. 

Overall, this approach shows respect, but it also provides information on how communication occurs 

within the family. 

Keep in mind that some clients may avoid stating the real reason for the session. In this scenario, you will 

need to spend time in facilitating a further discussion, so the family session is based on the real purpose 

for treatment. This scenario is uncommon. Yet, if it occurs, you can switch the format briefy and state that 

the session will involve meeting the family individually, in dyads, and as a whole: that you will be asking 

different members at different times to be in the family session while others wait in another room. You 

should say that the family session will always end with everyone together. If this scenario occurs, it usually 

involves clients’ reluctance to talk about the presenting diffculties with their children. In this case, you 

walk the children out of the room, guiding them to another room that includes adult supervision and 

an activity. You want to let the children know that you will be returning shortly to bring them back into 

the session. Then, you return to the family session and privately discuss clients’ reluctance and how they 

would like to handle the discussion with their children. You invite the children back into the room and 

follow the plan that was discussed. You can also use the same strategy if clients did not tell an adult family 

member about the reason for the session. 

[Everyone acknowledges in their own words that 

Marlene’s drinking was a problem. They all address 

concern for Marlene. When the children speak, 

although quite reluctantly, the younger, Tanya (age 

10) states that she misses her mom.] 

TANYA: I miss you. [Both mom and Tanya become 

tearful.] 

MARLENE: [Some silence.] I know, but I need to be 

here so that I can come back to you. 

PROVIDER: Tanya, if there was one thing that you 

would like to change in your family, what would it 

be? 

TANYA: I want my mom back. I don’t want anyone 

taking her away. 

MARLENE: [Tearful.] Tanya, who do you think is 

taking me away? 

TANYA: [She looks at her mom and surprisingly 

mentions the alcohol. Marlene didn’t think that her 

children really knew about her drinking.] Alcohol 

takes you away. 

[Marlene doesn’t say anything, but it is clear that 

this has affected her.] 

PROVIDER: [Nolee takes newsprint and lays it 

on the foor in the center of the family circle. She 

draws the word “alcohol.”] Tanya, what would you 

like to say to alcohol right now? 

[Marlene encourages her.] 

TANYA: [She begins to show anger.] I don’t like 

you. You always take my mom. Why don’t you 

leave her alone? 

[Nolee prompts Tanya and asks her if there is 

anything else she would like to say to alcohol.] 

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TANYA: I just want to be with my mom. 

PROVIDER: Who else would like to say something 

to alcohol? [Nolee redirects everyone to speak as if 

alcohol were in the room and toward the paper on 

the foor.] 

MARLENE’S MOTHER: You used to take me too. 

You have taken too many people in our village and 

my family. I want it to stop. I’m so glad that I have 

my daughter and son-in-law back. I’m going to do 

anything I need to keep them away from you. You 

don’t belong here, in our village, or our camps. I 

want to say goodbye to you. You are not from us. 

I love my daughter, and I see her suffer when she 

is with you. [Marlene’s mother reaches next to her 

daughter and holds her hand.] I’ve been looking at 

my daughter as the problem, not you. 

HONORING CHILDREN, MAKING 

RELATIVES 

This is a cultural adaptation of the Parent– 

Child Interaction Therapy approach. This 

adaptation supports traditional native parenting 

practices and values, focuses on parents who 

have diffculty with parenting skills or with 

addressing their children’s problematic behavior. 

It incorporates an essential native belief that 

children are the center of the circle (Bigfoot & 

Funderbunk, 2011). 

PROVIDER: Does anyone else want to say 

something to alcohol? 

MARLENE: [Nods and pauses.] You’ve taken so 

much from me. I’ve known you for some time. And 

the goodbye will be hard, but I don’t want to lose 

my children to you. I need to walk away. I need to 

walk a different path, to learn more from our old 

ways, to show our ways to my children. It’s a White 

man’s disease, so I need to fx it here. Then I can 

get away from it. You have broken the circle. 

PROVIDER: Who else would like to speak? [This 

portion of the session continues. Family members 

take turns speaking about alcohol. Then the 

provider asks everyone what they heard as they sat 

in the room and listened to each other. Afterward, 

the session transitions into having just the adults 

in the session as the children go with another 

provider who works with children.] 

A traditional elder is someone who 

follows the teachings of ancestors. It 

is said that traditional elders walk and 

talk the good way of life. Traditional 

elders teach and share the wisdom 

they have gained of the culture, history, 

and language. The sharing of their 

wisdom is healing (Anishnawbe Health 

Toronto, 2011). Not every older person 

is recognized as an elder of the tribe. It 

is important to help your client identify 

an elder who will be supportive of his or 

her journey of recovery into wellness. 

The second segment of the family session 

[The session continued after the children left the 

room. This next portion includes Marlene, her 

spouse, her mother, and her great-uncle. In this 

session, Marlene’s spouse ends his phone participation early because of his work schedule.] 

PROVIDER: As you have all stated, the exercise 

helped you remove the alcohol from the person. 

That alcohol is the problem, not the person. 

Marlene, what do you think this means? 

MARLENE: I never looked at it that way. I am 

not the disease. I don’t need to carry the shame. 

It doesn’t mean that I haven’t done things while 

drinking, but I’m a different person when I don’t 

drink. Alcohol pushed out what needs to be in 

the center of the circle—our traditional ways, my 

children, and family. 

MARLENE’S MOM: I’ve been blaming other things 

besides alcohol. 

GREAT-UNCLE: I am honored in being here and 

being invited to attend the session. Alcohol is 

a problem in our village; but it was not ours. It 

was brought to us. Alcohol pulls you away from 

yourself, family, and ways of knowing. [Marlene 

nods and is tearful.] When you are ready to 

come home, you know that our ways can replace 

alcohol—that instead of looking at alcohol in the 

center of the circle, our culture can be there. 

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MASTER PROVIDER NOTE 

Noninterference is a common value across 

American Indian and Alaska Native cultures. It 

is an unspoken relational boundary between 

relatives and others; it allows things to happen 

the way they are meant to be. Noninterference 

helps maintain peace or decreases confict 

within the family and community, reinforces the 

importance of interdependence and autonomy, 

and allows people to learn from their own 

actions. When practiced, it shows respect. It is 

one of several native beliefs and practices that 

help maintain peace within the community. 

For providers who have some knowledge of 

American Indian and Alaska Native cultures, 

noninterference can easily be misconstrued. 

Noninterference is not synonymous with 

unwillingness to act. Rather, it allows relatives, 

including children, to have choices. Therefore, 

interventions that present or explore alternative 

choices when clients face challenges are 

effective as long as suggestions are not directive. 

[Time passes in silence for a few minutes as 

Marlene is visibly overwhelmed.] 

PROVIDER: [Nolee checks in with the great-uncle 

and Marlene to gain informal permission to 

continue in the session.] Marlene, what will help 

you replace alcohol in the center of the circle? 

MARLENE: Don’t know. [Silence.] Going home to 

camp. They tell me here that I need to be around 

people who support me. 

SPOUSE: [On the phone.] You know it’s hard, but 

people in the village who I didn’t think would be 

supportive have been. I’ve gone to the clinic to 

meet up with two other people in the village who 

have decided not to drink. I just thought everyone 

drank. Marlene, there are people around you who 

don’t drink and who want you well. I want our lives 

not to center on alcohol, but around our family. 

[Marlene acknowledges with a “yes” on the phone. 

Her husband has to leave the session at this point 

because of his work schedule.] 

PROVIDER: Who is in your life right now that can 

stand with you and support you as you heal? 

MARLENE: All of this feels too much. I am not 

used to it. Don’t know if I can trust it. I don’t trust 

myself. I do trust what everyone is saying today. It’s 

hard to hear, but good to hear, too. 

[The session continues with a discussion of how to 

obtain support and what type of support her mom, 

great-uncle, and spouse could provide. Nolee 

and Marlene’s great-uncle explore subsistence 

practices Marlene could resume without alcohol. 

Nolee introduces several Internet options to access 

regular support from those in recovery once she 

returns to the village. Nolee conducts a brief family 

systems psychoeducation on wellness and illness: 

one person, experience, or part of the system can 

affect the whole system (or community) for better 

or worse.] 

FAMILY THERAPY: USING A 

SYSTEMS APPROACH 

In becoming culturally competent, a provider 

must select strategies that complement 

traditional healing ways. One theoretical 

orientation that can be easily adapted is the use 

of family system approaches. In Alaska Native and 

American Indian cultures, individuals function 

as a part of the group, whether it be family, clan, 

or community. Family therapy approaches that 

incorporate a systems perspective recognize that 

everything occurs in context with everything 

else. If change occurs in one area, then the 

surrounding area will change as well. If one 

person changes, it affects everyone in the family 

and village, whether the change is for the good 

or not. 

The third segment of the family session: Family 

recovery crest 

At the end of the session, Nolee gathers the entire 

family to create a recovery crest. She frst gains 

informal permission from the elder and then asks 

if he will guide the family. She asks them to create 

a crest by drawing important animals, images, 

and symbols that represent stories and strengths 

of their family history. She suggests that they talk 

about the stories as they create the crest. This 

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activity continues after the family session ends at 

the facility. They will have an opportunity to share 

their creation at a community meeting during 

the family program. The family uses their clan 

crest, along with other symbols that represent 

family stories of personal survival, subsistence, 

cultural values and beliefs, community, and the 

like. Once the family has a clear idea about the 

activity, Nolee takes the opportunity to thank the 

family for coming, for the gift of sharing, and for 

the ability to support and listen to each other. She 

gives each member a small gift made by other 

treatment community members: a beaded ribbon. 

After checking in with everyone in the family, she 

asked the great-uncle if he would like to provide 

the closing. 

MASTER PROVIDER NOTE 

It is often easier for people who practice 

traditional ways to talk while engaged in an 

activity (e.g., Hopi quilt making). This has 

become a cultural style of relating to others. In 

subsistence cultures, people use visiting time 

as an opportunity to get something useful 

accomplished at the same time. 

Summary 

During treatment, Marlene recognized the importance of surrounding herself with people who 

provide support and do not drink. She practiced 

how to reach out to others using technology so 

that she was confdent she will be able to do so 

when she returns to her remote village. Marlene 

is likely to face other challenges beyond the geographic barriers; she may need additional traditional and mainstream interventions to help heal from 

traumatic experiences, including witnessing her 

cousin’s death, sexual abuse, and historical trauma. 

Binge drinking has been her primary coping 

strategy when she was not engaged in subsistence 

activities or at camp. 

During treatment, she came to understand that her 

participation in subsistence activities had saved her 

from more devastating effects of alcohol abuse. 

Although Marlene spoke of many activities that 

would need to occur for her to maintain recovery, 

she defned recovery as reconnecting to her traditional ways for herself and her family. She used 

the exercise highlighted in the family preparation 

session to begin talking with her children about 

traditional ways, beliefs, and strengths. Before her 

discharge, she enrolled her children in a cultural 

camp conducted by elders in her community. 

During treatment, Marlene acknowledged that she 

had self-medicated with alcohol to manage her low 

mood and past traumas. She gained a signifcant 

insight when she recognized that alcohol was in 

the middle of the circle, rather than her children or 

family. 

During treatment, Marlene decided that she 

needed to change the legacy for her children. She 

hopes her children will see and learn from her, 

their father, her mother, and her great-uncle—that 

coping can happen without alcohol and that traditional ways can guide them through life’s hardships. 

If her children start drinking or using drugs later 

on, she wants to show through her sobriety that 

recovery is possible: that there are healthy options. 

YUUYARAQ: THE WAY OF THE 

HUMAN BEING 

To gather an understanding of the experiences 

for many Alaska Native tribes and villages, 

Yuuyaraq: The Way of the Human Being provides 

a descriptive and historical narrative. This seminal 

work introduces the idea of generational trauma 

and the continual effects of the “Great Death”— 

epidemics that affected Alaska Natives from 1700 

to the 1940s (Napoleon, 1996). 

TLINGIT CULTURAL VALUES 

Haa aani. Connection: honoring our land 

Haa Shuká. Past, present, and future 

generations: honoring our ancestors and future 

generations 

Haa latseen. Strength: achieve inner and physical 

strength 

Wooch yax. Balance: maintaining spiritual and 

social balance and harmony 

(For more information, see Sealaska Heritage 

Institute, 2009.) 

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SUGGESTIONS FOR WORKING WITH INDIVIDUALS WHO PRACTICE 

TRADITIONAL WAYS 

• Accommodate the interactive style of traditional clients while not overwhelming American Indian and 

Alaska Native clients with too much verbal and written information. English may be a second language 

for traditional American Indian or Alaska Native clients, so an interpreter may be necessary. The speed and 

complexity of verbal communication may be diffcult for clients to understand and absorb at the same 

time, and written assignments may not work. The pace of conversation for traditional people is often 

slower than for non-native clients and staff. Coming from cultures in which the written word is relatively 

new, the truth and accuracy of oral communication is important. Words are chosen carefully. American 

Indians and Alaska Natives who are traditional are excellent listeners and learn by listening, watching, and 

doing. This level of attention will be sustained as long as the learning is relevant and valued by clients. 

• Learn and respect traditional values. For example, for those who practice traditional ways, community and 

family needs are often more important than individual needs. Entering treatment for the sake of others 

can be a powerful motivator. Self-suffciency and noninterference are fundamental values. Individuals 

have the right to make their own choices and learn from them without interference or directives from 

others. Giving uninvited advice violates these values. For many American Indian and Alaska Native 

cultures, saying “no” is seen as disrespectful; therefore, teaching and rehearsing refusal skills that match 

people’s communication styles is vital. 

• Many traditional people live in communities that are remote and offer few mainstream recovery 

resources. As a provider, you must learn to incorporate traditional supports and activities for healing. You 

will want to learn how to integrate telehealth and innovative strategies in your clients’ continuing care 

plans to provide alternatives in accessing recovery support, including online recovery meetings, peer 

support, follow-up calls, videoconferencing with providers (if accessible), home visits, and transportation. 

Keep in mind that many clients will return home to those who still use or drink. 

TALKING CIRCLES 

A talking circle, rooted in the traditional practices of native culture, is a gathering used to consider a 

particular problem or issue. The talking circle provides a nonhierarchical safe format whereby everyone 

has a voice and can speak without interruption. It is an effective approach that can be easily adapted as 

a peer-led or elder- or provider-facilitated circle within a treatment program. The talking circle expresses 

the American Indian and Alaska Native values of cooperation over competition, respect for everyone, and 

noninterference. 

Format 

People gather in a circle, usually seated, and the facilitator might open with some “good words” or a prayer. 

Before the circle keeper or elder introduces a topic or question, he or she speaks about the purpose of the 

circle, lists the ground rules, and introduces the meaning of the talking object (or the talking stick). Often, 

the object selected has signifcance, which may or may not be conveyed in the opening. The facilitator may 

also invite requests for other ground rules. 

The facilitator then introduces questions or a topic and asks participants to refect and respond. Moving 

clockwise, the object passes from one person to the next. Only the person who holds the object can speak. 

It is considered rude for anyone else to speak, even in a whisper to someone close by. It is expected that 

everyone listens to the speaker, as they would expect people to listen to them in return. These circles can 

take time, as every person must be given the opportunity to speak. The person holding the item can talk 

as long as he or she wants or say nothing at all. Traditionally, it may take one circle or a number of times 

around before it ends. Talking circles can last for hours. If individuals join the circle late, they are given an 

opportunity to speak. If someone begins to talk out of turn, the circle keeper reminds the group of the 

ground rules and refocuses attention back to the person with the talking object. 

Continued on next page 

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TALKING CIRCLES (CONTINUED) 

Using Talking Circles in a Treatment Setting 

There are important differences between a talking circle and a therapy group. Both may have a place in 

your treatment approach. A signifcant difference between the two is that there is no discussion, feedback, 

or interpretation from anyone (including the facilitator) while or after a participant shares in the talking 

circle. 

Sample topics for circles include: 

• What is a valuable lesson you learned “the hard way” regarding your drug or alcohol use? 

• How has alcohol use affected your community? Your family? You? 

• What do you plan to do each day to honor your decision to stay sober? 

• How do alcohol or drugs harm your spirit, mind, and body? 

• What are things that you can do to keep you well? Or to heal? 

Another difference between a talking circle and a therapy group is the issue of time. In most treatment 

programs and settings, activities run on time schedules. When using a talking circle format, here are some 

potential modifcations: 

• The circle keeper sets up the talking circle as a continual process, in which people sit in the same order 

and speakers resume in the same order upon returning to the circle. The circle may spread across several 

days, using the scheduled group time within the program. 

• Alternatively, the leader might ask permission to limit the amount of time for each circle member to 

speak to allow completion in the available time. 

For more information and application of talking circles in behavioral medicine, see Mehl-Madrona and 

Mainguy (2014). 

For an example of a community talking circle, including dialog, process, and ceremony, see Picou (2000). 

This descriptive article provides excerpts from circles focused on the personal and community effects and 

losses from the Exxon Valdez oil spill. 

HOW TO FIND TRADITIONAL HEALERS 

Providers working with American Indian and Alaska Native clients need relationships with traditional 

healers to collaborate in providing meaningful and powerful treatment and recovery services. Some tips to 

keep in mind: 

• Finding traditional healers is sometimes diffcult. American Indian or Alaska Native individuals doing 

healing work often keep a low profle, as secrecy was essential during the many generations when 

practicing traditional ceremonies was illegal, and this secrecy became a custom. Hence, be wary of 

anyone who approaches your treatment program unsolicited to market him- or herself as a healer; this 

behavior contradicts traditional ways. This individual is likely a “plastic shaman” or impostor. 

• As a result of the government’s efforts to suppress and eradicate native spiritual practices and the 

introduction of Christian religions by missionaries and boarding schools, many American Indians and 

Alaska Natives do not know or do not practice their tribe’s spiritual traditions. Interested providers may 

have to ask many people in order to fnd helpful information. 

• American Indians and Alaska Natives who practice traditional spiritual ways are often protective about 

their practices. As in recent years, interest in their practices has become trendy in some non-native circles, 

even resulting in non-native people presenting themselves as healers and conducting their interpretation 

of sacred practices and ceremonies. This is seen as a serious violation of sacred practice; it profoundly 

disrespects traditional healers, who have spent many years learning and preparing for their work. 

Continued on next page 

108 Chapter 2 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

HOW TO FIND TRADITIONAL HEALERS (CONTINUED) 

• You will fnd it easier to locate credible traditional healers as you develop relationships in native 

communities and as people develop trust in your motives and intentions. You could ask people who know 

you through professional or personal recovery activities. Tribal behavioral health, healthcare, and court 

services providers may be helpful sources of information. It is important to use respected members of the 

native community to vet appropriate healers. Certain issues may require a healer with specialized skills. 

Judicious choice of sources also prevents the use of inauthentic individuals posing as healers. 

• Traditional elders can often refer you to spiritual advisors, some of whom are called teachers, medicine 

men and women, shamans, or healers. In some traditions, practitioners resist these names, simply calling 

themselves “someone who helps.” 

• Your inquiries must be made in person, not over the phone or email. When you visit an elder, it is proper 

to bring a gift such as a package of tobacco, sage, sweetgrass, or cedar. Ask the person who refers you to 

an elder about the local practice regarding gifts. 

• When you visit with an elder, thank the person for meeting with you, and tell him or her how you got 

there, including information about yourself and what need you are looking to fll for your clients. Ask what 

ideas he or she has about what might be helpful. Be interested, but respectful, in the person’s own path 

to this work. 

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TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Vignette 4—Philip: Making Connections Between Losses and 

Alcohol Use, Using One-Stop Outreach and Case Management 

Services for Homelessness and Treatment Service Needs, and Building 

Relationships Using Traditional Practices in Recovery 

Overview 

Philip’s story is all too common in Alaska. Alienated 

from his home village because of his drinking and 

lack of resources, Philip has been camping outside 

a city with other individuals who are homeless. 

Here he fnds acceptance, freedom from racism 

and prejudice, and a group to which he can 

belong; however, he does not want to continue 

camping. He reports periodic, but extended, 

binge drinking and presents with sadness over 

the repeated deaths in his village from suicides 

and accidents of young people, including one 

nephew, a cousin, and close friend. Philip wants to 

fnd housing and help, but he struggles in asking 

for assistance. He believes that homeless shelters, 

treatment programs, or other services with four 

walls will be too confning and that he will face 

more prejudice. 

We have a duty to each other, and 

we need to make a difference. 

Everyone has a specialty—we need 

to utilize this expertise and in turn, 

offer our services to our people.” 

Source: Ukpeagvik Iñupiat Corporation, 2015, p. 5. 

In this vignette, Anthony, an Alaska Native provider, 

meets with Philip at a native treatment center. 

Philip had agreed to come to the program for a 

few days for detoxifcation, but he emphasized that 

it was only for a few days to get out of the cold and 

to sober up. Anthony, the provider, is a 24-year-old 

recent graduate who attended school in Arizona 

and returned to Alaska to be with his family and 

to work within the Alaska Native community. He 

frequently says that he owes his education to his 

aaka (grandmother), who helped him think about 

what was most important—to serve others and the 

community. Anthony obtained a scholarship from 

his village corporation and made a commitment 

to himself to give back to the community upon 

his return. Anthony is focused on learning about 

available regional resources to assist those who 

have been separated from family, displaced from 

home or lodging, and unable to fnd employment. 

Philip’s Case History 

Philip is a 34-year-old Alaska Native male who 

moved to the city approximately 6 months ago 

from a remote village. He has been living in a camp 

on the outskirts of town with other people who are 

homeless. He was self-referred to a native program 

after participating in a 1-day, one-stop event for 

individuals who are homeless to access services. 

Philip was provided transportation to the treatment 

services and agreed to enter detox. 

He is the youngest of four children (two brothers 

and one sister). He describes his sibling relationships as close, particularly with his sister and her 

family. Before Philip was born, his father left the 

village and reportedly did not know that Philip was 

his child for several years. Philip also disclosed that 

he experienced physical and emotional abuse as a 

child and that his mother was alcohol dependent. 

His maternal grandparents assumed legal custody 

of him when he was around 11 years of age. Philip 

notes that he was raised Catholic. He stated that 

the church, as well as other Christian religions, 

historically did not accept his village’s cultural 

traditions, and he feels conficted in his traditional 

spiritual beliefs and about religion in general. 

Never look for a psychological 

explanation unless every effort 

to fnd a cultural one has been 

exhausted.” 

—Margaret Mead 

Source: Benedict & Mead, 1959. 

110 Chapter 2 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

HOMELESSNESS IN ALASKA 

Not unlike homeless populations in the lower 48, members of Alaska’s homeless population often have a 

history of mental or substance use disorders, physical or sexual victimization, or military service (or some 

combination of these). Some Alaska Natives leave their village with the hope of fnding lower living costs 

and employment and training opportunities in urban areas. Housing and living expenses in rural areas are 

rising faster than wages, forcing at-risk families to migrate to urban areas. If the individual or family spends 

all their money after migrating to the city or town, it is then diffcult to afford transportation to return home 

or to communicate with their relatives, who may be able to cover the costs of return to the community. 

The individual or family then fnd themselves unable to access affordable housing. They are often forced to 

make very diffcult decisions between housing and other basic needs. At the same time, affordable housing, 

emergency shelters, and transitional housing in urban areas are limited. For example, Fairbanks, AK, has 

one shelter, and it serves an area of 90,000 square miles (Department of Housing and Urban Development, 

2016). 

Models of Addressing Homelessness 

Some of the most effective models of addressing homelessness are services focused on one-stop outreach 

and Housing First principles. 

Housing First. Housing First goals are to end homelessness and promote client choice, recovery, and 

community integration. Housing First engages people whom traditional supportive housing providers have 

been unable to engage by offering immediate access to permanent independent apartments in buildings 

rented from private landlords. Clients have their own lease or sublease and only risk eviction from their 

apartments for nonpayment of rent, creating unacceptable disturbances to neighbors, or other violations 

of a standard lease. To prevent evictions, teams work closely with clients and landlords to address potential 

problems. Refusal to engage in treatment does not precipitate a loss of housing. Relapses to substance 

abuse or mental health crises are addressed by providing intensive treatment or facilitating admission 

to detoxifcation or the hospital to address the clinical crisis. Afterward, clients return to their apartments 

(Stein & Santos, 1998). 

Stand Down for Homeless Veterans. This program brings services to one location, enabling individuals 

to access services at one stop on a given day. Stand Down for veterans who are homeless was modeled 

after the Stand Down concept used during the Vietnam War to provide a safe retreat for units returning 

from combat operations. At secure base camp areas, troops were able to take care of personal hygiene, get 

clean uniforms, enjoy warm meals, receive medical and dental care, mail and receive letters, and enjoy the 

camaraderie of friends in a safe environment. Stand Down afforded battle-weary soldiers the opportunity 

to renew their spirit, health, and overall sense of well-being. Stand Down for veterans who are homeless 

focuses on similar objectives, and achieving those objectives requires a wide range of support services 

and time. The program is successful because it brings these services to one location, making them more 

accessible to veterans who are homeless. 

Project Homeless Connect. Similar to Stand Down, Project Homeless Connect is a 1-day, one-stop event to 

provide housing, services, and hospitality in a convenient one-stop model directly to people experiencing 

homelessness. It is a collaborative effort between service providers, government agencies, the private 

sector, and the community. It is a way to bring providers, agencies, and the community together so that the 

individual or family can obtain access to services in one setting. 

IS IT A CULTURAL BELIEF OR IS IT A DIAGNOSIS? 

Some American Indian and Alaska Native cultures believe they are experiencing—or will experience—bad 

things as a means of making right or paying for a wrongdoing, such as breaking a cultural taboo. This 

wrongdoing may be something that a person has done or something that occurred within his or her family 

from a previous generation. Admitting this can sound paranoid or delusional if the provider is not familiar 

with the individual’s traditional spiritual or cultural beliefs. 

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TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

These are the stories I heard at 

home and in my village when I was 

a child. There was an elder woman 

in our village who said something 

negative about never wanting to 

have children with disabilities. All 

of her children were already born 

and raised. But her granddaughter 

was born deaf. It came back to 

her. There was a skinny boy who 

always teased people who were 

overweight. He became obese as 

an adult. The thought process 

is that what you put out there is 

going to come back.” 

—TIP Consensus Panel Member 

Philip began experimenting with drugs and alcohol 

at age 9. He drank and used whatever his mother 

had around the house. He is unsure of the amounts 

he used but reports that it was “a lot.” After Philip 

began living with his grandparents, he no longer 

drank or used alcohol or drugs until after graduation from high school, when he began to drink and 

smoke marijuana. He reports that he did not use 

regularly until he left his village, because his use 

depended on availability. Since moving to town, 

his use of alcohol has steadily increased. He usually 

drinks every day, getting drunk about three or four 

times a week, but his use continues to depend 

on whether he can share someone else’s stash or 

buy alcohol. Philip reports that his marijuana use is 

irregular and that he smokes “only when someone 

has it.” He says that he does not go searching for 

the drug, nor does he use other drugs at this time. 

He describes himself as a “quiet, nervous, and 

sad” drinker. In the past decade, he states that he 

has lost a few friends and relatives to suicide and 

snow machine accidents in his village. He describes 

his nervousness and low mood as something that 

never leaves him. 

Philip is divorced and has not had contact with 

his ex-wife and son for about 7 years. His ex-wife 

moved to another Alaska village and then out 

of state about 5 years ago to live with her sister. 

Philip’s relationships with women have all been 

short-term; he reports that all of the women he 

has dated have had trouble with drinking, with the 

exception of his ex-wife. The marriage lasted for 

almost a year and ended soon after the birth of 

their son. Philip feels bad that he is not raising his 

son. 

In his village, when he is not drinking, he assists 

elders by cutting wood and hunting for them, and 

he has been involved in carving projects for the 

community. He is a traditional wood carver and as a 

young adolescent became interested in traditional 

Northwest artwork, called formline. He also does 

small engine repairs to snow machines and boats. 

Philip has never been in treatment. He fears that 

it would feel like being in jail and is worried that 

everyone would be prejudiced toward him, as he 

has heard several people in town refer to “the 

drunk natives downtown.” He wants his freedom, 

yet he recognizes that he needs help. He reports 

that he feels that no one will understand his 

cultural ways and how they affect his life. As an 

example, Philip explains that he believes he has 

“wronged” someone in the past and that is why 

his life is “like this.” Although he cannot identify 

the person he has “wronged,” he is sure that he 

has been disrespectful or is “paying for it now” for 

some wrongdoing in his family. 

Philip graduated from high school but, because of 

his drinking, he struggled to keep employment in 

the village. He was accepted into the Navy but was 

released after a urinalysis came back positive for 

marijuana. He is a skilled self-taught carpenter and 

has had jobs as a laborer in the past. He is a carver, 

like his maternal grandfather, but reports that his 

drinking and recent move to the city prevent him 

from doing this work. He has two misdemeanor 

convictions: one for DUI and another for public 

intoxication. Philip relocated to the city after the 

loss of a close friend in his village and his inability 

to fnd work near his village. His poor work history 

and his criminal record make his job search diffcult. 

Since moving to the city, he has been unable 

to fnd a job. Although he had been living with 

friends, he has been camping with other individuals 

who are homeless in a park outside of town for 

112 Chapter 2 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

the past 2 months. Philip reports that he does not 

like living in the camp. Although he knows how to 

survive and camp and has done so most of his life, 

he is fearful of being beaten up, freezing to death, 

and being arrested. He worries that his drinking 

will lead to these consequences, as it has for other 

people living this way. He reports that he no longer 

wants to live close to a city. He just wants to stop 

drinking so he can return to his village, but he does 

not have the money to return home, and he is not 

sure that he would be welcomed. He has had no 

contact with family for months. 

Objectives for Vignette 4 

The objectives are: 

1. To highlight that outreach and case management can be powerful tools in breaking down 

barriers to housing and treatment. 

2. To reinforce the importance of Housing First 

principles. 

3. To demonstrate how to help Philip connect his 

alcohol use and history of losses. 

4. To show the use of experiential exercises to 

welcome clients back to their community. 

5. To reinforce the use of traditional practices and 

the community as a path toward recovery. 

Client–Provider Dialog 

This vignette provides excerpts from three sessions: 

one session in the detoxifcation unit, an individual 

session in residential treatment, and a group 

session. The frst session begins at a detoxifcation 

center that serves Alaska Natives. Philip agreed to 

come to the detoxifcation center after he attended 

a one-stop event for homelessness in the nearby 

city. He stated that he would not have known 

about it, except that several people came to their 

camp to talk about it. The program’s philosophy 

is Housing First, so Philip will be provided housing 

options if he chooses to leave after detoxifcation. 

Once Philip agreed to go to the Alaska Native 

program, arrangements were made to store his 

belongings and limited camping gear. This was a 

pivotal factor for Philip in deciding to go to the 

program. He is not sure if he wants to stay and 

honestly reports that his main motivation is to get 

out of the cold, maybe fnd housing, and sober 

up. Yet, he does admit that he is interested in 

returning to his village. At the same time, he has 

mixed feelings in returning home; he does not 

want to “show up in his current state,” and he is 

almost certain that he would not fnd work. Philip 

is anxious in the frst session during detoxifcation 

and not sure he can stay in the “four walls.” The 

intake worker had already established language 

preferences; Philip prefers English. He already 

requested that he be called Philip, rather than 

using his last name to address him. 

Detoxifcation counseling session 

PROVIDER: Good morning, Philip. My name 

is Anthony. I am Alaska Native and have been 

working at this treatment facility for the last year. 

My family and I come from a remote village located 

in the Arctic Slope region; most of my family still 

lives there. I want to thank you for seeing me today. 

An outreach worker brought you in two nights ago, 

and I’d like to spend some time talking about your 

situation. Is that okay with you? [Philip nods.] 

MASTER PROVIDER NOTE 

In counseling strategies that focus on building 

relationships, including MI, it is good practice 

to ask permission when introducing a set of 

questions or before providing suggestions. 

PROVIDER: What would be important for me to 

know about you or your situation right now? 

PHILIP: I’m in pretty bad shape right now. I needed 

“three hots and a cot” and didn’t want to go to a 

city program. They don’t say good things about us. 

I’ve been camping, and we had to move several 

times because police would come to check on us 

or try to get us into a program. I was getting tired 

and wanted to get out of the cold. [Some silence.] 

Not sure this was a good move. 

Chapter 2 113 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

PROVIDER: You’re not sure about your decision to 

come here, even though you want to get out of the 

cold and sober up. [Philip nods yes.] 

PHILIP: I thought coming to a city would bring 

in some money. It didn’t happen that way. After 

staying with some friends, I felt as if I was a burden 

and needed to get out. I’ve been drinking more 

now than I ever did. 

PROVIDER: So, it’s more than three hots and a cot; 

the alcohol was getting to you. 

PHILIP: Not sure what happened. I’ve had bad 

times before, but if the booze is around—I drink it. 

I guess I always did. 

PROVIDER: Was there ever a time when you didn’t 

drink it, even if it was around? 

PHILIP: When I lived with my grandparents and my 

sister’s family. I respected them, and they are the 

few people I know who don’t drink in my village. 

My grandparents always say, it is White man’s 

poison. I’m beginning to believe it. Sometimes I 

feel possessed. It controls me. [Philip begins to 

look very uneasy or anxious. He starts looking at 

the door.] 

PROVIDER: Can I ask you what just happened? Are 

you feeling okay? [From the provider’s perspective, 

Philip has started looking pale and uncomfortable.] 

PHILIP: I got to get out of here. 

PROVIDER: Do you mean that you need to leave 

this room or leave the detoxifcation center? [No 

response.] Philip, do you want to stand outside? 

[He replies, “Yes.” They both go outside and stand 

together. Some time passes before there is an 

exchange.] How’s this? 

PHILIP: Feels better. [Pause.] Sometimes I just 

have to get up and walk. [Philip and the provider 

talk briefy about how this can be done while he is 

fnishing up detoxifcation.] 

PROVIDER: [Still outside.] Philip, can I ask you 

another question? [He nods.] How has alcohol 

possessed you? 

PHILIP: I’ve drunk when I didn’t want to drink 

or I promised myself that I wouldn’t drink. I’ve 

done things that I would never do if I didn’t drink. 

Sometimes, I think I left my grandparents and 

family because of it. I couldn’t be around them 

and drink. The drink pulls me to another world. 

[Philip gestures that it’s good to go back inside.] It’s 

getting cold. 

PROVIDER: [They begin walking back to the 

offce.] Philip, I can see that alcohol has caused you 

many losses, and from what you say, it’s robbed 

you of your family and support. 

PHILIP: [Some time passes before Philip responds.] 

It’s taken my nephew, cousin, and another friend in 

my village. It also has me by the throat. That’s the 

image I have. 

PROVIDER: [Anthony nods.] It’s cutting off your 

breath. [Philip nods, and then more silence]. 

PHILIP: I want to fnd my way back. 

PROVIDER: Back to? 

PHILIP: To my life, my way of life, to my family. 

[Pause.] I’m missing seasonal camp now. 

PROVIDER: How do you see doing this? 

PHILIP: Got to face the evil spirits. And got to give 

back the White man’s poison. 

PROVIDER: Any thoughts on how to do this? 

[Philip shakes his head no.] Do you want to know 

how we might do that here? [Philip nods. Anthony 

then uses the remainder of the session to talk 

about the Alaska Native services after detoxifcation and then potential housing opportunities after 

treatment, if Philip does not return to his village.] 

PHILIP: [Humorously.] I guess I am here for more 

than three hots and a cot. I heard the food wasn’t 

that good anyway. [Philip agrees to the next steps 

but worries that he will feel trapped. To conclude, 

they develop a plan for how Philip can alert others 

when he is feeling trapped. At the end of detoxifcation, he moves to inpatient and keeps Anthony 

as his provider.] 

114 Chapter 2 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

Individual treatment counseling session 

This session takes place during Philip’s second 

week of treatment. He spent 5 days in detoxifcation prior to his transfer to the residential unit. 

The residential program is a 45-day average stay, 

followed by step-down services, including housing, 

continuing care services, and continued case management. The Alaska Native treatment program 

supports Housing First principles, whereby the 

case manager helps facilitate appropriate housing 

options if clients do not complete treatment. Every 

effort is made to support clients and to encourage 

treatment. Overall, the native program focuses on 

connection with others and with heritage; one main 

ingredient that supports the program principles 

is the staffng patterns. If clients in detoxifcation 

agree to residential treatment, the providers 

assigned during detoxifcation follow the same 

clients throughout residential treatment. 

In this session, the dialog returns to the losses 

that Philip has encountered in his life. Some of his 

losses are related to his alcohol use, whereas other 

signifcant losses have happened when relatives 

have been under the infuence. These losses have 

occurred against the backdrop of historical traumas 

experienced across generations among Alaska 

Natives. A few years ago, Philip’s nephew died by 

suicide while drinking, and one of Philip’s close 

friends also took his own life. Philip left his village 

shortly after his friend’s death. The dialog begins 

halfway through the session and focuses on Philip’s 

concerns after treatment. 

TO LIVE TO SEE THE GREAT DAY 

THAT DAWNS: PREVENTING 

SUICIDE BY AMERICAN INDIAN 

AND ALASKA NATIVE YOUTH 

AND YOUNG ADULTS 

This manual lays the groundwork for communitybased suicide prevention and mental health 

promotion plans for American Indian and Alaska 

Native youth and young adults; it also addresses 

risks, protective factors, and awareness and 

describes prevention models for action. 

Source: HHS, 2010. 

[Anthony, the provider, and Philip greet each 

other. Anthony offers Philip some coffee at the 

start of the session. They have had three individual 

sessions, and Anthony also conducts one daily 

group session that Philip attends. The group 

sessions are centered on the principle that culture 

is prevention and the path to healing. The group 

sessions use relapse prevention strategies and 

incorporate cultural beliefs, traditions, elder participation, and creative works. The following dialog 

begins midsession.] 

PROVIDER: Philip, I noticed that you appear to 

be focused more on the losses in your family and 

village this week. I hear more energy spent on 

this than talking about your alcohol use or other 

concerns. I know from our prior talks that you, as 

well as your village, have experienced signifcant 

losses. Would you be willing to tell me more about 

these losses? 

PHILIP: [Philip waits a bit to respond, looking away 

from Anthony, and then nods.] Everyone knows 

everyone in our village. Alcohol has taken my 

nephew Rob, my friend Lee, and another cousin. 

Both my nephew and Lee were drinking when 

they killed themselves. Every time I walked down 

the road, I saw Lee. We did everything together, 

setting up camp, hunting, fshing, and smoking 

fsh. [Philip starts telling a funny story about Lee 

when they were fshing for humpies (pink salmon). 

Anthony just listens as Philip tells the story.] 

PROVIDER: You’ve known Lee all your life. 

PHILIP: [Philip nods.] I left not so long after his 

death. [In a prior session, Philip had already 

disclosed that the community had a ceremony to 

honor Lee.] 

PROVIDER: Do you think this was one of the 

reasons you left? 

PHILIP: When he died, I didn’t want to do 

the things I would normally do. I felt as if I did 

something wrong or maybe I didn’t do what I was 

supposed to do. When I could get it, I would drink 

alone and didn’t want to show my grandparents or 

my sister that I was drinking. I respect my grandparents and left thinking that I could get a job 

somewhere else and get away from things. Lee’s 

death really affected everyone in the village. 

Chapter 2 115 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

PROVIDER: It sounds as if Lee’s death pushed you 

further toward alcohol, and alcohol pushed you 

further away from your family and community. 

PHILIP: I feel as if I’m carrying Lee. I have this 

image and this feeling. Years ago, while hunting, 

he broke his ankle. I had to help him get back to 

camp and then get help. I remember carrying him 

partway, and I have that same feeling at times. 

Sometimes I drink when I feel it. 

PROVIDER: What does it mean to you? [Philip 

looked confused about the question.] When you 

have this feeling of carrying Lee, what is it saying to 

you? 

PHILIP: Not sure. [Silence.] We have always looked 

out for each other. And I know he’s looking out for 

me. I just can’t fnd a place for his death. 

PROVIDER: Knowing what you know, what might it 

be like to return to your village? 

PHILIP: I think it might be hard for me not to 

drink, and I would be reminded again and again. 

Sometimes I think I need to fnd a place where I 

can let Lee be with all. [Using his wit and humor, 

Philip replies.] I guess I’ve been carrying him and 

keeping him all to myself. 

PROVIDER: You may want to give some thought as 

to how you might do that—to fnd a place where 

you can let him be with all. [Time passes in the 

session.] 

MASTER PROVIDER NOTE 

As a provider, it is important to match the 

language and the words used by the client in the 

session; for example, the phrase, “fnd a place 

where you can let him be with all.” Even if you 

are from the same clan, house, village, region, or 

tribe as your client, it is a mistake to assume that 

beliefs and the expression of those beliefs are 

the same. Considerable differences exist, often 

infuenced by life experiences, family upbringing, 

elders, as well as outsiders (e.g., historical 

infuence of missionaries on traditional beliefs 

and practices). 

PROVIDER: I know you haven’t had any recent 

contact with relatives from your village, and you 

wanted to get sober before making any contact. 

PHILIP: I miss my relatives, and my grandparents 

are getting older. I feel as if I shamed them for 

leaving, but I’ve had no way of getting back to 

them or even contacting them before coming here. 

I feel pulled to go home, but I have nothing to 

share. 

PROVIDER: When you say, nothing to share, what 

do you mean? 

PHILIP: I haven’t changed, well, until now. I didn’t 

fnd work or housing. I didn’t deal with Lee’s death. 

I feel pulled. 

PROVIDER: To go home? [Philip nods.] 

PHILIP: I need to be sober for my family and 

community. I know that I need to do something to 

share Lee’s life and my loss. I need to be someone 

in the community who shows a different path, away 

from alcohol and suicide. 

PROVIDER: So, your time here is a way back home. 

[Philip nods.] 

[The session ends on this last exchange. Anthony 

reminds Philip that there are others in the program, 

including peer support staff and elders, and that 

he might want to spend time sitting with these 

feelings and talking about Lee as well as the things 

he might do to replace alcohol and his cravings 

for alcohol. Philip had already begun to do this 

in the group and treatment community, but he 

now appears more interested in connecting with 

peer specialists and elders who are involved in the 

treatment program.] 

Group treatment counseling session: 

Welcome home 

This group session, facilitated by Philip’s provider 

(Anthony), takes place a few days after the individual session depicted above. Anthony is trained and 

accustomed to using experiential group exercises 

to help clients connect to their feelings and gain 

awareness. He also believes that these exercises 

are more akin to native teachings and learning 

styles that integrate mind, body, spirit, and the 

environment as one. Prior to using the experiential 

116 Chapter 2 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

exercises, he assessed Philip’s readiness and 

willingness to participate. In this segment, the 

dialog centers on an experiential exercise called 

“Welcome Home.” 

The Welcome Home exercise is rooted in Virginia 

Satir’s communication theory and experiential 

practices (Satir & Baldwin, 1983). It has been 

carried through the work of many clinicians and 

facilitators trained in experiential, sculpting, and 

psychodramatic techniques. The origins of this 

exercise stem from the Vietnam era, when service 

members returning to the United States were 

not welcomed home and were often insulted or 

shamed by the community (Greene, 1989). 

In more recent years, the Welcome Home exercise 

has been adapted through the work of Jane 

Middelton-Moz (1989, 2010) and others to help 

heal, honor, and welcome home American Indians 

and Alaska Natives who attended boarding 

schools. Many American Indians and Alaska Natives 

who returned from these institutions never had 

an opportunity to be welcomed home. Coupled 

with the history of trauma that occurred and the 

shame-based strategies often used and reinforced 

in the boarding schools, many returned home with 

no sense of belonging. This exercise provides an 

opportunity to change this on an emotional level. 

The following dialog presents another way of 

setting up the Welcome Home exercise for an 

individual. 

[Anthony already checked in with all group 

members. The session focused on discussing what 

it would mean to return home sober (e.g., home 

meaning community, family, village). Then, the 

Welcome Home exercise was introduced, and 

Philip was asked to help set up the exercise.] 

LEARNING FROM THE ELDERS 

As professionals, we are taught from a Eurocentric framework that involves many rules and regulations. 

When involving elders in the treatment process, remember not to be overly rigid in imposing structure 

on how they should participate. Although there may be specifc regulations that you must follow as a 

treatment provider, remember that imposing unnecessary rules and structure can be a further display of 

devaluing native culture. Remember that traditional practices were banned and forbidden in Alaska Native 

communities and among American Indians. When providing some direction to clients on how to consult 

elders in treatment and in the community, you should suggest that clients seek guidance rather than 

merely ask for advice. As stated by one consensus panel member, “Asking for an opinion is different than 

asking for guidance.” 

Inuit Elders’ Message on Suicide Prevention 

When you feel overwhelmed, sad, or have a problem that seems to have no solution: 

• Talk to someone you trust: Keeping problems inside will just make them seem worse. 

• Change your thoughts: Remind yourself that although life is sometimes diffcult, things will change, 

days are never the same; tell yourself that you can make changes; tell yourself that you can feel better. 

• Get outside into nature, be active: This will help take your mind off problems and make you feel better. 

• Focus on helping others: You will feel good about yourself and take your mind off your problems. 

• Don’t isolate yourself: Go out, be with others, be active. 

• Pray: You can always talk to God. 

• Stay busy: Learn new things; do things. 

• Learn how to handle arguments and problems with other people. 

• Believe in yourself: Don’t put yourself down; learn ways to develop strength and competence. 

• Remember that you are not alone: Others care about you; others have had similar problems and made 

it through. 

• Learn traditional skills: You will feel proud to be an Inuk. 

Source: Korhonen, 2006, pp. iv–v. 

Chapter 2 117 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

WELCOME HOME: BOARDING 

SCHOOL EXERCISE 

Jane Middleton-Moz’s healing workshops 

facilitate a powerful exercise wherein she has 

participants form two concentric circles—an inner 

and an outer circle. Those who attended boarding 

school are standing in the inner circle, and those 

who did not form the outer circle. The inner and 

outer circle members face each other. Those 

standing in the outer circle offer handshakes 

or hugs and verbally welcome the inner circle 

members home or back from boarding school. 

When the frst welcome is complete between 

each pair, the inner circle moves in the same 

direction (clockwise or counterclockwise) to 

the next person and repeats the process again 

and again until the circle rotates completely 

back to the starting place. This exercise can be 

exceptionally powerful and emotional, providing 

a great healing experience. 

As a facilitator, several points are important to 

remember. It doesn’t matter if there are not the 

same number of participants in each circle. If you 

have an uneven number between circles, you 

just give more time for people to receive or give 

“Welcome Home” greetings. Also, you want to 

make sure you leave plenty of time for everyone 

to talk about their experience, whether they’re 

standing in the inner circle or the outer circle. 

Sometimes, individuals who are standing in 

the outer circle may begin to recognize similar 

feelings—not belonging to or feeling like a part of 

a community or group. In this scenario, you can 

have them switch circles. 

You can use alternatives to this exercise when you 

are facilitating a Welcome Home for only one or 

two people in a group. One alternative is to have 

everyone join a large circle, and then you, as the 

provider, walk with the identifed person around 

the large circle to receive “welcome home” 

gestures. In this exercise, you have the person 

move from one person to the next after being 

greeted and welcomed home. 

PROVIDER: Philip, would you be willing to use 

your experiences and the memories of your village, 

family, and relatives to do this next exercise about 

returning home? You don’t have to know what to 

do, I will guide you. [Philip agrees. Then Anthony 

MASTER PROVIDER NOTE 

In conducting experiential group exercises, it is 

important to facilitate them near the beginning 

of the session so that every group member has 

an opportunity to talk about the meaning of the 

exercise afterward. 

asks Philip to stand. He then asks if the remaining 

eight members could stand in front of the room. 

Participation is optional.] 

PROVIDER: Philip, I want you to imagine going 

home to your village. Can you picture it? [Philip 

nods.] What do you picture? 

PHILIP: I’m getting out of the plane and walking 

into town. I don’t feel right in my own skin. 

PROVIDER: What else do you notice? 

PHILIP: I feel nervous. I am wondering who I’m 

going to see frst. 

PROVIDER: Okay. Now, Philip, I want you to 

imagine that you are walking down the road. [Philip 

nods.] Now, picture people in your village standing 

outside greeting you as you were walking into 

town. Can you picture them? [Philip says, “Yes.”] 

Who do you initially notice? 

PHILIP: My grandparents, my sister, her husband, 

my niece. [He becomes tearful.] 

PROVIDER: [Anthony prompts Philip.] Anyone 

else? 

PHILIP: Warren [cousin], Ben [friend], and Enoch 

[elder]. 

PROVIDER: What is it like to picture your relatives 

welcoming you to the village? 

PHILIP: I don’t know. [Pause.] It feels as if I don’t 

deserve it. 

PROVIDER: Philip, can you help me out just a little 

longer? I know that it’s bringing up some feelings. 

[Philip nods.] 

PROVIDER: [Anthony nods in return.] Philip, let’s 

just assign everyone in the group to stand in as one 

118 Chapter 2 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

of your relatives. It doesn’t matter who represents 

whom. [Everyone quickly, along with Philip’s input, 

chooses or is asked to play a role]. Think for a 

moment about how each person would greet you. 

Remember it is the way that you would like to be 

greeted and welcomed home. 

MASTER PROVIDER NOTE 

Remember, you should always be walking 

alongside your client in experiential exercises to 

safely facilitate, to remain engaged in his or her 

experience, and to respond quickly, if needed. 

Similarly, it is important to gently remind the 

group not to have private conservations during 

these exercises. Experiential exercises can 

be powerful, and side conversations can be 

disruptive or easily be interpreted as judgmental 

commentary when a participant feels vulnerable. 

When you assign roles and scripted messages, 

it is important that the group atmosphere is 

nonshaming when a role player forgets his or 

her role or phrases. You can always tell the group 

that there is shame-free forgetting and that 

if you forget your role or line, someone in the 

group will be able to recall. 

Also, it is typically ineffective to have clients ad 

lib in their roles, especially during an exercise 

that is initially focused on an individual. Often, 

their dialog would refect their own life circumstances rather than that of the group member 

who is the center of the experiential exercise. 

All too often, this group member will feel less 

connected to the exercise as a result and report 

that this is not his or her experience. 

It is better to assign one or two phrases for each 

role generated by the central client. Even with 

this limited verbal exchange, the exercise can be 

surprisingly powerful and healing. As a provider, 

your foremost role is to create and maintain 

safety; therefore, assigned phrases are a better 

choice in general in this rendition of Welcome 

Home. Of course, there will be moments where 

impromptu exchanges happen—and healing 

occurs. As a provider, you need to be mindful not 

to shut down those spirit-flled moments, when 

appropriate. 

PHILIP: [He begins with his grandfather.] My 

grandfather would just greet me this way. [Philip 

demonstrates.] He wouldn’t say anything. My 

grandmother would hug me, and say... [After Philip 

assigns an expression or greeting for everyone, 

each member is asked to remember the greeting. 

Then Philip is asked to imagine once again that he 

is walking into town; he stands across the room 

and walks slowly toward the group as if walking 

into town. As he comes close to the group, group 

members share their greetings with Philip once he 

stands in front of them.] 

PROVIDER: Philip, I just want you to take it in as 

you are standing and listening to the welcome. I 

am standing here with you to also welcome you 

home. 

PHILIP: [He doesn’t say much at this time, but he 

is very focused on the greetings. He listens as each 

member welcomes him home.] I don’t have words 

for what I’m feeling. 

PROVIDER: Maybe it’s about just taking it in. 

[Anthony maintains the silence for a bit.] Philip, can 

you take a mental picture of this scene that you 

created, and hold onto it? [Philip nods. During the 

exercise, another group member (Karen) was visibly 

affected by the exercise. Anthony asked if she 

would like to experience the Welcome Home.] 

PROVIDER: Philip, would you be willing to further 

assist the group, reverse roles, and take Karen’s 

place in being someone from the community that 

welcomes her home? [He agrees.] Philip, this is an 

opportunity for you to experience this from both 

sides. And, as you welcome Karen home, I want 

you to think how you might feel welcoming her 

home regardless of her past, her alcohol use, her 

unemployment, and her history of being homeless. 

[Then Karen and Philip switch roles. The exercise 

is repeated, with members of the community 

welcoming her home. Anthony then asks what the 

experience was like for Karen. She talks about the 

Chapter 2 119 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

healing she experienced in the exercise; for many 

years, she hasn’t felt as if she belongs. Some other 

group members begin to share similar stories, and 

still others talk about how meaningful it was for 

them to be in the role as a greeter. Afterward, the 

focus of the group exercise returns to Philip.] 

MASTER PROVIDER NOTE 

Role reversal can be a powerful counseling tool. 

Typically, it can help manage the intensity of the 

experience by removing the group’s focus from 

the client. It allows the client to see a different 

perspective and can lead to more compassion 

and awareness of others and of himself or 

herself. By providing an opportunity for other 

group members to experience the exercise or 

to process the experience afterwards, it turns 

an individually focused exercise in a group to a 

group experience. 

PROVIDER: Philip, I would like to take this opportunity to thank you for leading this group exercise. 

Is there anything else that you would like to share? 

PHILIP: When I took the other role, I realized that I 

haven’t been hearing the caring messages from my 

family. Before I left, I cut those voices off. I walked 

away carrying Lee and the losses that his death 

caused. The drink helped to drown the losses too. 

I think I need to fnd a way to return home. And I 

need to carry Lee home and fnd a place for him 

surrounded by his relatives. 

[The session ends. About a week later, Philip had 

the idea of doing a carving to honor Lee once he 

returns to the village after treatment. It becomes 

clear that Philip has made a decision to return to 

his village. The treatment program helped support 

Philip in contacting his sister, who had wanted him 

to stay and live with her family before he left. Philip 

made contact with his sister prior to his decision 

to go to an Alaska Native transitional housing unit 

before returning home.] 

USE OF SOCIAL MEDIA TO 

CONNECT ALASKA NATIVES 

WHO ARE HOMELESS WITH 

THEIR FAMILIES 

The Facebook group Forget Me Not has taken off 

since its inception and currently has thousands 

of members. An Ahtna Athabascan positive rap 

singer and motivational speaker “came up with 

the idea after speaking with a homeless Native 

woman who approached him asking for spare 

change. The woman told him she was from —— 

‘She got real teary-eyed and said she wanted to 

go home. Before I left I told her I would do what I 

can.’ 

“But after he returned home, [he] couldn’t 

remember her name or anything other than 

the town she was from. He knew there must 

be a better way to help Native homeless people 

connect with the families who have lost track of 

them. After about a week he came up with the 

idea of using Facebook. He started a group that he 

named after the Alaska state fower, the forget me 

not.... 

“Members can post pictures of homeless people 

they encounter on the street and list their names 

and village of origin along with any message 

they might want to send to their loved ones. 

Connections are made and the word spreads. 

Of course, some homeless people don’t wish 

to participate, which is fne. ‘I’m not trying to 

sell them anything....’ Family members seeking 

homeless relatives can also post pictures and 

request the group’s help. That’s how Jerry —— 

found her brother Johnny. 

“Using Facebook to connect the homeless ... with 

their families in far-off villages opens a channel 

more profound than most people realize. Native 

identity is often reestablished as friends and 

relatives reach out across cyberspace. The surface 

appearances of homelessness and alcoholism, 

which is all many see, lose their illusion of 

permanence when a channel of communication 

with the past is opened. Homeless Natives 

remember who they really are and begin the 

path back to wholeness.” 

Source: Hopper, 2015, paragraphs 5–9. 

120 Chapter 2 
Part 1—Guide for Providers Serving American Indians and Alaska Natives TIP 61

Continuing care planning 

Throughout Philip’s treatment, staff worked hard 

to anticipate and develop plans for his continuing 

care, particularly housing, if he decided not to 

return to his village. Near the completion of his 

residential treatment, Philip wanted more time 

before returning home. His case manager arranged 

his transfer to a transitional housing facility with 

the Tribal Housing Authority. The facility provides 

continuing care for substance abuse treatment, 

employment counseling, and an onsite computer 

training center. Philip’s hope is to return to his 

carving and to gain suffcient skills to work within 

his region’s corporation, even though employment 

is limited. 

Philip was determined to spend 6 months in transitional housing and return to his village for summer 

camp. He agreed with the house rules, including 

vocational training or employment after 28 days 

of entering the program and maintaining sobriety. 

Case management was involved in his transitions 

to provide additional support and interventions if 

a return to use occurred or housing issues resurfaced. After 6 months, Philip returned to his village. 

He has a part-time job, spends time carving with 

his grandfather, lives with his sister’s family, and 

uses some telehealth services and phone contact 

through the community health center for continuing care services. In honor of his friend Lee, who 

died from alcohol use and suicide, Philip began to 

volunteer at the school and provide traditional art 

lessons, including formline art and carving. 

Summary 

In treatment, Philip began to draw the connection 

between his experiences of loss, alcohol consumption, and the role that both played in separating 

him from his relatives, village, traditions, and 

history. Without initial outreach, Philip may not 

have had access to housing, treatment, or any 

further choices in whether he could return to his 

village. The one-stop model to assess his needs 

and to aid in accessing culturally appropriate 

services broke the downward spiral brought on by 

lack of employment and housing, his disconnection 

from his community, and his alcohol use. Outreach 

services addressed barriers that obstructed Philip’s 

interest in treatment and laid the groundwork 

through case management to help him gain access 

to Alaska Native treatment services, transitional 

housing, job training, and reunifcation with his 

village. Philip returned to his village knowing that 

he could make a contribution. Through teaching 

his traditional skills and art, he would help younger 

people connect with their history, traditions, 

and community. He helped young people gain 

awareness of their own gifts and contributions. 

Through his own challenges, he learned that 

tradition was a powerful pathway to healing. 

May the story give you strength. 

May the belief relieve your pain.” 

—Mohawk Onondaga healer 

Source: Peate, 2003. 

Chapter 2 121 
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TIP 61 BEHAVIORAL HEALTH SERVICES FOR 

AMERICAN INDIANS AND ALASKA NATIVES

Part 2: Implementation Guide for Behavioral Health Program 

Administrators Serving American Indians and Alaska Natives 

For Behavioral Health Service Providers, Program Administrators, and 

Clinical Supervisors 

Part 2 of this Treatment Improvement Protocol addresses how to improve treatment outcomes for 

American Indian and Alaska Native clients by increasing provider competencies; providing holistic, 

trauma-informed services; and adopting culturally responsive program policies and procedures. 

TIP Navigation 

Executive Summary 

For behavioral health service providers, program administrators, clinical supervisors, and researchers 

Part 1: Practical Guide to the Provision of Behavioral Health Services for American Indians and 

Alaska Natives 

For behavioral health service providers 

Part 2: Implementation Guide for Behavioral Health Program Administrators Serving American 

Indians and Alaska Natives 

For behavioral health service providers, program administrators, and clinical supervisors 

Appendix and Index 

Part 3: Literature Review 

For behavioral health service providers, program administrators, clinical supervisors, and researchers 
TIP 61

PART 2: IMPLEMENTATION GUIDE FOR BEHAVIORAL HEALTH PROGRAM 

ADMINISTRATORS SERVING AMERICAN INDIANS AND ALASKA NATIVES 

Behavioral Health Services for American Indians and Alaska Natives 

Contents 

Part 2, Chapter 1..........................................................125 

Introduction ...............................................................125 

Becoming a Culturally Responsive Organization ..................................125 

Workforce Professional Development ..........................................139 

Part 2, Chapter 2..........................................................155 

Introduction ...............................................................155 

Developing a Culturally Competent and Responsive Workforce .....................155 

Developing Native EBPs......................................................178 

Integrating Care: Traditional Practices in Behavioral Health Programs ................181 

Creating Sustainability.......................................................186 

Exhibits 

Exhibit 2.1-1. Evidence-Based Tribal Practices.....................................133 

Exhibit 2.1-2. Navigating Life Curriculum Sessions.................................134 

APPENDIX—BIBLIOGRAPHY ..............................................201 

INDEX ...................................................................213 

124 
Part 2, Chapter 1 

TIP 61 BEHAVIORAL HEALTH SERVICES FOR 

AMERICAN INDIANS AND ALASKA NATIVES

Introduction 

An Overview of Part 2 

In Part 1, this Treatment Improvement Protocol 

(TIP) focused on the knowledge, skills, and application of cultural competence in counseling. 

In Part 2, attention turns to implementing this 

knowledge on an administrative level. This chapter 

refects the voices of consensus panel members 

and others who have contributed ideas to the 

development of this TIP. This section highlights the 

knowledge, challenges, and strategies important 

to program development, implementation, and 

sustainability. It is designed for administrative 

staff, including program directors, managers, and 

clinical supervisors providing services in villages, 

in rural and urban areas, and on reservations. It is 

written for those who have less cultural knowledge 

or experience in providing services and for others 

looking for ideas on how to meet the day-to-day 

challenges in program management, including 

workforce development. Whether you are a native 

or non-native provider, the information serves as 

a guide on how to remain culturally responsive to 

your clients and community. 

Chapter 1 frst addresses key ingredients in developing a culturally responsive organization. The next 

section highlights organizational challenges and 

paths to solutions. Then, the chapter addresses 

workforce and professional development with 

emphasis on activities that support investment in 

staff and future leadership. The chapter ends with 

a review of culturally responsive behavioral health 

competencies to serve as a guide for staff development and program aspirations. Chapter 2 contains 

samples of additional resources and materials that 

support day-to-day administrative and programmatic activities. Part 1 is equally important for 

administrators, program managers, and clinical 

supervisors to read, as it sets the course for Part 2. 

It’s not how you integrate culture 

into services but how you integrate 

services into the culture.” 

—Deborah Painte 

Source: National Indian Child Welfare Association, 

2015, p. 3. 

Becoming a Culturally Responsive 

Organization 

Cultural competence refers to the ability to 

effectively provide services to clients with diverse 

values, beliefs, and behaviors. Within an organization, it involves the ability to tailor services 

and service delivery in a culturally relevant and 

meaningful way. For a guide to creating a culturally 

responsive organization, refer to TIP 59, Improving 

Cultural Competence, Chapter 4 (Substance 

Abuse and Mental Health Services Administration 

[SAMHSA], 2014a). 

As noted in Part 1, Chapter 1, of this TIP, serious 

health disparities exist among American Indians 

and Alaska Natives, leading to poorer health 

outcomes when compared with the general population nationally. Many factors contribute to native 

health disparities, including an inadequate healthcare delivery system, insuffcient funding, absence 

of culturally appropriate education, language 

barriers, inaccessible and unavailable services, poor 

infrastructure, and the lack of culturally responsive 

services and trauma-informed care. 

Approximately 6.8 million people in the United 

States identifed as American Indian or Alaska 

Native in 2017 (Census Bureau, Population 

Division, 2018). Tribes and villages have a unique 

government-to-government relationship with the 

United States that has been shaped by colonialism, 

nation-to-nation treaties, federal laws, executive 

125 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

orders, and Supreme Court decisions. Although 

you might think of American Indians or Alaska 

Natives as a single racial or ethnic group, there are 

573 federally recognized tribes. Each individual 

nation has its own history and culture with wide 

variations in language, membership, and resources. 

This is signifcant for you as an administrator, 

particularly if your program serves a community 

where clients come from different tribes—such as 

programs that provide services in urban communities. By developing your organization’s capacity for 

culturally responsive care, you will more likely meet 

the needs of a diverse American Indian and Alaska 

Native population. Part 3, the online literature 

review of this TIP, contains more information about 

variations in behavioral health needs within native 

populations. “Why It Matters: The Organizational 

Benefts of Culturally Responsive Care” (see above) 

outlines the benefts of an organization’s cultural 

responsiveness. 

WHY IT MATTERS: THE ORGANIZATIONAL BENEFITS OF CULTURALLY 

RESPONSIVE CARE 

A 2013 report by the Health Research & Educational Trust outlines numerous benefts to organizations that 

take a culturally responsive approach to care. 

Social Benefts 

• Increases mutual respect and understanding between patient and organization 

• Increases trust 

• Promotes inclusion of all community members 

• Increases community participation and involvement in health issues 

• Assists patients and families in their care 

• Promotes patient and family responsibilities for health 

Health Benefts 

• Improves patient data collection 

• Increases preventive care by patients 

• Reduces care disparities in the patient population 

• Increases cost savings by reducing medical errors, number of treatments, and legal costs 

• Reduces the number of missed medical visits 

Business Benefts 

• Incorporates different perspectives, ideas, and strategies into the decision-making process 

• Decreases barriers that slow progress 

• Moves toward meeting legal and regulatory guidelines 

• Improves effciency of care services 

See the full report, Becoming a Culturally Competent Health Care Organization (Health Research & 

Educational Trust, 2013), for more information. 

Qualities of a Culturally Responsive 

Organization 

This section briefy describes some distinguishing 

characteristics of a culturally responsive organization serving American Indian and Alaska Native 

clients and communities, along with suggestions 

for specifc actions to take to make them a reality. 

Please note that this list, although comprehensive, 

is not defnitive. You may fnd that your organization needs to respond differently to meet the 

needs of your community. 

Involve the community and take an active 

role 

Communities can play an important role in 

improving the provision of behavioral health 

services and treatment. Creating culturally responsive services requires the participation of the native 

community, including leaders, council members, 

126 Chapter 1 
Part 2—Guide for Administrators Serving American Indians and Alaska Natives TIP 61

community members, potential clients, and their 

families. Engaging and establishing a positive 

relationship with local leadership and the native 

community can work to alleviate initial feelings of 

mistrust and can serve as a resource to strengthen your program’s effectiveness. For example, 

community leaders who support your program may 

be able to conduct more effective outreach than 

the program can by itself. Similarly, community 

involvement can lead to a sense of ownership and 

pride in the services. 

By involving the community, providers can identify 

potential obstacles early on and develop ways 

to overcome these challenges with the help and 

advice of tribal community partners. Community 

members can also provide invaluable assistance in 

other areas, such as providing information about 

the most pressing behavioral health problems 

within the community, coordinating the services of 

traditional healers for your services, and recommending individuals who can provide staff education and 

training on local native culture(s) and history. 

Likewise, make it a point to engage with the 

community outside of the program. This will help 

the community become more familiar with the 

organization’s presence and may potentially 

increase awareness and use of program services. 

Pursue a collaborative relationship with 

tribal leadership 

The support of tribal leadership is critical to establishing a positive, trust-based relationship with 

the American Indian and Alaska Native community 

and to helping ensure the program’s success and 

sustainability over the long term. Reach out to 

a tribal leader (e.g., a council member or health 

board director), but remember to listen when you 

meet. As a service provider, you are working for 

him or her. Show an interest in and learn from the 

information people share with you. It may help if 

you or a senior staff member serves as community 

liaison to keep tribal leaders and representatives 

up-to-date about the program and to respond to 

any questions, comments, or concerns. 

ENGAGING WITH TRIBAL 

COMMUNITIES 

Etiquette Do’s 

• Listen and observe; be comfortable with 

silence. 

• Correctly pronounce names (use American 

Indian/Alaska Native names when appropriate). 

• Be transparent about your role and 

expectations. 

• Establish rapport. 

• Invite questions and knowledge seeking. 

• Accept offers. 

• Shake hands respectfully. 

Etiquette Don’ts 

• Don’t talk too loud or fast. 

• Don’t impose personal values or beliefs. 

• Don’t claim a vague tribal affliation. 

• Don’t point your fnger. 

• Don’t rush things. 

• Don’t touch sacred items. 

• Don’t take pictures without permission. 

• Don’t shake hands aggressively or assertively. 

Source: Kauffman & Associates (personal email and 

document attachments, March 1, 2016). 

Understand and respect tribal and 

community diferences 

American Indian and Alaska Native history, 

traditional practices, protocols, and ceremonies 

vary across tribes. For example, you will often 

fnd a blend of traditional spiritual practices and 

organized religion within a single tribal community. 

It is important to inquire and educate yourself 

about these differences rather than making assumptions. Ultimately, each American Indian and 

Alaska Native client experiences his or her culture 

in a unique way. It is up to the organization to work 

with the client to understand the client’s experience and to tailor services accordingly by asking 

about his or her tribe and cultural identity. 

Chapter 1 127 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Gain knowledge of tribal history and 

understand its impact and the impact of 

historical trauma in the community 

Clients and the community may express an initial 

lack of trust when you frst attempt to engage 

them. This behavior is often rooted in negative 

experiences with past providers and in the effects 

of historical trauma, recent traumas, and racism. 

The organization must openly acknowledge these 

experiences and their effects on the community. 

Most importantly, the program needs to incorporate trauma-informed care across all levels 

of service—ensuring that each staff member 

approaches interactions with clients from this 

perspective. 

TRAUMA-INFORMED CARE: A CRITICAL APPROACH IN PROVIDING 

CULTURALLY RESPONSIVE SERVICES FOR AMERICAN INDIANS AND 

ALASKA NATIVES 

“In our view, community healing along with individual and family healing are necessary to thoroughly 

address historical unresolved grief and its present manifestations. The process is not quick nor is it easy. 

However, without such a commitment to healing the past, we will not be able to address the resultant 

trauma and prevent the continuation of such atrocities in the present. Nor will we be able to provide the 

positive and healthy community activism needed to stop and prevent the social pathologies of suicide, 

homicide, domestic violence, child abuse, and alcoholism so prevalent in American Indian communities—as 

in society at large—today. 

“The crux of our argument has far-reaching implications for other colonized, oppressed peoples 

throughout history and those being oppressed, as we write, that are obvious to us. Wherever peoples are 

being decimated and destroyed, subsequent generations will suffer. We need only heed the traditional 

American Indian wisdom that, in decisions made today, we must consider the impact upon the next seven 

generations. The concept of historical unresolved grief has powerful implications not only for healing from 

our past but for giving us the strength and commitment to save ourselves and future generations.” 

Source: Brave Heart & DeBruyn, 1998, p. 75. 

What Is Trauma-Informed Care? 

“A program, organization, or system that is trauma informed realizes the widespread impact of trauma and 

understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, 

staff, and others involved with the system; and responds by fully integrating knowledge about trauma into 

policies, procedures, practices, and settings, and seeks to actively resist re-traumatization.” 

Source: SAMHSA, Trauma and Justice Strategic Initiative, 2012, p. 4. 

For a comprehensive guide to creating a trauma-informed behavioral health service, refer to TIP 57, 

Trauma-Informed Care in Behavioral Health Services (SAMHSA, 2014b). 

Engage in honest, open, and culturally 

appropriate communication 

Trust is established in part through honest communication. When communicating with clients or the 

native community, be clear in meaning and realistic 

in regard to expectations about your services. 

Follow through with your message and promises 

to clients and the community, as your behavior will 

serve as evidence of your trustworthiness and commitment as a provider. In addition, remember that 

culturally responsive communication operates in 

two directions, and although your program disseminates information to clients, be open to receiving 

information and feedback as well. Actively listen to 

this input, as it can help you revise your program’s 

services or approach to better meet community 

needs. 

In addition to honest communication, it is 

important to use culturally appropriate communication when engaging with American Indian and 

Alaska Native clients and community members. Use 

clients’ preferred language when either speaking in 

person or using written materials. This may require 

the use of an interpreter. In many communities, it 

is customary to let tribal elders speak frst without 

interruption. Thus, when engaging with elder tribal 

128 Chapter 1 
Part 2—Guide for Administrators Serving American Indians and Alaska Natives TIP 61

members—either in conversation or as clients—you 

should expect to be silent and actively listen as the 

elder speaks. When sharing information or a specifc 

message, try using stories or real-life examples 

rather than technical language where possible. 

Respect and value native knowledge and 

cultural worldviews 

A culturally responsive organization understands 

the inherent value of tribal knowledge and demonstrates respect for tribal values and worldviews. For 

example, a tribal welcome may involve an offer, 

such as shared food or a gift. It would be rude 

to refuse this welcoming gesture. You might also 

offer food—particularly traditional foods—during 

program activities or client intakes when appropriate. You may need to make a similar effort to 

integrate cultural and traditional practices into 

program services and interventions as appropriate 

for each client. For example, a treatment plan for 

a client who prefers the use of traditional healing 

methods may include the use of healing circles, 

sessions with a traditional healer, or (if the client is 

physically capable) sweat lodges or fasting. Policies 

and procedures need to refect the value of traditional practices, and leadership needs to afford 

clients and staff opportunities either on facility 

grounds or at an alternative place in the community 

to access these healing traditions. In addition, the 

organization needs to honor native knowledge in 

determining evidence-based and best practices. 

Commit and support the importance of 

cultural knowledge and culturally responsive 

services at all levels 

As an administrator, you need to demonstrate that 

leadership is committed to supporting and integrating culturally responsive services at all levels, 

from offce manager to board members. Set aside 

a portion of the organization’s operational budget 

or pursue grant and other funding opportunities 

to support costs and activities targeting cultural 

responsiveness, including staff training, interpreter 

services, and community outreach efforts. Include 

language that refects the organization’s commitment to cultural responsiveness in the mission 

and vision statements as well as in policies and 

procedures manuals. Consider creating an advisory 

board or internal workgroup dedicated to evaluating and promoting the organization’s efforts to 

effectively respond to the cultural needs of clients 

and the community (i.e., implementing an organizational self-assessment). 

At a staff level, make staff education and training 

in cultural competence a part of the orientation 

process for new hires and a regularly scheduled 

professional development activity for current 

program personnel. Institute recruitment and hiring 

policies aimed at diversifying the organization’s 

workforce and at promoting an American Indian 

and Alaska Native behavioral health workforce and 

leadership for the next generation. 

Recognize tribal community strengths 

One of the benefts of engaging with American 

Indian and Alaska Native communities as partners 

is that it offers an opportunity to identify and 

make use of tribal resources and strengths, 

such as family ties, larger community networks, 

physical resources, intergenerational knowledge 

and wisdom, and community resilience. It may 

also involve other tribal departments or partner 

agencies that can offer resources and support. This 

strengths-based approach builds on the strengths 

and resilience of the community to create solutions, 

rather than focusing solely on issues or areas in 

need of improvement. 

STRENGTHS OF TRIBAL SYSTEMS 

OF CARE 

• Grassroots foundation 

• Local leadership 

• Culture as core 

• Infuence of language 

• Vision for the future 

• Power of communication 

• Organizational infrastructure 

• Tribal college and state university partnerships 

• Integration of new treatments 

• Tribal wraparound services 

• Investment in advocacy 

• Tribal–borough–county–state relationship 

• Tribal peer support 

Source: National Indian Child Welfare Association, 2015. 

Chapter 1 129 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Historically, the Indian Health 

Service (IHS) was an entirely federal 

system, but in recent decades it 

has evolved in a profound way. 

Tribal governments now directly 

manage more than half of IHSappropriated funds and the great 

majority of physical facilities under 

self-governance contracts and 

compacts. In addition, 34 nonproft 

Urban Indian Health centers 

provide care for AI/AN [American 

Indian/Alaska Native] people and 

other underserved communities in 

urban locations. The IHS, Tribal, and 

Urban health care facilities have 

come to be known collectively [as] 

the Indian Health System.” 

Source: Hays, Carroll, Ferguson, Fore, & Horton, 

2014, p. 986. 

Administrative Challenges and Paths to 

Solutions 

Program administrators may face a wide range 

of challenges when attempting to design and 

implement programs and services specifcally 

tailored to meet the needs of American Indian 

and Alaska Native clients. Although some of these 

challenges include operational concerns about 

funding sources and reporting requirements, 

certifcation, and staffng, others are more often encountered when working with native communities 

in different settings. For example, programs that 

provide services to clients on a reservation must 

learn to work collaboratively with the community 

and tribal leadership. Programs serving clients in an 

off-reservation urban setting will need to work with 

the communities and tribal services, and also tailor 

services and staff training to effectively meet the 

needs of clients from different tribes who present a 

more diverse range of history, culture, and values. 

Although daunting, it is possible for programs to 

plan for and effectively address these challenges. 

What’s more, these issues provide an opportunity 

for program administrators to effectively engage 

with tribal, rural, and urban Indian communities 

throughout the program implementation process. 

This collaborative relationship not only helps 

ensure that services provided are culturally 

responsive, but also helps position the program 

for long-term success by using community buy-in, 

commitment, and support. 

Although the challenges listed below involve 

operational and workforce development issues, 

many diffculties stem from administrative staff 

giving insuffcient attention to the importance 

of engaging in culturally competent practices. 

By overlooking these practices, administrators 

themselves avoid recognition of their own cultural 

awareness and bias, fail to invest in learning about 

local culture(s) and American Indian and Alaska 

Native history, neglect to understand and use 

the principles of culturally responsive services 

and processes, and disregard the involvement of 

local native governance and communities before 

planning and implementing a specifc service or 

program for American Indians and Alaska Natives. 

The consensus panel identifed several administrative challenges. The items below draw attention to 

core challenges that most programs face in developing, implementing, evaluating, and sustaining 

services, yet they do not represent every obstacle. 

In the following section, several core challenges 

are presented along with ideas on how to address 

them. These suggestions are called the “path to 

solutions.” 

Determining how best to collect, organize, 

and manage data 

Service providers may have limited infrastructure 

to gather, manage, and maintain data, including 

limited access to computers, software applications, 

and culturally relevant digitized intake, assessment, 

and planning tools. 

Path to solutions 

• Contact well-established American Indian and 

Alaska Native treatment services and organizations to gain knowledge about culturally 

130 Chapter 1 
Part 2—Guide for Administrators Serving American Indians and Alaska Natives TIP 61

relevant digitized tools. It is not likely that you, 

as the administrator or program manager, will 

need to create these tools. Instead, you may 

need to adapt existing tools to refect more 

tribe-specifc information. 

• Seek grants that assist in building infrastructure 

to implement services. 

• Crowdsource for acquisition of computers and 

software applications. 

• Seek technical assistance from other American 

Indian and Alaska Native service providers. 

Analyzing data for reporting purposes and 

for securing funding 

Service providers typically face considerable 

reporting requirements, especially when the service 

uses multiple funding sources. Although extensive 

data may be already available within the treatment 

service program, service providers may not know 

how to analyze the data for reporting purposes. 

Likewise, service providers may not have access to 

technical assistance or resources to summarize and 

interpret the data in a meaningful way to validate 

service needs, outcomes, or impact to obtain 

future grants or other funding resources. (Service 

providers who are already fscally challenged in 

implementing programs are less likely to view data 

analysis to be as important as care.) 

BUILDING THE EVALUATION 

CAPACITY: GATHERING, 

ANALYZING, AND USING DATA 

Factors that facilitate evaluation capacity of local 

programs serving American Indian and Alaska 

Native populations include but are not limited to 

the accessibility of culturally competent technical 

assistance providers, investment in building 

strong program–provider relationships, support of 

innovative and cultural adaptations of evidencebased strategies, respect for circular views on 

change, use of culturally responsive evaluation 

methods, and focus on strengths-based 

programming. For more information on building 

evaluation capacity serving American Indian and 

Alaska Native populations, see SAMHSA, Center 

for Substance Abuse Prevention (CSAP), 2014. 

Path to solutions 

• Gain culturally competent technical assistance 

from the outset either from the grant source or 

other similar programs using the same funding 

source to learn how best to gather and analyze 

data. 

• Whether you are a native or non-native service 

provider, remember that tribes have experienced a long history of abuse surrounding data 

misuse. Tribes have faced signifcant negative 

consequences when their identifed data 

have been used for research, including loss of 

contracts and resources, disregard for tribal 

community member or tribe-specifc confdentiality, loss of employment, and so forth. As a 

provider, you need to develop a plan in collaboration with native community leadership on how 

the information is used with integrity. 

• Research needs to be approved through the 

tribe’s institutional review board or tribal 

council. Data are property, and property 

ownership needs to be determined and agreed 

upon with tribal governance. Keep in mind that 

staff may also be reluctant to gather certain 

or consistent data because their value is not 

understood; data collection takes too much 

time away from building relationships; or there 

is concern about data misuse, confdentiality, 

or gathering information in a manner that is not 

culturally responsive. These concerns need to 

be addressed through conversations with staff, 

supervision, and staff trainings. 

Obtaining program funding 

First and foremost, service providers need to 

understand how to access the funds necessary to 

maintain or expand behavioral health services in 

American Indian and Alaska Native communities. 

Programs with limited resources often need to 

obtain funds from multiple sources. Although this 

is a viable option, it can also create competing 

and conficting interests and reporting demands 

from the different funding sources. With limited 

resources, service providers not only have to make 

diffcult decisions on service provisions; they also 

need to be quite creative in using these funds to 

maximize the benefts. 

Chapter 1 131 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Path to solutions 

• Diversify funding streams. Funding limitations 

can cause a program to fail before implementation even begins. Programs should be prepared 

to secure funding from a diverse range of 

sources. Potential funding sources include IHS, 

Medicaid, Medicare, state and local coffers, 

discretionary federal funds, the Bureau of Indian 

Affairs, and tribal budgets. This kind of variation 

in funding options is necessary to sustain a 

program over time. 

• Partner or contract with established programs to 

maximize the use of available funds for services. 

Increasing access to services 

Providers working with American Indian and Alaska 

Native populations frequently face challenges implementing effective programs in remote communities where clients have diffculty accessing services 

because of a lack of service awareness, transportation, phone or Internet services, child care, or 

insurance or healthcare fnancing. For some, the 

distance to the service provider is prohibitive. 

Programs may also not have viable options to refer 

clients who have geographic hardships or would 

prefer to use a different service provider. Even if a 

referral is feasible, the challenges that often exist in 

interagency communication and collaboration may 

create additional obstacles for clients in gaining 

access to equitable and appropriate care. 

Path to solutions 

• Incorporate a client needs assessment and 

evaluation as part of the program’s operation. 

By identifying service needs, providers can 

tailor services to meet the current cultural and 

treatment needs of the community. A needs assessment allows a program to identify and build 

on the community’s strengths and resources 

and provides another avenue through which to 

engage tribal leaders and community members. 

Regular evaluation will help programs assess the 

impact of their efforts, identify strengths and 

weaknesses, and guide program development, 

capacity building, and sustainability efforts. 

• Provide one-stop services so that clients and 

their families can access services at one location, 

including outreach activities to connect individuals 

with available services. 

• Offer a “warm handoff” whereby clients are 

physically taken and introduced to the new 

service to bridge the referral gap. Under these 

circumstances, clients are more likely to follow 

through with the referral. 

• Develop outreach, educational programs, and 

community events in multiple languages. 

• Provide mobile or telehealth services. Bring the 

services to the client rather than the client to 

the services. In planning these services, think 

through the process carefully. Will the client 

or family members need child care during the 

mobile service? Is the community educated 

about how telehealth works at the health clinic? 

• Form partnerships between states and tribes. 

Refer to Partnering With Tribal Governments 

To Meet the Mental Health Needs of American 

Indian/Alaska Native Consumers (National 

Association of State Mental Health Program 

Directors, 2015). 

Integrating care 

American Indian and Alaska Native perspectives 

on healing are holistic. The beliefs surrounding the 

path to illness as well as healing are integrated; the 

mind, body, spirit, or environment are seen as one; 

all is connected. When programs do not integrate 

behavioral health services, primary health care, 

and other social services, they fail to encompass a 

culturally responsive approach to treatment, and 

ultimately can have a signifcant negative impact on 

treatment seeking, quality of and responsiveness to 

care, and outcome. 

Path to solutions 

• Build alliances between services to coordinate 

care. 

• Include a cultural component in services, if 

possible (e.g., craft workshops). 

• Create accessible one-stop services. 

• Include health and behavioral health service 

providers. For example, use a psychiatric nurse 

practitioner in house to assess for co-occurring 

conditions. 

Developing native evidence-based practices 

For years, considerable focus has been placed on 

employing mainstream evidence-based practices 

(EBPs) in native programs and in communities. 

132 Chapter 1 
Part 2—Guide for Administrators Serving American Indians and Alaska Natives TIP 61

Although mainstream EBPs can be effective 

avenues of intervention, they are perceived as 

mainstream approaches while ignoring or failing 

to honor native practices, knowledge, and 

culture. For many years, funding has been tied to 

these mainstream EBPs, while representation of 

American Indian and Alaska Native participants 

in the research that supports these mainstream 

EBPs is nearly nonexistent. Changes are now 

occurring, including increases in native-specifc, 

culturally adaptive research and in representation 

of American Indian and Alaska Native individuals 

among research participants. We now see an 

increase in respect, acknowledgment, and focus 

on native ways of knowing; the establishment of 

community-based and tribal participatory research; 

and the development of research mentor programs 

for American Indians and Alaska Natives, such as 

the National Institute on Drug Abuse’s American 

Indian/Alaska Native Researchers and Scholars 

Work Group’s Native-to-Native Mentoring program. 

Path to solutions 

• Gain technical assistance or support from 

SAMHSA’s National American Indian and Alaska 

Native Addiction Technology Transfer Center 

(NAI & AN ATTC) to review EBPs that may be 

culturally adapted to your clients and their needs. 

• Use a Native American framework in creating 

criteria for evidence-based tribal practices 

(Exhibit 2.1-1; refer to Exhibit 2.1-2 for a sample 

curriculum). 

EXHIBIT 2.1-1. Evidence-Based Tribal Practices 

In the Native American framework, there are several specifc criteria for evidence-based tribal practices. 

These criteria are: 

1. Longevity: A tribal practice rooted in long-held traditions (e.g., canoe journey, sweat lodge, and 

subsistence practices). 

2. Teachings: A tribal practice based on specifc teachings (e.g., the medicine wheel, origin stories). 

3. Values: A tribal practice that incorporates the values and worldview of American Indian and Alaska 

Native cultures (e.g., a holistic tribal treatment practice focused on harmony and acceptance). 

4. Principles: A tribal practice that is rooted in traditional principles (e.g., Mehl-Medrona’s principles of 

treatment of chronic illness; 1997). 

5. Elders: A tribal practice that is reviewed and approved by elders. It constitutes evidence of 

appropriateness and effectiveness within the Native American framework. 

6. Community: A tribal practice that is guided by community feedback. 

Source: Oregon Addictions & Mental Health Division, n.d. 

Creating sustainability 

Although many service providers face funding 

issues from the outset, the more formidable task 

is maintaining interventions and programs for 

the long term after initial funding has ended. The 

consensus panel emphasized that service programs 

often face sustainability issues after initiation of 

newly funded programs. Although well-established 

programs and tribal organizations can dedicate 

more resources for fund development to secure 

long-term fnancial sustainability, most programs, 

regardless of current status, are concerned with 

sustainability for the future. 

SAMHSA’S TRIBAL TRAINING 

AND TECHNICAL ASSISTANCE 

CENTER 

This Center supports native community 

self-determination through infrastructure 

development, capacity building, and program 

planning and implementation. 

Chapter 1 133 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

EXHIBIT 2.1-2. Navigating Life Curriculum Sessions 

SESSION TITLE SESSION GOALS/FOCUS* 

*Traditional stories, cultural activities, and speakers from the community are woven throughout the sessions. 

1. Canoe Journey as a 

Metaphor for Healing 

• Introduce and discuss the Four Seasons/Four Winds, a traditional 

Suquamish/S’Klallam concept used to frame daily life and teach life 

skills, a schedule set by nature that traditional livelihood revolved 

around. 

• Discuss the Northwest native traditional canoe journey and how it can 

serve as a metaphor for life. Each session ends with a refection back 

to this concept. Other traditional beliefs are also discussed. 

• Information about alcohol is also included. 

2. Who Am I? Beginning at 

the Center • Learn about S’Klallam and Suquamish values, traditional ways to 

introduce oneself, self-awareness genealogy, family ties and integrity, 

and how to use the concept of the Four Seasons/Four Winds as a part 

of self-defnition. Participants are encouraged to explore the idea of a 

physical self, mental self, emotional self, and spiritual self. 

• Information about marijuana is also included. 

3. How Am I Perceived? 

Media Awareness and 

Literacy 

• Focus on how American Indians/Alaska Natives and, specifcally, how 

the Suquamish and S’Klallam people are portrayed in the media; learn 

how to recognize when stereotypes are being used, how American 

Indian and Alaska Native culture has been exploited and history has 

been misrepresented, and how to stand up against stereotypes. 

• Information about prescription drugs is also included. 

4. Community Help and 

Support: Help on the 

Journey 

• Learn about the importance of community, how they are a part 

of many communities, and the importance of giving back to their 

community; learn how to identify where they can go for help in their 

own community; learn what it means to be a mentor and how they 

can become mentors for those around them. 

• Information about club drugs and stimulants is also included. 

5. Moods and Coping With 

Negative Emotions 

• Learn about different emotions and positive and negative self-talk; 

learn about depression and suicide, how to cope with negative 

emotions and diffcult situations, and how to fnd a safe person or 

place to express emotions. 

• Information about inhalants is also included. 

6. Who Will I Become? Goal 

Setting 

• Explore what kinds of goals are important and learn a step-by-step 

approach to setting goals; begin to understand the importance of 

goal setting and learn how to cope with obstacles that might hinder 

achieving set goals. 

• Information about hallucinogens is also included. 

Continued on next page 

134 Chapter 1 
Part 2—Guide for Administrators Serving American Indians and Alaska Natives TIP 61

EXHIBIT 2.1-2. Navigating Life Curriculum Sessions (continued) 

SESSION TITLE SESSION GOALS/FOCUS* 

7. Overcoming Obstacles: 

Solving Problems 

• Learn how to recognize when there is a problem, learn ways to 

solve problems and make good decisions, and discuss where to go 

when there is a problem; learn how to defne a problem, brainstorm 

solutions, pick the best solution, make and act on a plan, and review/ 

revise the plan if needed. 

• Information about nicotine is also included. 

8. Listening • Teach listening skills: Effective listening is discussed and the 

importance of listening is illustrated through Suquamish and 

S’Klallam storytelling and other traditional activities. Traditional values 

stress respect and the belief that you must be an effective listener 

before you can become an effective communicator. 

• Information about methamphetamines is also included. 

9. Effective Communication: 

Expressing Thoughts and 

Feelings 

• Teach effective communications skills, including how to disagree 

respectfully, how to use refusal and assertiveness skills, and how to 

deal with peer reactions to assertiveness. Participants practice positive 

ways to resolve confict and to express feelings. 

• Information about opiates is also included. 

10. Safe Journey Without 

Alcohol/Drugs 

• Learn about addictions, how expectancies infuence perception, and 

about the consequences of drug and alcohol use/abuse. 

• Refecting on the “canoe way of life” as an example of “life’s journey.” 

11. Strengthening Our 

Community 

• Focus on fnding leaders within the tribal community to serve as 

role models; learning about the Boldt decision, tribal sovereignty, 

leadership, and how to make good choices within the community. 

• This session includes feld trips into the community to volunteer with 

important community projects. 

12. Honoring Ceremony • This ceremony is a way to acknowledge youth for program completion 

and honor their unique attributes. Mentors are invited by the youth 

to attend and can talk about the youth and their accomplishments. 

Tribal elders, leaders, and families are also invited to witness the 

ceremony and share a meal. 

• Gifts are prepared and given formally, and digital stories are shared. 

*Traditional stories, cultural activities, and speakers from the community are woven throughout the sessions. 

Source: Donovan et al., 2015. Adapted with permission. 

Path to solutions 

The following suggestions are adapted from 

the National Evaluation of the Comprehensive 

Community Mental Health Services for Children 

and Their Families Program: Exploratory 

Description of Financing and Sustainability in 

American Indian and Alaska Native System of Care 

Communities (Walter R. McDonald & Associates 

& ICF Macro, 2009). The comprehensive report 

highlights the key elements of sustainability and 

steps to develop a fexible sustainability plan. 

Some examples of the report’s recommendations 

are highlighted next: 

Chapter 1 135 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

• Begin planning for long-term fnancial sustainability on the frst day funding begins, or even 

before actually receiving the grant, taking care 

to build planning on the foundation of local 

cultural strengths (p. 16). 

• Create a sustainability planning team that 

includes key decision makers (e.g., tribal-elected 

offcials, administrators, program planners, 

fnance staff) (p. 16). 

• Conduct a site visit to another tribal system that 

has successfully implemented a sustainability 

strategy for a peer-to-peer learning opportunity 

(p. 18). 

• Develop a staff training curriculum based on 

local tribal values and service design to advance 

staff service skills and credentials (p. 17). 

• Meet with the state credentialing board for 

licensed behavioral health service providers to 

discuss the tribal curriculum concept and ensure 

that the state licensing board will approve the 

tribal curriculum (p. 17). 

• Develop a data-driven argument that shows the 

need for tribal system of care funding, emphasizing human and fnancial cost-savings by 

redeploying funds from high-cost state services 

that tend to be less effective to lower cost tribal 

services that tend to be more effective (p. 17). 

Developing a culturally competent and 

responsive workforce 

Program administrators struggle to meet the 

demands of staff development. Immediate 

demands, often caused by staff shortages and 

turnover, take precedence over long-term strategies to invest in the future workforce. However, 

program administrators need to be committed to 

developing a culturally competent workforce when 

providing services to American Indian and Alaska 

Native clients. This commitment involves attracting, 

supporting, and retaining native staff; creating or 

obtaining relevant tribal-specifc curriculums that 

increase cultural competence; and implementing 

strategies to promote ongoing professional development to increase competence and promote 

leadership skills, such as the provision of clinical 

supervision and professional mentoring. 

The Native American Center for Health 

Professions created a digital mentoring 

website called We Are Healers. The 

website showcases short, engaging 

videos of American Indians working 

in health professions and provides 

a behind-the-scenes look at their 

jobs. These stories help American 

Indian students explore health felds 

and connect to mentorship tools 

and resources. See more at www. 

wearehealers.org/home-video. 

Path to solutions 

• Connect with tribal colleges and create 

internships. 

• Conduct outreach to elementary and secondary 

schools and organizations serving younger 

people in native communities to promote 

interest in the feld at an early age. 

• Develop facilitator-led educational groups to 

promote interest. 

• Create mentoring programs for clinical and 

administrative roles. 

• Become a resource for how to fnd educational 

assistance (e.g., federal traineeships, internships, 

scholarships). 

• Encourage tribal colleges to incorporate certifcations into their programs, including in-class 

and online courses. 

• Create opportunities with state universities to 

develop American Indian curriculums along with 

internships and work-study programs in tribal 

communities. 

Collaborating with native communities and 

tribal leadership on a regular basis 

American Indian and Alaska Native cultural beliefs 

revolve around the value of connectedness and 

the importance of relationships. Relationship 

building needs to be the center supporting pole 

in developing services. Native communities have 

136 Chapter 1 
Part 2—Guide for Administrators Serving American Indians and Alaska Natives TIP 61

considerable cause not to trust behavioral health 

services, which historically have imposed culturally 

blind diagnoses; employed institutionalism, such 

as boarding schools and mandated state hospitalizations; have failed to provide adequate funds 

or have misappropriated funds; have tied the 

availability of resources to adopting mainstream 

EBPs or certifcation processes that inadequately 

represent native populations and force assimilation; 

and failed to recognize and honor American Indian 

and Alaska Native sovereignty. Without investment 

and involvement in native communities and their 

leadership to gain guidance, services will be poorly 

matched to the population and underutilized by 

the community, and funding for these services will 

further strain agency and tribal resources. 

WORKFORCE DEVELOPMENT IN 

PRACTICE: THE SPOKANE TRIBE 

HEALTH AND HUMAN SERVICES 

BEHAVIORAL HEALTH PROGRAM 

To address staff shortages in a geographically 

remote area, the Behavioral Health Program 

implemented two workforce development 

strategies. The frst focuses on providing 

professional development opportunities for 

qualifed tribal member employees over a 

2-year period. The second strategy involves a 

partnership with the National Health Service 

Corps (NHSC) Loan Repayment Program as an 

approved service site. This program attracts staff 

by reducing and eliminating student loans in 

exchange for the provision of medical, dental, 

and behavioral and mental health services to 

underserved populations. 

Source: IHS, 2011. 

Path to solutions 

• Engage the community and tribal leadership 

early and regularly. Community and tribal governance involvement in behavioral health service 

planning and implementation is a key factor in 

achieving long-term success. 

• Plan ahead to allow signifcant time for relationship building. Often, the time required to build 

trusting connections is underestimated. 

• Make sure community members are involved in 

program service implementation, including staff 

assignments, board appointments, inclusion of 

traditional healers and elders, and use of native 

peer specialists. 

• Develop local community focus and advisory 

groups to discuss key service needs. 

• Engage the community by housing community 

events at the facility as well as attending local 

community events, when appropriate. 

• Honor sovereignty. Most federally recognized 

tribes in the Unites States exist as sovereign 

nations. Providers who serve American Indian 

and Alaska Native clients must acknowledge 

and respect this sovereignty by working with 

the community and their tribal leadership when 

planning for and implementing behavioral 

health services. Understanding sovereignty 

is critical to successful service provision and 

program sustainability. Specifc laws, codes, 

regulations, and procedures vary from tribe to 

tribe and may be quite different from state laws 

(e.g., employment regulations). 

• Use community-based models for intervention and prevention, such as the Community 

Readiness Model (Plested, Jumper Thurman, 

& Edwards, 2014). 

Fifty-four percent of the mental 

health programs and 84 percent of 

the alcohol and substance abuse 

programs [in native communities] are 

now operated by tribes. This evolution 

in behavioral healthcare delivery and 

management is changing the face of 

behavioral health services in Indian 

Country. In the last decade, tribes 

have increasingly used the Indian 

Self-Determination and Education 

Assistance Act to establish and provide 

their own behavioral health services 

(IHS, 2011, p. 1). 

Chapter 1 137 
TIP 61

 

 

 

Behavioral Health Services for American Indians and Alaska Natives 

ENGAGING NATIVE COMMUNITIES: THE COMMUNITY READINESS MODEL 

The Community Readiness Model was developed in 1994 at Colorado State University with the aim 

of building the capacity of tribal communities/nations so that they might recognize and build on the 

strengths from within to begin a healing process of healthy change. 

The Community Readiness Model will help you assess the community’s readiness for change, the needs 

of the community, and strategies to address needs related to the identifed specifc issue (e.g., HIV/AIDS, 

suicide, substance abuse). 

The Community Readiness Model: 

• Provides the community “truth” about an issue, which may or may not be the real “truth,” thus setting 

strategies based on the community’s readiness. 

• Models community change that integrates a community’s culture, resources, and level of readiness to 

more effectively address the identifed issue. 

• Allows communities to defne issues and strategies in their own contexts. 

• Builds cooperation among systems and individuals. 

• Increases capacity for the identifed issue and intervention. 

• Encourages community investment in the issue and awareness. 

• Is applicable to any community (geographic, issue-based, organizational, etc.). 

• Can address a wide range of issues. 

• Guides the complex process of system and community change. 

Sample Content of Manual: Dimensions of Readiness 

Dimensions of readiness are key factors that infuence your community’s preparedness to take action 

on (THE ISSUE). The six dimensions identifed and measured in the Community Readiness Model are 

comprehensive in nature. They are an excellent tool for diagnosing your community’s needs and for 

developing strategies that meet those needs. 

A. Community Efforts: To what extent are there efforts, programs, and policies that address (THE ISSUE)? 

B. Community Knowledge of the Efforts: To what extent do community members know about local efforts 

and their effectiveness, and are the efforts accessible to all segments of the community? 

C. Leadership: To what extent are appointed leaders and infuential community members supportive of 

(THE ISSUE)? 

D. Community Climate: What is the prevailing attitude of the community toward (THE ISSUE)? Is it one of 

helplessness or one of responsibility and empowerment? 

E. Community Knowledge About the Issue: To what extent do community members know about or have 

access to information on (THE ISSUE), and how it impacts your community? 

F. Resources Related to the Issue: To what extent are local resources (e.g., people, time, money, space) 

available to support efforts? 

Your community’s status with respect to each of the dimensions forms the basis of the overall level of 

community readiness. 

Source: Plested et al., 2014. 

138 Chapter 1 
Part 2—Guide for Administrators Serving American Indians and Alaska Natives TIP 61

Workforce Professional 

Development 

As an administrator, your responsibilities include 

providing staff with the resources to effectively meet 

the needs of clients and the community. A core 

resource is the investment in building and improving 

the skills and capabilities of behavioral health staff 

through education, training, clinical supervision, and 

other activities. These professional development 

activities can play a powerful role in building clinical 

competence, in creating leadership opportunities, 

and in recruiting and retaining staff. In turn, your 

commitment to professional development may 

improve client treatment engagement from the initial 

intake to continuing care, treatment outcomes, and 

treatment acceptance in the community. 

Staff training and education are 

important elements in building skills, 

including personal strategies in how 

to develop therapeutic relationships. 

However, skill training never replaces 

the importance of investing in 

the relationship. Although this is 

old knowledge, science related to 

substance abuse supports it: the 

provider’s empathy and interpersonal 

ways have the greatest impact on 

outcome among individuals seeking 

treatment (Miller & Rose, 2009). 

As with most actions, the effects of professional development are circular. Staff members see training 

and education as a beneft, the training improves 

the functioning of your organization, clients have 

better treatment experiences and outcomes, the 

program becomes more accepted and respected in 

the community, the program attracts more individuals to the program (including others who develop 

an interest in providing services), and the process 

continues. The following sections address training 

and education, clinical supervision, and mentoring. 

Training and Education 

The immediate goal of education and training 

is to improve the capacity of staff members to 

When you see a new trail, or a 

footprint you do not know, follow 

it to the point of knowing.” 

—Santee Sioux 

Source: C. A. O. Eastman, 1907, p. 522. 

effectively perform their duties in their current 

roles. In other words, you are helping staff 

members to become better providers to meet 

the needs of your clients. However, if the goal of 

education and training ended here, it would be a 

disservice to staff and American Indian and Alaska 

Native communities. Education and training goals 

should extend beyond current needs. With the 

current challenges in building an American Indian 

and Alaska Native workforce as well as a culturally 

competent non-native behavioral health workforce, 

education and training also need to focus on the 

development of leadership and administrative skills 

for the next generation. 

CSAP’S PREVENTION 

FELLOWSHIP PROGRAM 

Developing the Next Generation 

of Prevention Leaders: Prevention 

Internship Program for Tribes and 

Tribal Organizations 

The Prevention Internship Program, a component 

of CSAP’s Prevention Fellowship Program, invites 

qualifed individuals with strong interest in 

substance abuse prevention and behavioral 

health for a 10-week paid internship program in 

participating tribal organizations throughout the 

United States. The Prevention Internship Program 

prepares interns to provide capacity-building 

technical assistance to support integration of 

mental and substance use disorder prevention 

services within tribal organization systems. 

Interns beneft from hands-on experience and 

trainings in mental and substance use disorder 

prevention, the Strategic Prevention Framework, 

workforce development, and evaluation. Interns 

learn new techniques, best practices, and 

knowledge from their professional and cultural 

experiences. 

Chapter 1 139 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

In addition to using basic provider and intervention 

materials to guide your education and training 

activities, supplementary information on the 

community itself can inform you of the potential 

training needs of your staff. This information can 

be obtained from a community needs assessment; 

client, family, and community feedback on clinical 

services; and reports on current events in the 

community (e.g., suicide rates in the community, 

the availability of new drugs of abuse, the 

incidence of diabetes, the occurrence of traumatic 

events). Although these areas are essential in 

guiding your plans, cultural training is paramount in 

laying a strong foundation when serving American 

Indian and Alaska Native clients and communities. 

THE ADDICTION TECHNOLOGY 

TRANSFER CENTER NETWORK 

The Addiction Technology Transfer Center 

(ATTC) Network offers a variety of training and 

educational opportunities for behavioral health 

service providers serving Indian Country. The 

ATTC Network strives to improve the health 

and well-being of American Indians and 

Alaska Natives through access to “high-quality, 

evidence-based, culturally appropriate, selfdirected behavioral health services and recovery 

supports ... that both honor and contribute to the 

health and well-being of native communities, 

tribes, and individuals.” The ATTC Network 

offers access to resources, including training 

curriculums, webinar presentations, online 

trainings, evidence-based best practices, and 

various informational print materials on topics 

such as: 

• Culturally informed clinical supervision. 

• The impact of colonization on native 

communities. 

• The Native American lesbian, gay, bisexual, 

transgender, and questioning (LGBTQ)/TwoSpirit curriculum. 

• Professional readiness: Attitudes and values. 

• The Native American curriculum for stateaccredited, nontribal mental health and 

substance abuse programs in South Dakota. 

See https://attcnetwork.org/centers/nationalamerican-indian-and-alaska-native-attc/home. 

Program staff serving American 

Indians and Alaska Natives in rural 

areas may beneft from training in 

computer use and phone technologies 

that can deliver care over a distance 

rather than exclusively in person. 

(See TIP 60, Using Technology-Based 

Therapeutic Tools in Behavioral Health 

Services [SAMHSA, 2015]). 

Providing cultural training and developing cultural 

competence form a main pathway in reducing 

health inequalities. We know that understanding 

tribal history and culture results in better healthcare 

communications with American Indian and Alaska 

Native clients and improved client outcomes (see 

review by Clifford, McCalman, Bainbridge, & Tsey, 

2015). The following segments focus on cultural 

training, with an emphasis on resources, content, 

and logistics. 

It is critical that [behavioral] 

healthcare professionals 

understand the stress and anxiety 

associated with AI/AN identity, 

the AI/AN acculturation and 

deculturation that trigger mental 

health disorders, and the need for 

traditional and cultural practices 

as a part of the treatment and 

prevention process.” 

Source: IHS, 2011, p. 10. 

Staf training on American Indian and Alaska 

Native history and culture 

Staff training on American Indian and Alaska Native 

history and culture is essential in providing culturally 

competent care. Training provides an orientation 

to cultural worldviews, practices, and historical 

events and an opportunity for participants to 

examine their own cultural identity and beliefs and 

how these beliefs infuence their perspectives on 

healing, communication, relationships, and clinical 

140 Chapter 1 
Part 2—Guide for Administrators Serving American Indians and Alaska Natives TIP 61

practice. But staff training on culture also necessitates a relearning of history. For many non-native 

and American Indian and Alaska Native people, 

formal education has either misrepresented historical events, failed to address American Indian 

and Alaska Native history, or minimized the dire 

consequences of “forced assimilation” policies that 

led to historical trauma and subsequent conditions 

that survive today. Embracing this relearning from 

a native perspective provides an opportunity to 

see native nations and American Indian and Alaska 

Native people with “eyes wide open.” Please see 

Part 1, Chapter 1, for an overview of historical events. 

Staff training also needs to incorporate the culture 

and history of the specifc tribes and communities who will use your services. Remember that 

each tribe and community has its own history. 

Staff training on American Indian and Alaska 

Native culture and history represents an opportunity to affect staff attitudes toward clients and 

increase cultural awareness of themselves and 

others. Appropriate training can strengthen the 

rationale for trauma-informed care; help staff 

become more cognizant of the impact of racism, 

microaggressions, prejudice, and historical trauma 

on clients, their families, and their communities; 

and encourage the exchange of knowledge 

between non-native and native staff and clients. 

Some staff members may not see the need for 

cultural training either because they see themselves 

as experts, believe that they already have cultural 

knowledge, disregard outright the value of cultural 

competence, or are culturally blind, failing to see 

that differences exist (e.g., “I treat everyone the 

same”). This attitude gives administrative or clinical 

supervisors an opportunity to provide a rationale, 

to discuss, and to reinforce the importance of 

cultural competence as a provider in the organization. Nonetheless, it may be a sign that your 

organization needs to conduct an organizational 

assessment on cultural competence, followed by 

the development and implementation of a plan to 

raise awareness, improve practices, and endorse 

polices that improve cultural competence with staff 

members and with organizational leadership. For 

specifc information on how to become a culturally 

responsive organization, refer to the step-by-step 

guidelines outlined in TIP 59, Improving Cultural 

Competence (SAMHSA, 2014a). 

Often, each level of the organization (leadership, staff, and clients) views cultural 

competence in differing ways. The key is fexibility—the fexibility to change 

and make things better. We worked with an organization [that] had concerns 

about serving their American Indian and Alaska Native clientele in a culturally 

appropriate way. They decided to use Community Readiness [Model] as the 

assessment tool for cultural competence. They treated the Board, the program 

management, the staff, and clients as separate communities during the 

organizational assessment. By doing this, they had four separate and distinct 

communities and readiness scores. Results were interesting. The Board and 

management thought the organization was very culturally responsive, but the 

frontline staff and clients did not agree. This was a wakeup call for the Board 

and program management. They immediately took the readiness scores into 

an all-day staff retreat, and each ‘community’ put together a strategic plan to 

raise readiness levels related to cultural competence. It was wonderful to see the 

change in the organization. The assessment itself was the intervention.” 

—Pamela Jumper Thurman, Ph.D., Western Cherokee, TIP Chair and Panel Member 

Chapter 1 141 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

WHAT IS CULTURAL 

COMPETENCE? 

The U.S. Department of Health and Human 

Services (HHS) defnes cultural competence 

as “the ability to honor and respect the beliefs, 

languages, interpersonal styles, and behaviors 

of individuals and families receiving services, as 

well as staff members who are providing such 

services” (HHS, 2003, p. 12). Cultural competence 

is an ongoing developmental process achieved 

over time and, as a result, requires a long-term 

commitment if it is to succeed. 

Arranging staf cultural training 

You can choose from a wide range of formal and 

informal instructional methods, including the use 

of a curriculum during group supervision or as a 

peer-led supervision group, regularly scheduled 

training sessions or educational lunches with 

various presenters or trainers, staff support to 

attend and participate in training and cultural 

activities in the local tribal community, and cultural 

programs led by American Indian and Alaska 

Native elders or other community members, 

including immersion programs. Part 1 of this TIP 

provides material that can be easily adapted for 

training. 

SAMHSA’s American Indian and Alaska 

Native Culture Card: A Guide to Build 

Cultural Awareness is an example of 

material available for staff education 

and training. This informative material 

and similar resources are available for 

free from SAMHSA’s website (https:// 

store.samhsa.gov). 

As an administrator, you may have specifc 

questions or concerns related to staff education 

and training on American Indian and Alaska Native 

history and culture. Before scheduling any kind of 

education and training, it is important to keep a 

few things in mind: 

• Your support of and commitment to education 

and training as an administrator is vital to the 

success of such efforts. 

• You need to be willing to commit program 

resources, including allowing time for trainings, 

rearranging schedules, and devoting funds for a 

trainer. If funds are limited, do not assume that 

you cannot provide the training. You may want 

to contact the NAI & AN ATTC, local trainers, 

or tribal colleges. Some trainers may volunteer 

their services if they know that the program has 

limited funds. 

• Community leaders and cultural advisors should 

be involved in or lead the design of the cultural 

training. This will not only help focus staff 

education and training on the history, culture, 

and values unique to your clients, but it will also 

help build community partnerships. 

• Learning and training styles need to be culturally 

responsive; that is, favoring engagement over 

abiding strictly to schedules or using experiential 

group activities rather than lectures. 

• You need to obtain feedback and evaluate the 

training to guide the selection of future training 

content, trainer selection, style of presentation, 

and location of training. 

NATIVE AMERICAN 

REHABILITATION ASSOCIATION’S 

CULTURAL ADVISORS 

The Native American Rehabilitation Association 

of the Northwest, Inc. (NARA) provides culturally 

appropriate education, physical and mental 

health services, and substance abuse treatment 

services to American Indians and Alaska Natives 

in the region. Culture and traditional practices 

are central components of the agency’s mission 

and activities. To help ensure the appropriate and 

accurate representation of American Indian and 

Alaska Native culture, NARA has established and 

collaborates with staff Cultural Advisors. These 

Advisors lead NARA’s Cultural and Community 

Services and work with all NARA programs to 

provide cultural competence training for staff and 

cultural activities and services for NARA’s clients. 

Identifying potential cultural trainers 

Selecting someone to train staff members in 

American Indian and Alaska Native culture(s) and 

history involves careful consideration, as having 

someone who provides inaccurate information will 

do more harm than providing no training at all. 

142 Chapter 1 
Part 2—Guide for Administrators Serving American Indians and Alaska Natives TIP 61

Whom you choose to serve as your program’s 

cultural trainer will depend on answers to several 

questions: 

• Are clients mainly from a single tribe or 

community, or is there representation from 

various tribes? 

• How often will staff members need training? 

• Will the trainer receive fnancial compensation 

for services? 

• Is the trainer American Indian or Alaska Native? 

• What specifc cultural knowledge and experience does the trainer need to have that clearly 

matches client needs? 

• Is the trainer endorsed by the local community 

and tribal governance? 

• Does the trainer have a good reputation for 

engaging staff members? 

• Have you asked for guidance from tribal and 

community leaders in trainer selection? 

• Are you working collaboratively with tribal 

leadership and community leaders to design the 

cultural training with the trainer? 

• Are you going to conduct a one-time training 

or ongoing training to promote knowledge 

adoption? 

WHAT MAKES SOMEONE A 

QUALIFIED CULTURAL TRAINER? 

Dixon and Iron (2006) include a list of 

qualifcations for cultural trainers used by an 

Alaskan hospital. In their work, a qualifed cultural 

trainer is someone who: 

• Has knowledge of the specifc topic(s). 

• Is respected by his or her community. 

• Has good rapport with people, including people 

outside his or her community (e.g., healthcare 

providers). 

• Is comfortable with public speaking. 

• Can speak, read, and write in the local tribal 

language. 

• Has experience providing training and lives a 

traditional subsistence way of life. 

Selecting training materials for cultural 

training 

General recommendations on selecting content 

center around several principles: relevance and 

accuracy of content, adaptability to practice, ease 

of understanding, tribal endorsement, and ability 

to engage participants. For cultural training, a 

number of online resources recommend content, 

training tools tailored to specifc tribes and communities, and training guidelines. The last section 

in this chapter, “Provider Competencies,” can also 

guide you in selecting content areas. Refer to 

Part 2, Chapter 2, for cultural training resources 

for nontribal behavioral health service providers. 

Trainings need to be designed specifc to the 

tribe(s) represented in your program, the services 

provided, and constraints of the geographic 

region, such as trainings for health clinics in remote 

villages. Along with tribe-specifc training materials 

and other resources, Part 1, Chapters 1 and 2, can 

be used as a supporting resource for trainings. The 

case histories and vignettes in Part 1, Chapter 2, 

can be adapted and used as role plays to engage 

participants. The following is a sample list of 

content areas for cultural training: 

• Tribal history 

• Family structure, dynamics, and parenting 

practices 

• Common terminology and languages 

• Tribal governance 

• Role of elders 

• Tribal justice and wellness court system 

• History of U.S. government policies and treaties 

with tribe(s) 

• Tribal and state relations 

• Worldviews 

• Historical traumas, including those specifc to 

the tribe, village, or region (e.g., Trail of Tears, 

chemical contamination of water, boarding 

schools, sexual assaults, kidnappings, loss of 

land and resources, sweeping epidemics) 

• Tribe-specifc artwork and food 

• Beliefs and attitudes about illness and healing 

• Tribal constitutions and codes 

• Role of health clinics 

• Tribal sovereignty 

• Children services and the Indian Child 

Welfare Act 

• Educational system 

• Attitudes toward alcohol and drugs 

Chapter 1 143 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

• Cultural practices (e.g., potlatches) 

• Traditional healing 

• History of ceremonies 

• Cultural etiquette and respect 

• Cultural awareness and humility 

• History of health services and experiences 

among American Indians and Alaska Natives, 

including the changing patterns of governance 

• Infuence of geographic regions 

• Role of public safety offcers 

• Native EBPs 

NATIVE AMERICAN CURRICULUM FOR STATE ACCREDITED, NON-TRIBAL 

MENTAL HEALTH & SUBSTANCE ABUSE PROGRAMS IN SOUTH DAKOTA 

This training program offers professionals an opportunity to improve their awareness of Native American 

culture, resulting in an enhanced treatment experience for Native American clients. The primary intent of 

this substance abuse-related curriculum is to provide an educational experience primarily for non-native 

staff members of state-accredited, nontribal mental health and substance abuse programs in South 

Dakota. The curriculum is also relevant for those working to address other aspects of behavioral health. 

Although this curriculum focuses primarily on Dakota, Lakota, and Nakota groups located in South Dakota, 

it has the potential to be adapted to refect the ways of other indigenous groups located in other states. This 

curriculum contains 19 modules. For certifcation hours and other pertinent information, contact the NAI & 

AN ATTC (see https://attcnetwork.org/centers/national-american-indian-and-alaska-native-attc/home). 

Leaving Footprints: Cultural Training 

Duane Mackey, Ed.D., a Santee Sioux tribal member, received his M.A. and Ed.D. from the University of 

South Dakota. He taught middle school and high school and coached football, golf, and basketball. He 

practiced as a guidance counselor and became the frst Director of Indian Education for the Sioux City 

School System. His team twice won the Nebraska state boys basketball tournament, which later led to his 

very strong commitment to human rights for American Indians. 

He dedicated his life to improving American Indian human rights and enhancing American Indian 

opportunities in education and research. He became a faculty member at the University of South Dakota, 

Addiction Studies Program, and was a Director of Native American Initiatives in the Prairielands ATTC, now 

known as the NAI & AN ATTC. In particular, Dr. Mackey developed American Indian curriculums specifcally 

designed for nontribal substance abuse treatment providers and has signifcantly infuenced the feld’s 

recognition that cultural training is paramount. He has left footprints that will continue to infuence care 

offered by native and non-native providers. 

In memory of Dr. Duane Mackey, “Waktaya Naji,” TIP Consensus Panel Member. 

The Dr. Duane Mackey “Waktaya Naji” Award 

This award acknowledges individuals who, in their addiction study careers, have made signifcant 

contributions in education, research, mentoring, and service among American Indian and Alaska Native 

peoples. The award signifes the promise of continued success of an individual and serves to inspire 

others to contribute to the addiction treatment feld for American Indian and Alaska Native people. It also 

recognizes individuals who, through their concerted efforts, have untiringly promoted and espoused the 

ideals of equality and justice for all peoples. 

Providing education resources: Staf 

opportunities 

Educational opportunity is another important 

ingredient of promoting professional development, 

improving the quality and outcome of services and 

supporting future leadership. Likewise, it can serve 

as a recruitment and retention strategy. Several 

specialized education and scholarship programs 

are available for students who wish to enter the behavioral health feld, as well as for recent graduates 

just entering the health feld. Several programs are 

available, such as the IHS Extern Program; IHS preparatory, pregraduate, and professional scholarship 

144 Chapter 1 
Part 2—Guide for Administrators Serving American Indians and Alaska Natives TIP 61

programs; and the NHSC Loan Repayment 

Program, for individuals in the healthcare feld who 

are willing to commit to flling needed positions 

within IHS. The IHS Loan Repayment Program 

offers assistance repaying health education student 

loans for qualifed candidates (both native and 

non-native) in exchange for a multiyear service 

commitment at a program or facility that serves 

an American Indian or Alaska Native community 

(see the IHS website for more information: www. 

ihs.gov/loanrepayment). Several states offer similar 

programs. In addition, the American Psychological 

Association offers a Pre- and Postdoctoral Minority 

Fellowship Program funded through SAMHSA. 

EDUCATIONAL INTERNSHIPS 

AND FELLOWSHIPS 

• The IHS Externship Program: www.ihs.gov/ 

scholarship/ihsexternprogram 

• SAMHSA: Minority Fellowship Program: www. 

samhsa.gov/minority-fellowship-program 

• Centers for Disease Control and Prevention: 

Public Health Training Fellowships: www.cdc. 

gov/Fellowships 

Loan Opportunities 

• The NHSC Loan Repayment Program: https:// 

nhsc.hrsa.gov/loanrepayment 

• The IHS Loan Repayment Program: www.ihs. 

gov/loanrepayment 

• (Alaska) SHARP-II: Providing Support-forService to Health Care Practitioners: http://dhss. 

alaska.gov/dph/HealthPlanning/Pages/sharp/ 

default.aspx 

• The Idaho State Loan Repayment Program: 

https://healthandwelfare.idaho.gov/Portals/0/ 

Health/Rural%20Health/SLRP%20FAQs%207-18. 

pdf 

If you, as a clinical supervisor, are 

going to serve as a resource and 

mentor in Indian Country, you 

need skills in providing traumainformed care, culturally adaptive 

and native EBPs, family therapy, and 

motivational interviewing (MI). You 

also need to have knowledge about 

traditional healing practices and build 

relationships and connections with 

spiritual advisors, traditional healers, 

elders, and others in the community. 

WHAT DO WE MEAN BY 

CLINICAL SUPERVISION? 

Clinical supervision is “a social infuence process 

that occurs over time, in which the supervisor 

participates with supervisees to ensure quality 

of clinical care. Effective supervisors observe, 

mentor, coach, evaluate, inspire, and create an 

atmosphere that promotes self-motivation, 

learning, and professional development. They 

build teams, create cohesion, resolve confict, 

and shape agency culture, while attending to 

ethical and diversity issues in all aspects of the 

process. Such supervision is key to both quality 

improvement and the successful implementation 

of consensus- and evidence-based practices.” 

Source: CSAT, 2009a, p. 3. 

Clinical Supervision 

Providing culturally competent clinical supervision 

is an important ingredient in professional development. Done well, it can help providers meet client 

needs in a culturally competent way; reinforce a 

community atmosphere among program staff; 

promote a nonjudgmental approach to learning; 

bridge the gap between education and day-to-day 

experience in the feld; help you, the administrator, 

retain staff; reduce health inequalities; and improve 

intervention outcomes. TIP 52, Clinical Supervision 

and Professional Development of the Substance 

Abuse Counselor (Center for Substance Abuse 

Treatment [CSAT], 2009a), provides considerable 

information on clinical supervision in behavioral 

health organizations, and it can serve as a primer 

for implementing clinical supervision. This section 

addresses the dynamics and challenges of clinical 

supervision that may arise when working crossculturally with non-native and native supervisors, 

supervisees, and clients. 

If you are an administrator managing a small tribal 

program or other community service, you may 

doubt that you can provide clinical supervision 

with limited funding, staff resources, and time 

Chapter 1 145 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

constraints. Foremost, clinical supervisors do not 

have to be full-time employees or work within 

the same program; they can be professionals 

who serve in a consulting role. Although licensing 

requirements and laws may restrict how you use supervisors; you may be able to fnd alternative ways 

of providing clinical supervision, such as telehealth 

supervision, facilitated group supervision, and 

peer-to-peer supervision groups. 

Most importantly, clinical supervision needs to 

occur in a safe, supportive, and nonjudgmental 

environment. Not unlike previous recommendations on embracing the spirit and philosophy of 

MI in counseling, the spirit of MI can be culturally 

responsive in supervision. Although several models 

of supervision exist, one model, Bernard and 

Goodyear’s (2004) four roles of clinical supervision, is compatible with MI and can be culturally 

adapted. Each role is an important element in 

building supervisor–supervisee relationships, and 

the roles change according to the needs of the 

supervisee as well as the supervisee’s client. For 

example, one moment you may be educating 

about the importance of traditional practices, 

whereas in the next moment you may be encouraging your supervisee to try something different 

in a session. The authors caution against using one 

particular role; instead, they advise supervisors to 

step out of their comfort zone to share knowledge, 

to encourage, to guide, and to collaborate. 

As reinforced throughout this TIP, relationships in 

American Indian and Alaska Native cultures are 

often not formed in prescribed environments or 

roles. Generally speaking, American Indians and 

Alaska Natives do not defne relationships based 

on titles, degrees, or positions; instead, relationships are often formed by the knowledge that you 

are known and accepted in the community and 

that you have a genuine interest in the community. 

SIX AREAS OF COMPETENCE 

AS A CULTURALLY COMPETENT 

SUPERVISOR 

1. Supervisor-Focused Personal Development: 

Supervisor has done extensive selfexploration regarding personal values, biases, 

and personal limitations. 

2. Supervisee-Focused Personal Development: 

Supervisor fosters supervisee self-exploration, 

awareness, and knowledge. 

3. Conceptualization: Supervisor promotes an 

understanding of the impact of individual 

and contextual factors on clients’ lives, such 

as the infuence of stereotypes and personal 

identity. 

4. Skill Development: Supervisor encourages 

fexibility between mainstream and both 

traditional and alternative interventions (for 

example, talking circles) as appropriate. 

5. Process: The supervisor–supervisee 

relationship is characterized by open and 

respectful communication. 

6. Outcome/Evaluation: Supervisors evaluate 

supervisees on their cultural competence, 

recommending additional or remedial 

education and training to address 

performance areas in need of improvement. 

Sources: Ancis & Ladany, 2001; Inman, 2008. 

Establishing a cross-cultural supervisor– 

supervisee relationship 

Culture is a major factor that infuences the 

relationship in clinical supervision. Differences in 

individual worldviews, values, traditions, history, and 

experiences inherently infuence a person’s biases, 

expectations, and behaviors. These differences get 

played out in clinical supervision. Remember there 

are at least three players: the supervisor, the supervisee, and the client—each with unique experiences, 

146 Chapter 1 
Part 2—Guide for Administrators Serving American Indians and Alaska Natives TIP 61

history, culture, and expectations that infuence 

the supervisor–supervisee relationship. From the 

outset, clinical supervision discussions should center 

on these areas. Initiating early discussions with 

supervisees regarding individual backgrounds and 

expectations can help establish a foundation on 

which to develop trust and empathy, and it demonstrates to staff your awareness of and willingness to 

discuss issues related to race and culture in a safe 

and supportive manner (Inman, 2008). 

Here are some questions to help guide your own 

self-awareness as a supervisor and facilitate a collaborative exploration with your supervisee (Corey, 

Haynes, Moulton, & Muratori, 2010): 

• How do you describe your (both supervisor and 

supervisee) ethnic and cultural identity? 

• What are the various cultural groups to which 

you belong? 

• In what ways do your worldviews (e.g., values, 

views, cultural practices) infuence how you work 

with clients and staff? 

• How might your cultural differences or similarities affect your clinical supervisory relationship? 

• How would you rate your knowledge of and 

comfort with discussing cultural issues, on a 

scale from 1 (very uncomfortable) to 10 (very 

comfortable)? Discuss what would need to 

happen to make you more comfortable or less 

comfortable. For example, if your supervisee 

initially responds with a 9 as very comfortable, 

you could ask, “What would need to happen 

to make it less comfortable, let’s say a 7. What 

would need to happen to make it a 10?” These 

questions make the discussion more informative 

and engaging rather than just talking about the 

rationale of the initial rating. 

• What challenges have you faced working with 

clients or coworkers whose culture differed from 

your own? 

CONDUCTING A CULTURAL 

AWARENESS SELF-EVALUATION 

An effective supervisor can acknowledge that 

he or she may have preexisting assumptions or 

experiences regarding different cultures that 

could infuence his or her interactions with staff 

members. It is crucial, then, that you be willing 

to evaluate your personal values, attitudes, 

experiences, and practices and how they could 

affect your interactions with supervisees and 

clients. Corey et al. (2010) offer some questions to 

consider as part of this self-evaluation: 

• How did I learn my cultural values? 

• What is my experience with other cultures and 

my perception of these cultures? 

• How might my beliefs affect the ability to 

supervise effectively? 

• How do I defne the relationship between 

culture and therapy? 

For additional resources and assessment tools, 

refer to TIP 59 (SAMHSA, 2014a). 

It is important to be fexible and 

humble as a clinical supervisor. I 

was thinking about gardening in 

our community, and how staff from 

the community would show up. We 

would come together to harvest the 

garden. During this time, there was 

a lot of ‘talk’ occurring, a coming 

together to listen, learn, and honor 

the wisdom of each other and our 

journey.” 

—Betty Poitra, Turtle Mountain Band of 

Chippewa, Belcourt, ND, TIP Contributor 

Supervision dynamics: Non-native supervisor 

with American Indian or Alaska Native 

supervisee 

A non-native supervisor of native supervisees 

should be able to demonstrate an understanding of 

the history, values, and culture of American Indians 

and Alaska Natives. However, it is not enough to 

know about the history and culture. You, as the 

clinical supervisor, need to demonstrate openness 

and humility to learn, including the willingness to 

learn about the history and culture specifc to the 

tribe or tribes represented in the program and 

among staff. You are not the expert on American 

Indian or Alaska Native history or ways, regardless 

of your background. Instead, you should remain 

receptive and fexible in modifying supervision 

Chapter 1 147 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

styles and techniques to match your supervisees’ 

needs and to improve your listening and relational 

skills when working with American Indian and 

Alaska Native staff and clients. 

Equally important, clinical supervisors need to 

monitor the supervisor–supervisee power dynamic, 

which is often affected by differences in race and 

culture. For example, White supervisors need to 

recognize that they may symbolically represent 

a history of oppression to an American Indian or 

Alaska Native supervisee. Although they should 

pay attention, listen, and help supervisees discuss 

their experiences in the role of supervisee, White 

supervisors should not refocus the session on their 

own feelings of “White guilt” or shame; nor should 

they attempt to share past experiences that may 

appear similar. In simple terms, it is not about you; 

rather, it is about your listening and learning. Similar 

to the role of provider in MI, your supervisees are 

the experts on their own experiences. You are there 

to help facilitate and guide the process. 

SUPERVISION AND CLIENT EXPERIENCES: THE INFLUENCE OF 

CULTURE 

American Indian and Alaska Native staff members working with American Indian and Alaska Native 

clients may encounter challenges that differ from those experienced by their non-native colleagues. 

Native supervisees may fnd that American Indian and Alaska Native clients want to discuss and obtain 

more personal information from them. As a supervisor, your role is to facilitate a discussion about what is 

culturally and clinically appropriate and fnd a balance that honors self-disclosure as well as boundaries. 

Remember that different cultures have different needs and expectations about personal space, emotional 

boundaries, and interpersonal boundaries. 

Relationships are particularly infuenced by community size. For example, if you live in a village of 600 

people, it is likely that your clients will be the store clerk, the pilot, and your child’s teacher or coach. In 

this scenario, there is no feasible way you can avoid many multiple relationships. Multiple relationships 

occur when a provider is in a professional role and another role with the same person, which raises ethical 

concerns for providers. Boundaries among American Indians and Alaska Natives are more fexible, so it 

takes some effort to balance boundaries and relationships. 

Another experience among native and non-native supervisees is the request from clients to meet needs 

outside the program’s parameters. For example, the provider has a client who asks directly for his or her 

advice and assistance in helping his niece who is depressed. Although he may be court-ordered to attend 

treatment, the client is more focused on getting help for his niece, even bringing her for his session at the 

center. As a clinical supervisor, you may believe it is inappropriate to comply with the client’s request. You 

may go further and assess that the client is focusing away from the reasons for his admission. Yet, it is not 

uncommon that American Indian and Alaska Native clients will seek assistance for others, especially after 

trust is formed in the relationship. Although your program may not be able to provide assessment and 

treatment services for his niece, you may be able to link the client to services and to anticipate that this 

will naturally happen if the program has developed good relations with the community. By anticipating 

that this is likely to happen, you can plan ahead on how best to manage informal requests for services and 

facilitate the access to care that falls out of the scope of services within your program. 

Supervision dynamics: Non-native supervisor 

with non-native supervisee 

In the non-native supervisor–supervisee relationship serving American Indian and Alaska Native 

clients, supervisors need to understand the history, 

culture, and beliefs of the community. They also 

need to become lifelong learners in cultural 

competence by seeking cultural consultation and 

further education and training, and by participating, 

when appropriate, in native community activities. 

When supervising non-native staff, a signifcant 

responsibility as a supervisor is reinforcing the 

value of and need for culturally responsive care 

while providing the resources to do so. Supervisors 

should attempt to increase their own and their 

supervisees’ awareness of how mainstream values 

and privilege affect treatment. Also, supervisors 

need to promote a strengths-based and traumainformed approach, rather than a perspective that 

views clients’ presenting concerns through the 

lens of defcits or pathology (e.g., framing clients’ 

148 Chapter 1 
TIP 61

 

Part 2—Guide for Administrators Serving American Indians and Alaska Natives 

behavioral reactions through a trauma-informed 

lens rather than interpreting the reaction as a 

diagnostic symptom of a personality disorder). 

For specifc suggestions and questions on how to 

facilitate cultural awareness during supervision, 

refer to “How To Engage in Self-Refection: A Tool 

for Counselor Training and Supervision,” TIP 59 

(SAMHSA, 2014a, p. 93). 

Supervision dynamics: American Indian or 

Alaska Native supervisor with non-native 

supervisee 

American Indian and Alaska Native supervisors 

should be cognizant of their beliefs and assumptions about non-native staff and how those beliefs 

may affect their relationships with non-native supervisees. At the same time, supervisors should also 

be aware of and make it a point to address supervisee beliefs and biases that may affect supervisee 

relationships and interactions with American Indian 

or Alaska Native clients. Using the self-awareness 

and self-refection questions highlighted in this 

chapter; the South direction in Part 1, Chapter 1, in 

this TIP; and TIP 59 (SAMHSA, 2014a); supervisors 

can guide discussions to further promote the 

development of cultural competence. 

Supervision dynamics: American Indian 

or Alaska Native supervisor with native 

supervisee 

Supervisors should be conscious of differences and 

issues that may arise in native supervisee–supervisor 

relationships, especially cultural identity and competence. Foremost, do not assume that native supervisees are culturally competent or knowledgeable 

about the specifc tribes you serve. Cultural identity 

may vary widely between you and your supervisees. You may be more traditional; they may have 

limited lifetime exposure to American Indian and 

Alaska Native cultures. You may have lived on a 

reservation your entire life; they may have lived 

in urban areas disconnected from their heritage. 

You may use traditional healing and ceremonies; 

they may rely on mainstream health care only. As a 

supervisor, build a bridge that enables supervisees 

to become culturally competent while honoring 

their path in cultural identity. 

POTENTIAL BENEFITS OF 

MENTORING PROGRAMS 

• Take the behavioral health services feld into 

the next generation. 

• Provide professional networking opportunities. 

• Develop mentee’s leadership qualities. 

• Encourage intellectual and professional 

development and stimulation. 

• Support professionals currently providing 

behavioral health services. 

• Provide a learning opportunity for both the 

mentee and mentor. 

• Offer opportunities to share knowledge and 

experiences and build collaborations. 

• Foster agency growth and workforce 

development. 

Source: NAI & AN ATTC, 2015. 

Mentoring 

Mentoring is another professional development 

activity that helps build and improve the skills and 

capabilities of staff members. It is evolving into a 

key workforce development approach in preparing 

the next generation of American Indian and Alaska 

Native behavioral health leaders and professionals. 

It complements native ways of knowing. 

Mentoring is typically a collaboration between two 

entities or individuals who have different levels of 

experience, such as a mentor–mentee relationship, 

whereby one person has more experience or a 

different experience to share; an organization that 

supports mentorship programs using its expertise 

to further develop the skills of an early career 

professional, including programs for youth; or an 

agency-to-agency mentorship program that shares 

knowledge and leadership skills to improve service 

capacity and sustainability. 

Mentoring is key to building an American Indian 

and Alaska Native behavioral health workforce. 

Although staff members may have educational 

degrees, certifcations, and licenses that have 

required practicum and internship experiences, 

mentorship programs do not have to require 

educational levels, licenses, or certifcations or even 

have specifc age requirements, depending on the 

Chapter 1 149 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

goals of the mentorship. Mentoring can be tailored 

formally or informally to match the needs and 

desired outcome for the individual or organization. 

A NOTE TO ADMINISTRATORS 

Ethics in Research With American 

Indian and Alaska Native 

Communities and Clients 

Researchers and administrators have an ethical 

responsibility to seek approval for research 

from tribal governance when working with 

American Indian and Alaska Native clients, 

tribes, and communities, regardless of location 

(e.g., Alaska Native Corporations, Urban Indian 

Health Organizations, American Indian tribal 

governments). Tribes need to give informed 

consent using a formal memorandum of 

agreement. This document clarifes the exact 

nature of the research; information that will 

be shared; how it will be shared; who will 

be involved in the research; what level of 

community involvement is required; who owns 

the data; who has copyright control; and how 

confdentiality is protected for the individual, 

tribe, and community. As an administrator, 

remain vigilant in respecting American Indian 

and Alaska Native intellectual, cultural, and 

spiritual property, including the acquisition and 

use of data. 

Provider Competencies 

Competence means capability. Are your staff 

members knowledgeable about American Indian 

and Alaska Native culture? Is this knowledge tribe 

specifc? Do they possess an understanding of 

American Indian as well as Alaska Native history 

and its effects on native families and communities 

today? What knowledge do they have about traditional healing and beliefs about illness and health? 

As an administrator or clinical supervisor, you want 

to determine the knowledge, understanding, skills, 

and attitudes needed for providers to be culturally 

competent to meet the needs of your clients. 

The text that follows lists provider competencies 

focused on the training, knowledge, understanding, skills, and attitudes needed to work with 

American Indians and Alaska Natives. The Western 

Interstate Commission for Higher Education 

(1998) convened an expert panel that compiled 

this list of competencies to serve as guidelines 

for managed care organizations providing mental 

health services to American Indian and Alaska 

Native clients. These competencies can guide the 

selection of your professional development activities as outlined in the previous section. This list is 

not exhaustive, and the order of items does not 

refect priority or the sequence in which to acquire 

certain skills and knowledge. An understanding of 

American Indian and Alaska Native history should 

support all the competencies discussed below. 

Although these competencies focus primarily on 

mental health, the majority of these factors also are 

important to effective substance abuse treatment 

and interventions with American Indian and Alaska 

Native clients. 

Training competencies 

The following list identifes specifc training needs 

for providers working with American Indian and 

Alaska Native clients and communities. The training 

includes: 

1. Specialized assessment and service delivery 

techniques that meet the cultural needs of 

American Indian and Alaska Native clients. 

2. Recognition and integration of the unique 

features of traditional, transitional or acculturating, and multicultural and multiracial clients and 

families. 

3. Appreciation of culturally based traditional 

healing systems and traditions of American 

Indian and Alaska Native communities served. 

4. Techniques to engage and build alliances with 

communities, as well as culturally acceptable 

and therapeutic boundary-setting with 

American Indian and Alaska Native clients. 

5. Interdisciplinary team interaction and functioning to promote effective care. 

6. Use of clients’ preferred language in the 

treatment process. 

7. Treatment of American Indian and Alaska 

Native LGBTQ/Two-Spirit people, with 

attention to issues related to combined 

prejudice regarding mental illness, ethnicity, 

sexuality, and gender roles. 

150 Chapter 1 
Part 2—Guide for Administrators Serving American Indians and Alaska Natives TIP 61

8. Documentation or communication of specialized assessment and service delivery methods 

such that staff who are not culturally competent 

will be able to beneft from it. 

Knowledge competencies 

Knowledge competencies should begin with selfawareness and self-knowledge about personal 

beliefs, values, norms, stereotypes, and biases and 

how these may infuence personal and professional 

interactions, particularly with clients. The following 

list identifes the areas of knowledge necessary to 

be culturally responsive toward American Indian 

and Alaska Native clients, supervisors, and other 

staff members. Areas of culturally responsive 

knowledge include: 

1. Differences in symptom expression, symptom 

language, and symptomatic patterns presented 

by American Indian and Alaska Native clients. 

2. Differences in thresholds of individual and 

social distress in American Indian and Alaska 

Native clients and tolerance of symptoms 

exhibited by their natural support systems, 

including individuals, families, and individuals’ 

or families’ informal and formal social context. 

3. Differences in the attribution of mental illness 

and issues around prejudice/shame specifc to 

American Indian and Alaska Native cultures. 

4. Differences in the acceptability and effectiveness 

of different treatment modalities in American 

Indian and Alaska Native populations. 

5. Culture-bound syndromes associated with the 

American Indian and Alaska Native communities served by the program. 

6. Use of formally trained interpreters by clinicians 

unable to communicate with clients using 

clients’ preferred language. 

7. Effects of class and ethnicity on behavior, 

attitudes, and values. 

8. Help-seeking behaviors common among 

American Indians and Alaska Natives. 

9. Self-treatment behaviors often found among 

American Indians and Alaska Natives, including 

substance misuse and self-medication. 

10. Roles and manifestations of spirituality, 

tradition, and faith in American Indian and 

Alaska Native communities. 

11. Roles of verbal and nonverbal language, 

speech patterns, and communication styles 

in American Indian and Alaska Native 

communities. 

12. Effects of human service policies on American 

Indians and Alaska Natives and reduction of 

barriers through informed participation in 

systems change efforts. 

13. Resources (e.g., agencies, individuals, informal 

helping networks, research) that can be used 

on behalf of American Indian and Alaska Native 

clients and communities. 

14. Roles and types of power relationships within 

the community, agency, or institution and 

their impact on American Indians and Alaska 

Natives. 

15. Recognition of the ways that mainstream 

professional values may confict with or be 

responsive to the needs of American Indians 

and Alaska Natives. 

Understanding competencies 

The following list describes areas of understanding 

that are particularly salient when working with 

American Indian and Alaska Native clients and 

communities, such as understanding historical 

factors that affect health, the effects of historical 

traumas, and traditional medicine. These areas 

include: 

1. Historical trauma that affects the mental health 

of Native Americans, such as racism, forced 

relocation, loss of sacred lands, and boarding 

school experiences. 

2. Factors that defne cultural differences among 

sovereign tribal nations and communities, 

including differences related to history, traditions, values, belief systems, acculturation and 

migration history, and language; this information is particularly important for providers who 

serve multiple tribes. 

3. Particular psychosocial stressors and traumas 

relevant for American Indian and Alaska Native 

clients, including war, personal trauma, unique 

aspects of cultural survival and maintenance, 

and socioeconomic status. 

4. Cultural variations across Indian Country. 

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TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

5. Native clients in a family life cycle and intergenerational conceptual framework, in addition to 

individual identity development in relation to 

family and cultural developmental frameworks. 

6. Differences in culturally acceptable behavior or 

psychopathological characteristics of American 

Indians and Alaska Natives. 

7. Traditional healing practices and the role of 

belief systems (e.g., religion, spirituality) in 

the treatment of American Indians and Alaska 

Natives. 

8. A community-based system of mental health 

services for American Indians and Alaska 

Natives, including appropriate, culturally 

relevant components and characteristics. 

9. Public administrative issues in developing, 

implementing, and evaluating programs for 

American Indians and Alaska Natives. 

10. Dynamics of language use and conceptual 

frameworks among monolingual and bilingual 

clients. 

11. The effects of the acculturation process on 

American Indians and Alaska Natives. 

Skill competencies 

The following list provides an overview of culturally 

responsive clinical skills necessary for behavioral 

health service providers. These skills include the 

ability to: 

1. Interview and assess minority clients and 

families based on psychological, social, biological, cultural, political, spiritual, environmental, 

and economic models. 

2. Communicate and listen effectively across 

cultures. 

3. Assess American Indian and Alaska Native 

clients with an understanding of cultural differences in psychopathology. 

4. Formulate culturally responsive service plans 

(case management and treatment) that are 

appropriate for clients’ and their families’ 

concept of mental illness. 

5. Create and implement multidisciplinary service 

plans (case management and treatment), 

including culture, family, and community. 

6. Use culturally appropriate community resources 

(e.g., family, clans, societies, church, community 

members, other groups). 

7. Provide psychotherapeutic and psychopharmacological interventions with an understanding 

of the cultural differences in treatment expectations and biological response to medications. 

8. Recognize the limitations of standardized 

psychological tests and testing procedures 

when used with American Indian and Alaska 

Native clients. 

9. Use a culturally sensitive approach to conducting research. 

10. Provide education and advocacy interventions 

that promote clients’ and families’ voices and 

ownership in shaping the service delivery 

system. 

11. When feasible, use the clients’ language to 

elicit the range and nuances of emotions, 

feelings, dynamics, and so forth. 

12. Know when and how to use interpreters and 

understand the limitations of using interpreters. 

Be aware of how interpreters (knowingly or 

unknowingly) may censor and modify information during the process of interpretation. 

13. Learn the particulars of social conventions 

(from engaging protocols to termination rituals) 

within American Indian and Alaska Native 

cultures. 

14. Be open to continually learning the cultures of 

American Indian and Alaska Native clients and 

families through varied and multiple techniques 

(e.g., conferences, visiting in community, 

reading books, hanging out, attending 

community forums). Cultural competence is a 

learning process, not a product. 

15. Be aware of racial and ethnic differences and 

know when to respond to culturally based cues. 

16. Assess the meaning of race and ethnicity for 

individual clients. 

17. Differentiate symptoms of intrapsychic stress 

from stress arising from the social structure. 

18. Work toward empowerment of clients and 

minority communities. 

152 Chapter 1 
Part 2—Guide for Administrators Serving American Indians and Alaska Natives TIP 61

19. Use community resources on behalf of 

American Indian and Alaska Native clients and 

their communities. 

20. Use agency resources on behalf of American 

Indian and Alaska Native clients and their 

communities. 

21. Recognize and combat racism, racial stereotypes, and myths held by individuals and 

institutions. 

22. Evaluate new techniques, exemplary practices, 

research, and knowledge for their validity and 

applicability in working with American Indians 

and Alaska Natives. 

Attitudinal competencies 

The following list identifes attitudes and values 

that providers need to cultivate to work effectively 

with American Indian and Alaska Native clients and 

communities. They include: 

1. Personal qualities that refect genuineness, 

accurate empathy, nonpossessive warmth, and 

a capacity to respond fexibly to a range of 

possible solutions. 

2. Acceptance of ethnic differences between 

people and how these differences affect the 

treatment process. 

3. Willingness to work with clients of various 

ethnic minority groups. 

4. Respect for the immigrant, migration, colonization, and dissolution of culture experience. 

Before You Leave 

As an administrator, your greatest challenges 

include funding and sustainability of your services, 

recruitment and retention of staff, implementing of 

workforce development activities, and employing 

strategies to support future leadership among 

American Indian and Alaska Native youth. Through 

collaboration with other organizations, making use 

of available resources, and involving community 

leadership, the route across rough waters will be 

safely navigated with others. The next chapter 

provides many hands-on resources that support the 

administrative issues, needs, and tasks outlined in 

this chapter. 

It must not be forgotten that our 

old ones aspired and dreamed, 

created and struggled, and cared 

for one another. This generation 

and future generations must 

remember that their greatest 

legacy is the teaching that 

everyone has healing gifts to 

build our common decency and 

wholeness.” 

—Martin Waukazoo, Lakota 

Source: Nebelkopf & Phillips, 2004, p. 5. 

Chapter 1 153 
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TIP 61 BEHAVIORAL HEALTH SERVICES FOR 

AMERICAN INDIANS AND ALASKA NATIVES

 

 

Part 2, Chapter 2 

Introduction 

If you have one hundred people 

who live together, and if each one 

cares for the rest, there is one mind.” 

—Shining Arrow, Crow 

The fnal chapter of this TIP provides you with 

organizational tools to help you, as administrators 

and program managers, address a number of the 

challenges mentioned in Part 2, Chapter 1. As you 

discover your unique pathways to designing and 

implementing programs and services specifcally 

tailored to meet the behavioral health needs of 

American Indian and Alaska Native clients, this 

chapter offers you tools for: 

• Developing a culturally competent and responsive workforce. 

• Developing native evidence-based practices 

(EBPs). 

• Integrating care, including traditional practices 

in behavioral health programs. 

• Creating sustainability. 

Some of these tools were originally developed for 

a specifc American Indian or Alaska Native tribe or 

community, so in some circumstances, the material 

was revised to make it suitable for a pan-native population. Further adaptations may be required if your 

program is serving a specifc tribe or community to 

make the material more culturally relevant. The tools 

presented in this chapter are either in the public 

domain, have been adapted from the original, 

or have been reprinted with permission from the 

author for use in your program. 

Developing a Culturally 

Competent and Responsive 

Workforce 

The frst step in developing a culturally competent 

and responsive workforce in American Indian and 

Alaska Native communities is hiring and then 

orienting new staff to the community, culture, and 

traditions of the people they will be serving. The 

Indian Health Service (IHS) has produced a number 

of publications (available at www.ihs.gov/retention/ 

retentionstrategies) that may be helpful to your 

program in recruiting and retaining staff. The New 

Hire Quick Reference Guide (IHS, 2015a) describes 

specifc tasks for working with newly hired staff in 

your organization, including the community liaison 

(see “The Role of the Community Liaison”). The 

tasks are organized chronologically beginning prior 

to the employee’s start date and continuing through 

the frst 6 months. 

THE ROLE OF THE COMMUNITY LIAISON 

A key staff member involved in the orientation of new behavioral health employees is the community 

liaison. The community liaison keeps the lines of communication open between the local community and 

the Indian health facility or behavioral health program. A tribal leader, an accepted community member, an 

elder, or a supervisor at your program may act as the liaison. He or she takes on specifc roles, such as: 

• An ambassador who understands your program’s mission and fosters goodwill and respect in the 

community, while also promoting the vision and values of the local tribe. 

• A leader who maintains strong, collaborative relationships between your program and the local 

community and shares information about local events and community issues with your program, tribal 

entities, and community stakeholders. 

• A guide who will introduce new staff to the community and expose staff to many aspects of the tribal 

culture, including ceremonial events, observances, and traditions. 

Source: IHS, 2014. 

155 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

NEW HIRE QUICK REFERENCE GUIDE 

1. Prior to the Start Date 

Welcoming an employee to your Indian health facility and paving the way for long-term success is 

easy if you set up an action plan that appropriately addresses his or her ability to succeed within the 

organization from the start. Your plan to integrate him or her into your facility should begin immediately 

following his or her acceptance of the job offer and incorporate the essential steps below. 

ACTION TO BE COMPLETED BY 

One of the most important documents a new hire needs is an offcial 

letter of hire from Human Resources (HR) detailing the position, 

responsibilities, salary, and specifc hiring terms. This letter provides 

offcial documentation of employment, which is necessary for 

mortgage lenders, school enrollment, health insurance, benefts, 

and utility activation, as well as other key tasks needed to settle in. 

Include a “Welcome” letter and an information packet containing 

information about the facility, community (background, traditions, 

observances), local site amenities (housing, transportation, schools, 

businesses, services, etc.), and other pertinent information about your 

site 1 month prior to the new hire coming on board. Include a point of 

contact such as a liaison or mentor at the facility. 

Chief Executive Offcer (CEO)/ 

Clinical Director/Supervisor 

Identify staff with similar responsibilities to function as the new 

employee’s coach/mentor for work-related processes and procedures. 

CEO/Clinical Director/Supervisor 

Work closely with your HR representative and arrange to have all 

necessary paperwork ready for the new employee’s arrival. 

CEO/Clinical Director/ 

Supervisor/HR Representative 

Likewise, notify your Information Technology (IT) department of 

the new hire and arrange to have all the necessary technology and 

telecommunications equipment set up prior to his or her arrival 

(computer, email, phone, beeper, etc.). 

CEO/Clinical Director/ 

Supervisor/IT Department 

Prepare the new employee’s work area with any necessary offce 

supplies prior to arrival date. 

CEO/Clinical Director/Supervisor 

Add the new employee to the department or unit’s organizational 

contact and routing lists within a week of reporting date. 

CEO/Clinical Director/Supervisor 

Schedule the new employee’s frst-week activities and prepare his or 

her agenda, including names, titles, and departments/areas of key 

contacts with whom he or she will meet. 

CEO/Clinical Director/Supervisor 

Send an introductory email to staff announcing the new employee’s 

arrival, function, and location. 

CEO/Clinical Director/Supervisor 

Make plans to have lunch with the new employee or arrange to have 

lunch brought in to the facility for a meet-and-greet with the staff on 

the frst day. 

CEO/Clinical Director/Supervisor 

Identify an appropriate community/facility representative to serve as 

a cultural liaison for the new hire. Arrange to have the chosen liaison 

available to meet with the new hire during his or her frst week to 

ensure he or she has an appropriate understanding of the community 

and tribal ways. 

CEO/Clinical Director/ 

Supervisor/Cultural Liaison 

Continued on next page 

156 Chapter 2 
Part 2—Implementation Guide for Behavioral Health Program Administrators TIP 61

NEW HIRE QUICK REFERENCE GUIDE (CONTINUED) 

2. The First Day 

Although a new job can be exciting for someone new to your team, it can also bring frst-day jitters and 

an overwhelming sense of stress while trying to remember names, learn new processes, and fnd his 

or her way around the facility. You can help to alleviate these concerns by putting the new hire at ease, 

assuring him or her that an organizational chart is available to use as a “who’s who” resource and to map 

out each team within each department. Also, let the new hire know that you have an open-door policy 

should he or she have any questions or concerns. In doing so, you will immediately establish a sense of 

value and an understanding that your support is always available. Also, take the frst day to confrm the 

new hire’s schedule, daily responsibilities and, if applicable, any previously agreed-upon telecommuting 

arrangement, and then share that information with the HR department representative who’s responsible 

for going over the new hire’s employee orientation. It is important to let the employee know that he or 

she should allow a few hours that frst day to go over all necessary documentation and employment 

benefts with HR. 

ACTION TO BE COMPLETED BY 

Be available to personally greet the new employee as he or she 

arrives. Schedule meetings, conferences, and phone calls for later in 

the day. 

CEO/Clinical Director/ 

Supervisor 

Personally, lead the new employee through a tour of the facility. 

Orient him or her to specifc locations, such as: 

• Lunchroom or break room 

• Bathrooms 

• Conference rooms 

• Offce equipment and supplies 

• Parking 

CEO/Clinical Director/ 

Supervisor 

Introduce the new employee to the HR representative responsible for 

going over all paperwork, benefts, etc. 

CEO/HR Representative 

Introduce the new employee to all staff and the chosen mentor with 

whom he or she will work. 

CEO/Clinical Director/ 

Supervisor 

Orient the new hire to all technology: 

• Phone/intercom systems 

• Computer system 

• IT/security 

• Time-management software 

• Meeting schedules 

CEO/Clinical Director/ 

Supervisor/IT Department 

Introduce the new employee to the executive staff—CEO (if other 

than the supervisor), Chief Marketing Offcer, Chief Financial Offcer, 

etc.—to acquaint him or her with management and to serve as a 

welcome to the entire facility team. 

CEO/Clinical Director/ 

Supervisor 

Continued on next page 

Chapter 2 157 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

NEW HIRE QUICK REFERENCE GUIDE (CONTINUED) 

3. The First Week 

Orientation sessions are not just important to new employees. They are also essential to the Indian health 

program because they address the organization’s policies and procedures and new-hire concerns and 

help staff members form accurate expectations about the job they have just taken on. Performing the 

tasks below will ensure that your new employees are fully on board right from the beginning. 

ACTION TO BE COMPLETED BY 

Meet to review and discuss the new hire’s IHS orientation, including 

explaining the following: 

• IHS Mission 

• Introduction to IHS (IHS 101) 

• Employee ethics 

• Communication 

• Customer service 

Supervisor 

Identify training and development activities needed within the frst 6 

months and sign up the new employee for appropriate classes. 

Supervisor 

Set performance expectations and discuss how and when the employee 

will be evaluated. 

Supervisor 

Review and discuss the employee’s frst week, answer his or her 

questions, and solicit his or her feedback. 

Supervisor 

Introduce the new hire to the community liaison chosen to help with his 

or her immersion to the community. Ensure the new hire understands 

the local traditions, heritage, cultural observances and ceremonies. 

Supervisor/Community 

Liaison 

4. Within the First 6 Months 

Inspiring a new employee to want to remain at your Indian health facility is an ongoing task. Retention 

is a process that must be actively nurtured and developed during the tenure of each employee. This 

includes giving your employees the attention they require and deserve, offering encouragement and 

support, acknowledging a job well done and ensuring that he or she has a voice within your organization 

and that his or her input—as well as the input of all staff members—is key to the success of your facility. In 

short—give your employees a reason to stay! 

ACTION TO BE COMPLETED BY 

Check in regularly with the new employee to see if there are any questions 

or concerns. Provide feedback often, including positive reinforcement. 

CEO/Clinical Director/ 

Supervisor 

Schedule a 6-month new-hire evaluation. Supervisor 

Provide monthly feedback to new employees regarding their job performance, including a formal performance evaluation in their third month. Supervisor 

Celebrate each new hire’s 6-month anniversary with a planned lunch or 

other form of recognition. 

CEO/Clinical Director/ 

Supervisor 

Adapted from material in the public domain. 

158 Chapter 2 
Part 2—Implementation Guide for Behavioral Health Program Administrators TIP 61

Once your staff is in place, it is essential to provide 

culturally appropriate education opportunities for 

immersion into tribal culture, training, and culturally 

appropriate clinical supervision for all staff, but particularly for non-native providers. Two instruments, 

the Native American Cultural Assessment Survey 

and the Sample Pretest for Non-Native Counselors, 

provided below, are adapted from the Native 

American Curriculum for State Accredited, NonTribal Mental Health & Substance Abuse Programs 

in South Dakota offered by the National American 

Indian and Alaska Native Addiction Technology 

Transfer Center. 

A NOTE TO ADMINISTRATORS AND PROGRAM MANAGERS 

The original training curriculum was developed to be applicable to a particular group of tribes, but in 

adapting these materials, the attempt was made to identify cultural practices that are common to a 

number of American Indian and Alaska Native cultures or are now considered pan-Native American. Not 

all of these practices may be relevant to a given native culture. These documents should be tailored, as 

appropriate, to specifc cultures (e.g., highlighting specifc traditional practices, introducing words from 

that culture’s language). These surveys were intended to assess the cultural knowledge of substance 

abuse providers, but they are relevant in any behavioral health setting that offers services to American 

Indian and Alaska Native clients. 

Chapter 2 159 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

The Native American Cultural Assessment Survey is a useful tool to help you evaluate the cultural competence of your entire program, but it can also be used to give you a sense of how well your organization is 

doing in recruitment and hiring, providing culturally responsive training and supervision to your staff, and 

offering opportunities for staff immersion in the local tribal culture. 

NATIVE AMERICAN CULTURAL ASSESSMENT SURVEY 

Date: __________________________ Facility Name: _______________________________________________________ 

Directions: 

Please provide information regarding the extent to which substance abuse programs in [insert your state] 

provide policies, programs, and services that refect [insert Native American tribes/groups found in your 

state] cultures. Please check the appropriate boxes or fll in the appropriate numbers to best refect your 

responses. 

Please note the following: 

• “Traditional” refers to Native Americans who understand and practice their cultural and spiritual 

beliefs/teachings 

• NA refers to Native American 

• S/A refers to Substance Abuse 

• D/L/N refers to the South Dakota tribes, Dakota, Lakota, and Nakota 

Respondent Data 

Your Gender: 

□ Male 

□ Female 

□ Other 

Your Predominant Ethnic Heritage: 

□ a. American Indian/Alaska Native 

□ b. Asian Pacifc/Pacifc Islander 

□ c. Black/African American 

□ d. Caucasian 

□ e. Hispanic or Latino-American 

□ f. Other: (Please Specify) ______________________ 

Certifcation Status: 

□ a. Not Certifed 

□ b. Level I 

□ c. Level II 

□ d. Level III 

□ e. Prevention 

 

 

___________________________________________ 

Certifed By: (Check all that apply) 

□ a. International Certifcation & Reciprocity 

Consortium (which has regional Native 

American certifcation exams) 

□ b. A regional association (e.g., the Regional 

Native American Chemical Dependency 

Association) 

□ c. State of [insert state] 

□ d. Other: (Please identify) 

Number of hours of training, specifcally related 

to D/L/N cultures, that you have had in the last 12 

months. 

□ a. None 

□ b. 1–5 hours 

□ c. 6–10 hours 

□ d. 11–15 hours 

□ e. 16–20 hours 

□ f. More than 20 hours 

Continued on next page 

160 Chapter 2 
TIP 61

Program Data 

___________________________________________ 

Which of the following descriptors best 

identifes your program? (Check all that apply) 

□ a. Correctional facility 

□ b. IHS program 

□ c. Private program 

□ d. State program 

□ e. Tribal program 

□ f. Veterans Administration program 

□ g. Other: (Please identify) 

 

 

 

 

 

___________________________________________ 

Type of services your program provides: 

(Check all that apply) 

□ a. Clinically managed low-intensity 

residential services (halfway house) 

□ b. Clinically managed residential 

detoxifcation services 

□ c. Day treatment services 

□ d. Early intervention services 

□ e. Gambling services 

□ f. Inhalant abuse/dependency treatment 

services 

□ g. Opioid substitution services 

□ h. Intensive outpatient services 

□ i. Medically monitored intensive inpatient 

treatment services (Adolescent) 

□ j. Medically monitored intensive inpatient 

treatment services (Adult) 

□ k. Outpatient services 

□ l. Prevention services 

□ m. Community mental health services 

□ n. Other: (Please specify) 

 

 

Program Accreditation Status: (Check all that apply) 

□ a. Accredited by the state of [insert state] 

□ b. Accredited by regional association (e.g., 

Northern Plains Chemical Dependency 

Association) 

□ c. Tribal accreditation 

□ d. Joint Commission on Accreditation of 

Healthcare Organizations Accreditation 

□ e. Accreditation status pending 

□ f. Nonaccredited program 

□ g. Other accreditation: (Please specify) 

___________________________________________ 

 

Program Location: (Check all that apply) 

□ a. On a Reservation 

□ b. Off-Reservation—Rural Area 

□ c. Off-Reservation—Urban Area 

 

___________________________________________ 

Ethnic Populations Served: 

□ a. All ethnic populations

□ b. Only persons of Native American/Alaskan 

heritage enrolled in a federally or staterecognized tribe/nation 

□ c. Other: (Please identify) 

 

___________________________________________ 

Population(s) served: (Check all that apply) 

□ a. Adult females 

□ b. Adult males 

□ c. Co-ed adults 

□ d. Adolescent females 

□ e. Adolescent males 

□ f. Co-ed adolescents 

□ g. Lesbian, gay, bisexual, transgender, and 

questioning (LGBTQ) adults 

□ h. LGBTQ adolescents 

□ i. Other: (Please identify) 

Part 2—Implementation Guide for Behavioral Health Program Administrators 

NATIVE AMERICAN CULTURAL ASSESSMENT SURVEY (CONTINUED) 

Continued on next page 

Chapter 2 161 
TIP 61

CLIENTS SERVED (Male/Female/Other) MALE FEMALE OTHER 

Total number of clients served during the past 12 months 

Total number of Native American clients served during the past 12 

months 

Total number of Native American clients served during the past 12 

months who reside on a reservation setting 

Total number of Native American clients served during the past 12 

months who reside on off-reservation settings 

Total number of transient Native Americans served during the past 12 

months 

Behavioral Health Services for American Indians and Alaska Natives 

NATIVE AMERICAN CULTURAL ASSESSMENT SURVEY (CONTINUED) 

Current Employee Certifcation Status: 

CERTIFICATION # ADMINISTRATORS # COUNSELORS # SUPPORT STAFF 

Trainee 

Level I 

Level II 

Level III 

Prevention 

Highest Educational Levels of Staff Members: 

EDUCATION LEVEL # ADMINISTRATORS # COUNSELORS # SUPPORT STAFF 

GED 

High School 

Associate’s Degree 

Bachelor’s Degree 

Master’s Degree 

Ph.D. 

Continued on next page 

162 Chapter 2 
TIP 61

BOARD/STAFF/MEMBERS/CONSULTANTS # NATIVE AMERICANS # NON-NATIVE AMERICANS 

Policy Board/Board of Directors 

Administrators/Directors 

Clinical Supervisors 

Certifed Counselors 

Counselor Trainees 

Medical Staff 

Psychologists 

Traditional Cultural Staff Consultants 

Social Workers 

Cooks, Security, Others 

Aides/Technicians 

Clerical Staff 

Custodial/Groundskeepers 

Computer Support Staff 

Other: (please specify) 

NATIVE AMERICAN CULTURAL ASSESSMENT SURVEY (CONTINUED) 

163 

Part 2—Implementation Guide for Behavioral Health Program Administrators 

Chapter 2 

Please provide further program information by circling the one most appropriate response number 

for each of the following statements. Use the following scale to express your level of agreement or 

disagreement with each statement: 

1=Strongly Disagree 2=Disagree 3=Agree 4=Strongly Agree ?=Don’t Know 

1 Program staff receive training on how to assess NA clients’ relationship 1 2 3 4 ? with their tribal culture. 

Program staff receive training on how to assess NA clients’ relationship 1 2 3 4 ? with their traditional tribal spiritual practices. 

3 Program has purifcation/sweat lodge on its grounds. 1 2 3 4 ? 

4 Program has access to a purifcation/sweat lodge located off the grounds 1 2 3 4 ? of the program. 

2 

Continued on next page 
TIP 61

1=Strongly Disagree 2=Disagree 3=Agree 4=Strongly Agree ?=Don’t Know 

5 Program conducts “client satisfaction surveys” to receive feedback from 1 2 3 4 ? clients regarding NA programs and services. 

6 When needed, the program provides NA language interpreters for clients 1 2 3 4 ? and staff. 

7 Program collects data of NA clients’ experiences with their culture 1 2 3 4 ? (language, songs, customs, etc.). 

8 Program collects data of NA clients’ experiences with their traditional, 1 2 3 4 ? spiritual ceremonies (purifcation lodges, vision quests, sun dances, etc.). 

9 Program has working relationships with one or more tribal health 1 2 3 4 ? departments of reservations in the state. 

10 Program has working relationships with one or more Urban Indian Health 1 2 3 4 ? Departments in the state. 

11 Program has working relationships with one or more IHS clinics or 1 2 3 4 ? hospitals in the state. 

12 Program has working relationships with one or more NA tribal mental 1 2 3 4 ? health departments. 

13 Program includes statements related to NA culture and spirituality in its 1 2 3 4 ? mission statement. 

14 Program board of directors or advisory board members monitor the 

program’s progress of including NA cultural beliefs and spiritual practices 1 2 3 4 ? 

into the treatment regimen. 

15 Program routinely contacts tribal and other NA programs to recruit staff. 1 2 3 4 ? 

16 Program has a resource pool of NA women and men who can make 1 2 3 4 ? presentations about culture and spirituality for staff and clients. 

17 Program routinely uses the services of a medicine man/woman. 1 2 3 4 ? 

18 Program employs a Native American Cultural Advisor on a part-time basis. 1 2 3 4 ? 

19 Program employs a Native American Spiritual Advisor on a full-time basis. 1 2 3 4 ? 

20 All new staff members receive orientation about NA cultures and spiritual 1 2 3 4 ? beliefs and practices. 

Behavioral Health Services for American Indians and Alaska Natives 

NATIVE AMERICAN CULTURAL ASSESSMENT SURVEY (CONTINUED) 

Continued on next page 

164 Chapter 2 
Part 2—Implementation Guide for Behavioral Health Program Administrators TIP 61

NATIVE AMERICAN CULTURAL ASSESSMENT SURVEY (CONTINUED) 

Cultural/Spiritual Activities: Program Staff 

Please use the following scale to identify the level of training that program staff members receive on the 

following aspects of D/L/N lifestyles: 

1=No Training at All 2=Little Training 3=Moderate Training 4=Extensive Training ?=Don’t Know 

1 Urban/Reservation political structures 1 2 3 4 ? 

2 Urban/Reservation social structures 1 2 3 4 ? 

3 Urban/Reservation economics 1 2 3 4 ? 

4 NA tribal histories 1 2 3 4 ? 

5 Colonization 1 2 3 4 ? 

6 Oppression 1 2 3 4 ? 

7 Cultural genocide 1 2 3 4 ? 

8 Historical grief issues 1 2 3 4 ? 

9 Urban/Reservation mental health services 1 2 3 4 ? 

10 Urban/Reservation social service programs 1 2 3 4 ? 

11 Healing ceremonies and medicine people 1 2 3 4 ? 

12 IHS programs/services 1 2 3 4 ? 

13 Bureau of Indian Affairs social service programs 1 2 3 4 ? 

14 Urban/Reservation substance abuse programs 1 2 3 4 ? 

15 NA languages 1 2 3 4 ? 

16 Tribal pow wow and ceremonial songs 1 2 3 4 ? 

17 Tribal artwork 1 2 3 4 ? 

18 Tribal crafts 1 2 3 4 ? 

19 How to make pow wow dancing regalia 1 2 3 4 ? 

20 How pow wows are structured 1 2 3 4 ? 

21 How tobacco is used in ceremonies 1 2 3 4 ? 

22 How other herbs [insert appropriate ones for NA cultures in your state] 1 2 3 4 ? are used in ceremonies 

Continued on next page 

Chapter 2 165 
TIP 61

1=No Training at All 2=Little Training 3=Moderate Training 4=Extensive Training ?=Don’t Know 

23 On the purposes of purifcation ceremonies 1 2 3 4 ? 

24 On the purposes of fasting/vision quest ceremonies 1 2 3 4 ? 

25 On the purposes of dancing ceremonies 1 2 3 4 ? 

26 On the purposes of other cultural ceremonies appropriate to 1 2 3 4 ? NA cultures in the state 

27 The family structure of the culture(s) 1 2 3 4 ? 

28 How healing ceremonies are conducted 1 2 3 4 ? 

29 How greeting or welcoming ceremonies are conducted 1 2 3 4 ? 

30 How ceremonies honoring an individual are conducted 1 2 3 4 ? 

31 How naming ceremonies are conducted, if applicable 1 2 3 4 ? 

32 The traditional religious beliefs of the culture(s) 1 2 3 4 ? 

33 On the purposes of Native American Church meetings 1 2 3 4 ? 

34 On appropriate uses of the sacred medicine, peyote 1 2 3 4 ? 

35 Cultural continuum/acculturation process as it relates to NA cultures 1 2 3 4 ? in the area 

36 Red Road concepts 1 2 3 4 ? 

37 Customs and protocols for grieving, wakes, funerals, and memorials 1 2 3 4 ? 

38 Other: (please describe) 1 2 3 4 ? 

Behavioral Health Services for American Indians and Alaska Natives 

NATIVE AMERICAN CULTURAL ASSESSMENT SURVEY (CONTINUED) 

Staff training regarding cultural/spiritual activities mostly occurs: 

□ a. Onsite 

□ b. Offsite 

□ c. Does not apply 

Continued on next page 

166 Chapter 2 
TIP 61

The number of times, in a fscal year, that the following program staff members attend offsite training 

programs to learn about NA cultures and spirituality. (Circle appropriate number) 

Policy Board Members 0 1 2 3 4 5 6 7 8 9 10/+ 

Advisory Board Members 0 1 2 3 4 5 6 7 8 9 10/+ 

Program Administrators 0 1 2 3 4 5 6 7 8 9 10/+ 

Counselors 0 1 2 3 4 5 6 7 8 9 10/+ 

Clerical Support Personnel 0 1 2 3 4 5 6 7 8 9 10/+ 

Support Personnel 0 1 2 3 4 5 6 7 8 9 10/+ 

Number of times, in a fscal year, that the following staff members attend onsite training programs to 

learn about NA cultures and spirituality. (Circle appropriate number) 

Policy Board Members 0 1 2 3 4 5 6 7 8 9 10/+ 

Advisory Board Members 0 1 2 3 4 5 6 7 8 9 10/+ 

Program Administrators 0 1 2 3 4 5 6 7 8 9 10/+ 

Counselors 0 1 2 3 4 5 6 7 8 9 10/+ 

Clerical Support Personnel 0 1 2 3 4 5 6 7 8 9 10/+ 

Support Personnel 0 1 2 3 4 5 6 7 8 9 10/+ 

Part 2—Implementation Guide for Behavioral Health Program Administrators 

NATIVE AMERICAN CULTURAL ASSESSMENT SURVEY (CONTINUED) 

Cultural/Spiritual Activities: Clients 

Please use the following scale to express your beliefs regarding amount of information clients receive 

during their treatment experience about the following aspects of NA cultures and spirituality: 

1=No Information at All 2=Little Information 3=Moderate Information 4=Extensive Information 

?=Don’t Know 

1 Reservation political structures 1 2 3 4 ? 

2 Reservation social structures 1 2 3 4 ? 

3 Reservation economics 1 2 3 4 ? 

4 Tribal histories 1 2 3 4 ? 

Continued on next page 

Chapter 2 167 
TIP 61

5

10

15

20

25

1=No Information at All 2=Little Information 3=Moderate Information 4=Extensive Information 

?=Don’t Know 

Colonization 1 2 3 4 ? 

6 Oppression 1 2 3 4 ? 

7 Cultural genocide 1 2 3 4 ? 

8 Historical grief issues 1 2 3 4 ? 

9 Reservation mental health services 1 2 3 4 ? 

Reservation social service programs 1 2 3 4 ? 

11 Healing ceremonies and medicine people 1 2 3 4 ? 

12 IHS programs/services 1 2 3 4 ? 

13 BIA social service programs 1 2 3 4 ? 

14 Reservation substance abuse programs 1 2 3 4 ? 

Classes in NA languages 1 2 3 4 ? 

16 Tribal pow wow and ceremonial songs 1 2 3 4 ? 

17 Tribal art work 1 2 3 4 ? 

18 Tribal crafts 1 2 3 4 ? 

19 How to make pow wow dancing regalia 1 2 3 4 ? 

How tobacco (or other appropriate herb) is used in ceremonies 1 2 3 4 ? 

21 How sage (or other appropriate herb) is used in ceremonies 1 2 3 4 ? 

22 How pow wows are structured 1 2 3 4 ? 

23 On the purposes of purifcation ceremonies 1 2 3 4 ? 

24 On the purposes of fasting/vision quest ceremonies 1 2 3 4 ? 

On the purposes of engaging in traditional outdoor activities (hunting, 

fshing, etc.) 1 2 3 4 ? 

26 On the purposes of dancing ceremonies 1 2 3 4 ? 

27 How welcoming ceremonies are conducted 1 2 3 4 ? 

28 How healing ceremonies are conducted 1 2 3 4 ? 

Behavioral Health Services for American Indians and Alaska Natives 

NATIVE AMERICAN CULTURAL ASSESSMENT SURVEY (CONTINUED) 

Continued on next page 

168 Chapter 2 
TIP 61

1=No Information at All 2=Little Information 3=Moderate Information 4=Extensive Information 

?=Don’t Know 

29 How honoring ceremonies are conducted 1 2 3 4 ? 

30 How naming ceremonies are conducted 1 2 3 4 ? 

31 On the purposes of Native American Church meetings 1 2 3 4 ? 

32 On appropriate uses of the sacred medicine, peyote 1 2 3 4 ? 

33 Cultural continuum/acculturation process as it relates to NA cultures 1 2 3 4 ? 

34 Red Road concepts 1 2 3 4 ? 

35 Customs and protocols for grieving, wakes, funerals and memorials 1 2 3 4 ? 

36 Other: (please describe) 1 2 3 4 ? 

Part 2—Implementation Guide for Behavioral Health Program Administrators 

NATIVE AMERICAN CULTURAL ASSESSMENT SURVEY (CONTINUED) 

Program allows clients to bring/use the following while in treatment: 

ITEM YES NO DON’T KNOW 

Appropriate objects for cultural/religious ceremonies 

Appropriate herbs for cultural/religious ceremonies 

Appropriate foods for cultural/religious ceremonies 

Tobacco for ceremonial/religious purposes 

Peyote for ceremonial/religious purposes 

When can clients begin to participate in NA cultural or spiritual ceremonies while they are in the 

treatment program? 

□ a. Never 

□ b. During the frst week of treatment 

□ c. Beginning with the second week of treatment 

□ d. Beginning with the third week of treatment 

□ e. From the fourth week of treatment 

□ f. At any time 

□ g. During certain steps or phases: (Please describe) ___________________________________________________ 

□ h. Other: (Please describe) ____________________________________________________________________________ 

Continued on next page 

Chapter 2 169 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

NATIVE AMERICAN CULTURAL ASSESSMENT SURVEY (CONTINUED) 

Cultural Resources 

Please use the following scale to identify the following D/L/N cultural resources available for clients and 

staff at your facility: 

1=Not at All 2=To a Small Extent 3=To a Moderate Extent 4=To a Great Extent ?=Don’t Know 

1 Books 1 2 3 4 ? 

2 Videotapes or DVDs 1 2 3 4 ? 

3 Cassette tapes or CDs 1 2 3 4 ? 

4 CD-ROMs 1 2 3 4 ? 

5 Computer software programs 1 2 3 4 ? 

6 Paintings/photographs/prints 1 2 3 4 ? 

7 Native American newspapers 1 2 3 4 ? 

8 Other media 1 2 3 4 ? 

9 The cultures of local NA peoples are refected in the decor (pictures, 

prints, furniture design, etc.) of the facility 1 2 3 4 ? 

10 The cultures of other NA peoples are refected in the decor (pictures, 

prints, furniture design, etc.) of the facility 1 2 3 4 ? 

11 Other: (please describe) 1 2 3 4 ? 

Treatment Continuum 

Please use the following scale to express your beliefs regarding the extent to which NA cultures and 

spirituality are integrated into the following: 

1=Not at All 2=To a Small Extent 3=To a Moderate Extent 4=To a Great Extent ?=Don’t Know 

1 Intake/assessment 1 2 3 4 ? 

2 Treatment/recovery planning 1 2 3 4 ? 

3 Client educational programs 1 2 3 4 ? 

4 Individual counseling 1 2 3 4 ? 

5 Group counseling 1 2 3 4 ? 

6 Family counseling 1 2 3 4 ? 

7 Discharge planning 1 2 3 4 ? 

8 Other: (please describe) 1 2 3 4 ? 

Continued on next page 

170 Chapter 2 
Part 2—Implementation Guide for Behavioral Health Program Administrators TIP 61

NATIVE AMERICAN CULTURAL ASSESSMENT SURVEY (CONTINUED) 

Please use the following scale to express your beliefs regarding the extent to which the following are 

part of the intake, screening, assessment, treatment, and discharge process for NA clients: 

1=Not at All 2=To a Small Extent 3=To a Moderate Extent 4=To a Great Extent ?=Don’t Know 

1 Screening for diabetes 1 2 3 4 ? 

2 Screening for HIV, hepatitis C, and other sexually transmitted diseases 1 2 3 4 ? 

3 Boarding school issues 1 2 3 4 ? 

4 Racial discrimination issues 1 2 3 4 ? 

5 Exploration of historical grief issues 1 2 3 4 ? 

6 Tribal/cultural identity 1 2 3 4 ? 

7 Knowledge of tribal culture 1 2 3 4 ? 

8 Levels of participation in tribal culture 1 2 3 4 ? 

9 Knowledge of tribal history 1 2 3 4 ? 

10 Knowledge of tribal language 1 2 3 4 ? 

11 Experiences with purifcation ceremonies 1 2 3 4 ? 

12 Experiences with vision quests 1 2 3 4 ? 

13 Experiences with other cultural ceremonies 1 2 3 4 ? 

14 Experiences in ceremonies conducted by a NA spiritual leader or 

medicine person 1 2 3 4 ? 

Program Needs 

Note: If additional space is needed for your responses, please use additional sheets with each of your responses 

numbered for the appropriate question. 

What do you believe are your program’s greatest needs to integrate NA cultural and spiritual ways into 

the treatment regimen? 

What do you believe are the greatest cultural and spiritual needs of your NA clients? 

Thank you for your participation. 

Source: Mackey & Zavadil, 2003a. Adapted with permission. 

Chapter 2 171 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

You can use the Sample Pretest for Non-Native Counselors to assess the knowledge of non-native 

providers before and after cultural competence training to evaluate how effective the training was in 

educating providers on key items of American Indian and Alaska Native culture. 

SAMPLE PRETEST FOR NON-NATIVE COUNSELORS 

1. What is the theoretical basis for the high prevalence of type 2 diabetes among Native American 

populations? 

a. The shortage of medical personnel (doctors, nurses, etc.) in healthcare facilities on reservations 

b. Being overweight and having insuffcient physical activity 

c. A lack of education about the prevention of diabetes 

d. A common virus that is unique to American Indians 

2. What are the language dialects of the tribal groups of tribes in your state? 

a. 

b. 

c. 

d. 

INSERT 

APPROPRIATE 

LANGUAGE 

GROUPS 

3. “Vision quest” ceremonies are primarily held to: 

a. Learn how to interpret dreams 

b. Learn how to become a medicine person 

c. Treat diabetes and health conditions related to alcohol abuse 

d. Offer prayers 

4. In relationships with the federal government, what distinguishes the Native American tribal groups 

from other ethnic minorities? 

a. Tribal groups have different languages, songs, dances, dress, and customs 

b. Tribal groups live primarily in remote areas 

c. Tribal groups are sovereign nations with their own governments 

d. Tribal groups can be members of the National Congress of American Indians 

5. What states are included in the (insert area that includes your state) area of IHS? 

a. 

b. 

c. 

d. 

INSERT 

APPROPRIATE 

STATES 

HERE 

6. The primary purpose of sweat lodge ceremonies is to: 

a. Offer prayers 

b. Provide opportunities to learn about tribal lore 

c. Create a sauna-like experience 

d. Offer opportunities for social interaction outside of the treatment setting 

7. To be recognized as a Native American by the U.S. federal government, what is the minimum 

amount of American Indian blood required? 

a. 1/2 

b. 1/3 

c. 1/4 

d. 1/8 

Continued on next page 

172 Chapter 2 
Part 2—Implementation Guide for Behavioral Health Program Administrators TIP 61

SAMPLE PRETEST FOR NON-NATIVE COUNSELORS (CONTINUED) 

8. A pow wow is: 

a. A Native American extended family 

b. A social gathering of Native Americans 

c. A religious ceremony 

d. None of the above 

9. Treaties, negotiated between the U.S. government and various tribal nations, usually contained 

which one of the following provisions? 

a. Tribes ceding lands for various resources (e.g., food, education, health benefts) 

b. The right of the federal government to employ Native Americans as scouts for the U.S. Army 

c. The right of individual Native Americans to vote in national elections 

d. The right for tribal nations to hunt buffalo 

10. On the national level, the BIA is a part of the: 

a. Department of Agriculture 

b. Department of Tribal Relations 

c. Department of Justice 

d. Department of the Interior 

11. The Indian Reorganization Act was passed in 1934 to: 

a. Establish reservations 

b. Reorganize the BIA 

c. Allow most tribes to manage their own affairs 

d. Establish reservation boundaries 

12. Which of the following is NOT a part of Grant’s Peace Policy? 

a. Indians were placed on reservations so that the “dictates of humanity and Christian civilization” 

could be met 

b. Schools and churches were to be established so that Indians would be taught a better way of life 

c. The government would hire “competent, upright and moral” agents to care for the Indians 

d. Profteers could make money on the supplies needed by the Indians 

13. Native American substance abuse programs receive their funding primarily from: 

a. The BIA 

b. The IHS 

c. The Department of Justice 

d. The Congress of American Indians 

14. In which year were all American Indians granted U.S. citizenship? 

a. 1924 

b. 1990 

c. 1920 

d. 1936 

15. Pan-Indianism as it relates to American Indians is: 

a. The belief that all American Indians are related 

b. A movement that promotes unity of American Indians of all tribes, pueblos, etc. 

c. A Native American musical tradition 

d. None of the above 

Continued on next page 

Chapter 2 173 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

SAMPLE PRETEST FOR NON-NATIVE COUNSELORS (CONTINUED) 

16. Which of the following is a hypothetical cause of substance abuse among the American Indian 

population? 

a. American Indians have a genetic make-up that makes them more susceptible to substance 

addiction 

b. When the future looks hopeless, risky behaviors such as substance abuse are less costly since there 

is less to lose 

c. Heavy alcohol consumption was adopted as a norm from whites which was then transferred from 

generation to generation 

d. Native American cultural patterns allow heavy alcohol consumption as an acceptable social 

behavior that produces positive bonding among tribal members 

e. All of the above 

17. The Native American Freedom of Religion Act of 1978 allowed for Native Americans to: 

a. Travel overseas to attend religious events 

b. Practice their own tribal spiritual beliefs and practices 

c. Become members of various church denominations 

d. Become missionaries 

18. All restrictions limiting Native Americans’ ability to purchase liquor from retail establishments (e.g., 

bars, saloons, etc.) the same as other U.S. citizens were lifted in which year? 

a. 1924 

b. 1934 

c. 1953 

d. 1975 

19. Native Americans: 

a. Get monthly checks from the U.S. government 

b. Get free monies for higher education 

c. Get free health care 

d. None of the above 

20. Historical trauma for Native Americans refers to: 

a. Disappointment concerning historical events 

b. The idea that traumatic events in the past continue to cause trauma among Native Americans today 

c. An attempt to gain reparations for actions of the U.S. government 

d. A painful childhood 

21. The entities that provide managed health care for Native Americans are: 

a. IHS, Tribal Health, BIA, and Public Health 

b. IHS, County Government, BIA, and Public Health 

c. IHS, BIA, Tribal Government, and Private Clinics 

d. IHS, Tribal Health, Urban Indian Health Programs, Veterans Administration, and Medicine People 

22. Generally, the preferred learning style of the more traditional Native American is: 

a. Visual 

b. Kinesthetic 

c. Auditory 

d. All of the above 

Continued on next page 

174 Chapter 2 
Part 2—Implementation Guide for Behavioral Health Program Administrators TIP 61

SAMPLE PRETEST FOR NON-NATIVE COUNSELORS (CONTINUED) 

23. The Red Road approach to treatment and recovery primarily includes: 

a. Adapting the 12 Steps to ft Native American cultural groups 

b. The cultural and spiritual ways of Native American tribal groups 

c. The services of guest speakers who are knowledgeable about Native American history 

d. The cognitive model that includes the book Wounded Warriors 

24. Which of the following use peyote in their ceremonies? 

a. The traditional medicine man 

b. The traditional medicine woman 

c. The Native American Church 

d. None of the above 

Answer Key: 

1) B 6) A 11) C 16) E 21) D 

2) C 7) C 12) D 17) B 22) D 

3) D 8) A 13) B 18) B 23) B 

4) C 9) A 14) A 19) D 24) C 

5) B 10) D 15) D 20) A 

Source: Mackey & Zavadil, 2003b. Adapted with permission. 

Chapter 2 175 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

American Indian and Alaska Native Workforce Development Resources 

The following table highlights additional resources available to assist you in your efforts to develop a 

culturally competent and responsive workforce. 

FIRST NATIONS BEHAVIORAL HEALTH ASSOCIATION (FNBHA) LISTING 

OF NATIVE WORKFORCE DEVELOPMENT PROGRAMS 

PROGRAM TITLE/ 

AUTHOR DESCRIPTION OUTCOMES WEBSITE 

Alaskan Rural 

Human Service 

Program, University 

of Alaska Fairbanks 

and State of Alaska 

Paraprofessional training 

and clinical supervision to 

serve remote villages with 

small populations and 

minimal access to licensed 

providers. Addresses 

substance abuse, suicide 

prevention, social services. 

Provided culturally 

congruent 

interventions with 

professional support 

via telemedicine and 

scheduled visits. 

www.uaf.edu/rhs 

Consultation Model 

With Traditional 

Healers, IHS policy, 

PL 95-341. 

American Indian 

Religious Freedom 

Act 

IHS and tribally operated 

health and behavioral 

health programs. Includes 

cultural orientation for new 

staff, providing space and 

time for ceremonies and 

linguistic and diagnostic 

consultations. 

Provided licensed 

and certifed care and 

treatment and local 

validation process for 

healers and practices. 

www.ihs.gov 

Project Making 

Medicine, Dolores 

Bigfoot, Ph.D., 

University of 

Oklahoma 

One year of clinical 

training for providers for 

tribally based treatment 

of child traumatic stress 

disorders. Includes 

cultural adaptations of 

trauma-focused cognitive– 

behavioral therapy. 

Improved local 

providers’ clinical 

child treatment skills, 

increased cultural 

effectiveness of 

treatment and cultural 

competence of nonnative providers. 

——— 

HHS, Mental 

Health Technicians, 

Counselor Aide 

Positions, IHS 

Paraprofessional training 

with clinical supervision and 

consultation by licensed 

staff, funded positions; able 

to serve as interpreters; 

may include telemedicine, 

addressing recruitment and 

retention issues for rural 

locations, and language and 

cultural barriers. 

Increased cultural 

competence of 

care, career ladder 

opportunities for tribal 

providers. 

www.ihs.gov 

Source: FNBHA, 2009. Adapted with permission. 

176 Chapter 2 
Part 2—Implementation Guide for Behavioral Health Program Administrators TIP 61

ADDITIONAL TRAINING AND WORKFORCE DEVELOPMENT RESOURCES 

• Information on the effectiveness of the Native American Curriculum for State Accredited, Non-Tribal 

Mental Health & Substance Abuse Programs in South Dakota training for non-native providers is available 

in the form of a conference poster (Mackey, Zavadil, Skinstad, Peters, & Summers, 2008) and can be 

downloaded online (www.888betsoff.com/links/08_presentations/handouts/1B.pdf). 

• Through the Diamond Threshold: Promoting Cultural Competency in Understanding American Indian 

Substance Misuse (Robbins, Asetoyer, Nelson, Stilen, & Tall Bear, 2011) includes a number of exercises that 

can be used with non-native providers and other staff members to better understand issues related to 

American Indian and Alaska Native behavioral health issues and services. Twelve training activities are 

included, along with training agendas for using the activities in a half-day, whole-day, or 2-day training. 

• The Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Tribal Training and 

Technical Assistance (TTA) Center supports native community self-determination through infrastructure 

development, capacity building, and program planning and implementation. The TTA website offers a 

series of training webinars on a variety of behavioral health topics (https://www.samhsa.gov/tribal-ttac/ 

webinars). 

• The Alaska Commission for Behavioral Health Certifcation (ACBHC) has established a process to 

nominate a traditional provider who offers services in your behavioral health program for lifetime 

certifcation. The ACBHC defnes a traditional provider as an individual who is either an Alaska Native 

or who has been raised with traditional values, provided voluntary services, and been a positive force in 

reducing substance abuse in the community. This certifcate is a way to acknowledge and validate the 

knowledge and wisdom of traditional healers. You can download the application form online 

(www.akcertifcation.org/wp-content/uploads/sites/13/2018/08/Traditional-Counselor-Recognition.pdf). 

Chapter 2 177 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Developing Native EBPs 

As you consider developing and implementing EBPs in your behavioral health service program, a good 

frst step is to review current practices and programs that are specifcally designed for American Indians 

and Alaska Natives. The table below presents summaries of these evidence- and practice-based programs 

and interventions that you might want to consider. It is based on criteria developed by an expert panel at a 

meeting sponsored by FNBHA in 2008 at Portland State University in Portland, OR. 

FNBHA CATALOG OF EFFECTIVE BEHAVIORAL HEALTH PRACTICES 

FOR TRIBAL COMMUNITIES 

Community Prevention and Education; Cultural and Subsistence Skill 

Development 

PROGRAM TITLE/ 

AUTHOR DESCRIPTION OUTCOMES WEBSITE 

Community Readiness 

Model, National 

Center for Community 

Readiness, Colorado 

State University 

Semi-structured surveys of 

key community stakeholders 

to assess readiness for 

prevention or intervention on 

identifed problems including 

mental health, substance 

abuse, HIV; all ages 

Community 

outreach, capacity 

building 

www.triethniccenter. 

colostate.edu/ 

communityreadiness-2 

Gathering of Native 

Americans (GONA), 

Tribal Tech, LLC and 

Kauffman & Associates, 

Inc. 

Structured 4-day journey to 

promote community wellness 

and healing to address a 

variety of problems including 

substance abuse, historical 

trauma, suicide, behavioral 

health; all ages 

Pending www.samhsa.gov/sites/ 

default/fles/gonagoan-curriculumfacilitator-guide.pdf 

Cultural Immersion 

Events: Camps, rides, 

walks, canoe journeys, 

fsh camps, extended 

family gatherings, 

indigenous food 

and herb gathering, 

indigenous arts and 

crafts 

Events planned by local 

tribal populations to address 

historical trauma, substance 

abuse, family dysfunction, 

gangs, teen pregnancies, 

obesity and diabetes; all ages 

Community 

outreach and 

engagement; 

promote healing; 

increase self-image; 

strengthen family 

and community 

relationships; 

increase social, 

recreational, and 

subsistence skills 

——— 

Circles of Care, 

University of Colorado 

and National Indian 

Child Welfare 

Association (NICWA) 

3-year participatory 

community training and 

evaluation to address children 

and families with emotional 

problems 

Community 

capacity building, 

engagement, use of 

data 

www.ucdenver.edu/ 

academics/colleges/ 

PublicHealth/ 

research/centers/ 

CAIANH/coc/Pages/ 

ProgramOverview.aspx 

and 

www.nicwa.org 

Continued on next page 

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FNBHA CATALOG OF EFFECTIVE BEHAVIORAL HEALTH PRACTICES 

FOR TRIBAL COMMUNITIES (CONTINUED) 

Early Intervention/Skill Building 

PROGRAM TITLE/ 

AUTHOR DESCRIPTION OUTCOMES WEBSITE 

To Live To See the 

Great Day That Dawns, 

Department of Health 

and Human Services 

(HHS) 

Community-based suicide 

prevention, using a menu of 

evidence- and culture-based 

practices 

Local workforce 

training and 

community 

mobilization to 

reduce suicide risk 

https://store.samhsa. 

gov 

Positive Indian 

Parenting, NICWA 

Parenting curriculum, 

developed by American 

Indian/Alaska Native 

Organization. Widely adopted 

and open to local cultural 

adaptations. Addresses child 

welfare and early intervention 

Increased parenting 

skills, incorporating 

tribal cultural 

features 

https://www.nicwa.org/ 

training-institutes 

Native H.O.P.E., Clayton 

Small, Ph.D., and One 

Sky Center 

Native Youth Training 

Manual, includes school 

and community screening 

tools, focusing on suicide 

prevention 

Increasing strengths, 

identifying warning 

signs, incorporating 

culture and 

ceremony 

www.oneskycenter.org/ 

wp-content/uploads/ 

2014/03/NativeHope 

YouthTrainingManual_ 

000.pdf 

Individual and Family Treatment 

PROGRAM TITLE/ 

AUTHOR DESCRIPTION OUTCOMES WEBSITE 

Honoring Children 

Series, Dolores Bigfoot, 

Ph.D., University of 

Oklahoma 

Adaptation of Parent–Child 

Interaction Therapy; mental 

health promotion addressing 

child trauma 

Improved 

parenting skills, 

early childhood 

intervention of child 

trauma 

www.icctc.org/ 

HCMC%20TFCBT%20 

Adaptation%200711.pdf 

Wraparound in Indian 

Country, Deb Painte, 

Native American 

Training Institute, 

University of Texas and 

University of Denver 

Family consultation in 

multidisciplinary care 

planning; tribal adaptation of 

practice-based wraparound 

services 

Family and youth 

advocacy and 

empowerment 

www.nativeinstitute. 

org 

Talking Circles, Public 

Domain 

Facilitated discussion; 

participants sit in a circle 

and pass object clockwise, 

signifying one’s turn to speak; 

addresses substance abuse 

and mental health issues 

Peer support, also 

used as a type of 

focus group to 

engage community 

interest in a topic 

——— 

Continued on next page 

Chapter 2 179 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

FNBHA CATALOG OF EFFECTIVE BEHAVIORAL HEALTH PRACTICES 

FOR TRIBAL COMMUNITIES (CONTINUED) 

PROGRAM TITLE/ 

AUTHOR DESCRIPTION OUTCOMES WEBSITE 

Equine-Assisted 

Therapy, Numerous 

tribal and private-sector 

practitioners 

Equine-assisted therapy for 

tribes incorporates cultural 

and historical issues and 

addresses substance abuse 

prevention and treatment, 

developmental disabilities, 

and incarcerated populations 

Increased trust, 

relationship- and 

skill building 

——— 

Recovery Services and Supports 

PROGRAM TITLE/ 

AUTHOR DESCRIPTION OUTCOMES WEBSITE 

American Indian 

and Alaska Native 

12-step meetings and 

fellowship, Public 

Domain 

Structured meetings to 

address alcohol, drug abuse, 

and gambling addictions; 

adults and youth 

Peer support 

for sobriety and 

rehabilitation 

www.nai-aa.com 

Sobriety Campouts, 

Public Domain 

Intertribal event addressing 

individual, family, and 

community substance abuse 

Peer support, family 

and community 

focus 

——— 

Healing Forest, 

Wellbriety, Sons and 

Daughters of Tradition, 

White Bison, Inc. 

Community events and 

structured prevention 

and treatment addressing 

historical trauma, adult and 

youth substance abuse, 

violence, self-destructive 

behaviors 

Community healing, 

reduced substance 

abuse, mentoring/ 

skill building for 

youth 

www.whitebison.org 

Native American 

Church, Public Domain 

Guided intertribal ceremony Peer support, 

community 

cohesion, cultural 

enhancement 

——— 

Sobriety pow wows Intertribal cultural event Builds social 

and recreational 

skills, community 

cohesion 

——— 

Sweat lodge 

ceremonies 

Spiritual purifcation 

ceremony 

Builds connection to 

Creation/Creator ——— 

Source: FNBHA, 2009. Adapted with permission. 

180 Chapter 2 
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Part 2—Implementation Guide for Behavioral Health Program Administrators 

Integrating Care: Traditional Practices in Behavioral Health Programs 

As mentioned previously, the American Indian and Alaska Native perspective on healing is holistic. In 

addition to integrating primary health care and other social services into your program, it is critically 

important to integrate traditional healing practices and healers into your behavioral health services for 

American Indian and Alaska Native clients. Likewise, you need to determine what tribal practices to include 

in American Indian and Alaska Native clients’ treatment and recovery plans and evaluate what beneft 

might be expected from them. This section contains an administrative tool, a Tribal Practice Approval 

Form, which can help you with this task. 

The Oregon Addictions & Mental Health Division (n.d.) has created a process for approving evidencebased tribal practices. The application form and instructions can help you identify, evaluate, and monitor 

American Indian and Alaska Native cultural and healing practices unique to your tribal community that you 

might want to include in your behavioral health service program. 

OREGON ADDICTIONS & MENTAL HEALTH DIVISION EVIDENCEBASED PROGRAMS TRIBAL PRACTICE APPROVAL FORM 

1. Name of Tribal Practice _____________________________________________________________________________ 

2. Brief Description ___________________________________________________________________________________ 

3. Other Examples of This Tribal Practice (Replications) 

4. Evidence Basis for the Tribal Practice: Historical/Cultural Connections 

Longevity (“Grandmother test”) 

Teachings on which practice is based 

Values incorporated in practice 

Principles incorporated in practice 

Elder’s approval of practice 

(“three elderly women test”) 

Community feedback/ 

evaluation of practice 

5. Basic Problems (or Goals) Addressed by This Tribal Practice 

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Chapter 2 181 
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COMMUNITY: 

Risk Factors Protective Factors 

FAMILY: 

Risk Factors Protective Factors 

PEER: 

Risk Factors Protective Factors 

SCHOOL: 

Risk Factors Protective Factors 

INDIVIDUAL: 

Risk Factors Protective Factors 

_____________________________________________________________________________________________________ 

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Behavioral Health Services for American Indians and Alaska Natives 

OREGON ADDICTIONS & MENTAL HEALTH DIVISION EVIDENCEBASED PROGRAMS TRIBAL PRACTICE APPROVAL FORM (CONTINUED) 

6. Target Populations 

7. Risk and Protective Factors Addressed 

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Part 2—Implementation Guide for Behavioral Health Program Administrators 

OREGON ADDICTIONS & MENTAL HEALTH DIVISION EVIDENCEBASED PROGRAMS TRIBAL PRACTICE APPROVAL FORM (CONTINUED) 

8. Tribal Practice—Personnel 

9. Tribal Practice—Activities 

10. Tribal Practice—Materials 

11. Tribal Practice—Optional Elements 

12. Outcomes 

Longevity (vs. avoidable death) 

Health (vs. diagnosis-specifc morbidity) 

Ability (vs. disability) 

Well-being (vs. pain and suffering) 

Social/Community/Cultural Connectedness 

Abstinence from/nonharmful use of AOD 

Employment 

Education 

Continued on next page 

Chapter 2 183 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

OREGON ADDICTIONS & MENTAL HEALTH DIVISION EVIDENCEBASED PROGRAMS TRIBAL PRACTICE APPROVAL FORM (CONTINUED) 

Healthy family 

Good behavior (e.g., noncriminal) 

Stable housing 

Psychological (attitudes; beliefs; 

knowledge; skills; lifestyle) 

13. Contact Person for Agency Providing the Tribal Practice 

Person _____________________________________________________________________________________________ 

Phone _____________________________________________________________________________________________ 

Email ______________________________________________________________________________________________ 

Instructions: 

1. Name of Tribal Practice—The name of the practice is important. It can be convenient to have the 

same name refecting a tribal practice that is used in many tribes (e.g., sweat lodge ceremony). 

However, every implementation is somewhat different—one canoe journey is not exactly the same as 

another, even in the same tribe. Identify a name that refects the tribal practice that you wish to use in 

your program. 

2. Brief Description of Tribal Practice—A brief description covers the critical elements of the practice; it is 

a summary of the specifcs in items 5–12: goal; target population; key elements; providers; and outcomes. 

3. Other Examples of the Tribal Practice—A powerful proof of effectiveness is simply the fact that 

a tribal practice has been implemented in other locations (“replication”). Give some examples of 

replication of this practice as a way to establish its potential effectiveness. 

4. Evidence Basis for the Tribal Practice: Historical/Cultural Connections—Evidence for the validity of a 

tribal practice is not limited to quantitative research. Other types of evidence increase your knowledge 

of the effectiveness and validity of practices in local and cultural contexts. In the Native American 

framework, several specifc criteria for valid tribal practices include longevity (“Grandmother test”), 

teachings on which practice is based, values incorporated in practice, principles incorporated into 

practice, elder’s approval of practice (“three elderly women test”), and community feedback/evaluation 

of practice. 

5. Program Goal—Describe one, broadly stated purpose—the intended outcome—for the tribal practice. 

A goal may be stated as reducing a specifc behavioral health problem or as improving health and 

thriving in some particular way. For example, reduction of a specifc mental illness like posttraumatic 

stress disorder, depression, childhood maladjustment, attention defcit hyperactivity disorder, or cooccurring (substance use and mental) disorders. 

6. Target Population—Use the Institute of Medicine’s Universal, Selective, and Indicated categories 

to classify your practice. Universal means everyone in a target group whether at risk or not at risk 

for having a behavioral health problem (e.g., youth). Selective means that the target population for 

a program is known to be at risk for developing the behavioral health problem (e.g., youth who are 

children of a parent with a substance abuse problem). Indicated means that the target population 

consists of individuals who exhibit some signs of the behavioral health problem (e.g., underage 

drinking youth). In addition, describe the target population in terms of sociodemographics or other 

characteristics. 

Continued on next page 

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OREGON ADDICTIONS & MENTAL HEALTH DIVISION EVIDENCEBASED PROGRAMS TRIBAL PRACTICE APPROVAL FORM (CONTINUED) 

7. Risk and Protective Factors—Describe the risk and protective factors associated with the community, 

family, peer group, school/workplace, and the individual that are addressed by the tribal practice. 

8. Tribal Practice Personnel—Describe the personnel (e.g., elders, medicine people, teachers, registered 

nurses, physicians, certifed counselors, volunteers) and their roles and qualifcations needed to 

perform the practice. 

9. Tribal Practice Activities—Describe the specifc and concrete elements of the tribal practice. It is not 

necessary to include details that are particularly sacred such as the use of specifc symbols in sacred 

sand painting; however, it can be helpful to describe other activities in detail. 

10. Tribal Practice Materials—Describe the materials you will need to engage in the practice such as a 

canoe, billboards, brochures, horses, sweat lodge, auditorium, campgrounds, cultural artifacts, etc. 

11. Tribal Practice Optional Elements—Describe optional materials or elements (e.g., prizes, certifcates 

of completion) for this practice. 

12. Outcomes—The possible areas in which a tribal practice might have outcomes is listed in the form. 

For any applicable outcome category, describe what changes the tribal practice will achieve (e.g., 

Social/Community/Cultural Connectedness might include increased knowledge of cultural songs and 

prayers, identifcation of participants with their culture, increased involvement in cultural events [e.g., 

pow wows]). Identify any available measures of the listed outcomes. 

13. Contact Information—Provide contact information for the individual responsible for and 

knowledgeable about the tribal practice. 

14. Once you have flled out this form, create a separate document, such as a workbook or manual, 

that describes the key elements of the practice, the personnel and practice materials required, and 

outcome measures of the effectiveness of the practice. This document can help you review the 

evidence, establish credibility with third parties, manage the practice, measure outcomes, and provide 

technical assistance to other behavioral health service programs that may want to implement similar 

tribal practices as part of their programs. 

Source: Oregon Addictions & Mental Health Division, n.d. Adapted with permission. 

A printable version of this form can be downloaded from www.oneskycenter.org/osc/health-care-issues 

/evidence-based-practices-and-best-practices. 

Chapter 2 185 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

Creating Sustainability 

Sustaining programs and systems of behavioral health care is an especially important issue in many 

American Indian and Alaska Native communities, where time-limited funding may be available to initiate 

a new service but not to support long-range services. The self-assessment tool that follows, developed by 

SAMHSA’s Center for Mental Health Services (CMHS) and the Child, Adolescent and Family Branch (2003), 

is intended to help communities and systems of care (SOCs) plan for sustaining their behavioral health 

initiatives. The self-assessment tool developed for American Indian and Alaska Native communities and 

SOCs should be used prior to developing a sustainability plan. 

AMERICAN INDIAN/ALASKA NATIVE SUSTAINABILITY SELFASSESSMENT TOOL 

The American Indian/Alaska Native Sustainability Self-Assessment Tool is intended to help you evaluate the 

progress that your community has made in developing and implementing strategic plans for sustaining an 

integrated behavioral health SOC and explore barriers that may need to be addressed to move forward. 

You can use the results of this self-assessment to complete a sustainability strategic plan, assess your 

community’s progress in implementing sustainability plan strategies, or determine changes or modifcations 

to your existing sustainability plan to increase the likelihood for success. This tool is designed to facilitate 

discussion among stakeholders, including representatives of behavioral health service programs, tribal 

representatives, and youth/family members. Although this particular tool is focused on assessing 

sustainability of youth and family services, it could be adapted to assess behavioral health services for adults, 

as well. The term “tribal” is used broadly throughout this document and refers to the 573 federally recognized 

American Indian tribes and Alaska Native villages. However, state-recognized tribes and off-reservation 

native communities may be included as part of the target population of non-native SOC communities. 

Consider the following broad questions as you complete this assessment. When exploring SOC elements 

and sustainability objectives, ask yourself, “Where do we want to be?” and, “What do we want to sustain?” 

For key indicators of success, ask, “How will we know when we have gotten there?” (For examples of key 

indicators, see the checklist at the end of this tool.) For progress ratings, use the “rating of progress” scale 

below. To identify barriers to achievement, ask, “What is standing in the way of our progress?” 

Rating of Progress: 1 – No plan to address 

2 – Plan developed to address 

3 – Early stage of implementing plan 

4 – Good progress in implementing plan 

5 – Plan fully implemented for sustaining 

or continuing post-grant 

Community: ________________________________________________________________ ____________________ Date: 

Vision and Philosophy 

SOC ELEMENTS AND 

SUSTAINABILITY OBJECTIVES 

KEY INDICATORS 

OF SUCCESS 

PROGRESS 

RATING 

BARRIERS TO 

ACHIEVEMENT 

A clear vision for sustaining 

the SOC framework has been 

defned and disseminated. 

Vision links with and supports 

local tribal culture. 

Continued on next page 

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AMERICAN INDIAN/ALASKA NATIVE SUSTAINABILITY SELFASSESSMENT TOOL (CONTINUED) 

SOC ELEMENTS AND 

SUSTAINABILITY OBJECTIVES 

KEY INDICATORS 

OF SUCCESS 

PROGRESS 

RATING 

BARRIERS TO 

ACHIEVEMENT 

Through social marketing practices, 

the needs of tribal children, youth, 

families, community partners, and 

stakeholders are integrated into 

the vision, philosophy, and goals of 

the SOC. 

The right key stakeholders, 

representing the diversity of the 

tribal community served, have 

been involved in defning and 

disseminating the vision. 

Clear-cut objectives for the 

cooperative agreement/grant 

have been identifed through 

a planning process and are 

developed and disseminated to 

tribal leadership and the tribal 

community. 

SOC values and principles are 

continually redefning the larger 

community-based service delivery 

system. 

A defnition for sustainability of 

the SOC framework to implement 

change at the policy, system, and 

practice level has been written in 

language that supports cultural 

values and is easily understood 

by the tribal community and 

disseminated. 

Ongoing education and training 

on SOC vision, philosophy, goals, 

and operation is being provided 

to tribal leadership, the tribal 

community, and key stakeholders. 

Continued on next page 

Chapter 2 187 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

AMERICAN INDIAN/ALASKA NATIVE SUSTAINABILITY SELFASSESSMENT TOOL (CONTINUED) 

Service Array 

SOC ELEMENTS AND 

SUSTAINABILITY OBJECTIVES 

KEY INDICATORS 

OF SUCCESS 

PROGRESS 

RATING 

BARRIERS TO 

ACHIEVEMENT 

Services that families and youth 

(inclusive of the full diversity of the 

community) prefer and fnd useful, 

including integration of traditional 

practices, are continually being 

created as needs change. 

Partner agencies and state, federal, 

tribal, or private resources support 

or fund the full array of services 

(including traditional practices). 

Access to appropriate and effective 

services and supports, including 

traditional practices, has been 

increased to meet needs. 

Ongoing mechanisms for providing 

individualized (with full recognition 

and support of cultural and 

linguistic preferences), integrated, 

and coordinated care are being 

implemented. Mechanisms 

include (a) appropriately trained or 

credentialed paraprofessional or 

professional staff, (b) supervision 

and professional development plans 

for staff, (c) appropriate level of 

community and cultural knowledge, 

and (d) incentive and rewards in 

place for consistency in promotion 

of SOC principles in family services. 

Mechanisms are in place to assure 

a service array that meets the 

relevant needs of the demographics 

of the community (based on age, 

race, ethnicity, language, spiritual 

identity, physical ability/disability, 

language, legal status, etc.). 

Continued on next page 

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AMERICAN INDIAN/ALASKA NATIVE SUSTAINABILITY SELFASSESSMENT TOOL (CONTINUED) 

SOC ELEMENTS AND 

SUSTAINABILITY OBJECTIVES 

KEY INDICATORS 

OF SUCCESS 

PROGRESS 

RATING 

BARRIERS TO 

ACHIEVEMENT 

Ongoing mechanisms have been 

developed to decrease reliance 

on out-of-community and outof-state placements and are 

being implemented. Includes a 

strong link with tribal courts, tribal 

child welfare, juvenile and other 

jurisdictional decision-makers; 

tracking decreases in the number 

of out-of-community placements; 

tracking increases in the number of 

in-community placement resources; 

and ensuring that in-community 

placement resources have adequate 

resources and a high level of family 

involvement. 

Ongoing training and technical 

assistance on culturally and 

linguistically competent service 

delivery, and on culturally and 

linguistically competent evidencebased and promising practices to 

SOC staff, family members, youth, 

community providers, and other 

stakeholders is being provided 

within the context of a well-thought 

out, long-term training plan. 

Management and Coordination 

SOC ELEMENTS AND 

SUSTAINABILITY OBJECTIVES 

KEY INDICATORS 

OF SUCCESS 

PROGRESS 

RATING 

BARRIERS TO 

ACHIEVEMENT 

Centralized location for 

management of SOC 

implementation has been identifed 

and is fully operational. 

Leadership for sustainability of 

SOC implementation efforts 

is maintained with a focus on 

continuity through continual 

training, workforce development, 

skill-building, and leadership 

development. 

Continued on next page 

Chapter 2 189 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

AMERICAN INDIAN/ALASKA NATIVE SUSTAINABILITY SELFASSESSMENT TOOL (CONTINUED) 

SOC ELEMENTS AND 

SUSTAINABILITY OBJECTIVES 

KEY INDICATORS 

OF SUCCESS 

PROGRESS 

RATING 

BARRIERS TO 

ACHIEVEMENT 

Ongoing mechanisms for using data 

and evaluation to support planning, 

development, and maintenance of 

implementation efforts have been 

created, with particular emphasis 

on partnership with the tribal 

community and ongoing community 

feedback loops. 

The leadership framework, 

administrative and service policies, 

and organizational structures refect 

the fexibility and innovation required 

of an effective SOC. 

Interagency Planning and Coordination 

SOC ELEMENTS AND 

SUSTAINABILITY OBJECTIVES 

KEY INDICATORS

OF SUCCESS 

PROGRESS 

RATING 

BARRIERS TO 

ACHIEVEMENT 

Ongoing mechanisms for 

interagency planning and 

coordination at the state/tribal/ 

territorial and local policy and system 

level are in place. 

Ongoing, shared administrative 

processes (e.g., memorandums 

of agreement) among two or 

more agencies that involve family 

members and youth are in place. 

Family and Youth Involvement 

SOC ELEMENTS AND 

SUSTAINABILITY OBJECTIVES 

KEY INDICATORS 

OF SUCCESS 

PROGRESS 

RATING 

BARRIERS TO 

ACHIEVEMENT 

Families and youth (refective of the 

full demographics and diversity of 

the community) are actively involved 

in policymaking and system reform, 

and they fll administrative or 

consultative roles at the system level. 

Families and youth (refective 

of the full demographics of the 

community) are active participants 

in evaluation efforts. 

Continued on next page 

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AMERICAN INDIAN/ALASKA NATIVE SUSTAINABILITY SELFASSESSMENT TOOL (CONTINUED) 

SOC ELEMENTS AND 

SUSTAINABILITY OBJECTIVES 

KEY INDICATORS 

OF SUCCESS 

PROGRESS 

RATING 

BARRIERS TO 

ACHIEVEMENT 

Families and youth (refective of 

the full demographics and diversity 

of the community) are active 

participants in evaluation efforts, 

with good understanding of how 

the evaluation efforts protect 

confdentiality and can serve to 

improve community services. 

Families and youth (refective of 

the full demographics and diversity 

of the community) are involved in 

the service planning and delivery 

process, through serving on 

planning teams or other ways of 

providing their perspective. 

Families and youth (refective of 

the full demographics and diversity 

of the community) participate in 

training, both as trainers and as 

participants in training activities. 

Peer-to-peer support is in place 

within the local provider network 

and among the other tribal SOC 

communities across the country. 

Cultural Competence 

SOC ELEMENTS AND 

SUSTAINABILITY OBJECTIVES 

KEY INDICATORS 

OF SUCCESS 

PROGRESS 

RATING 

BARRIERS TO 

ACHIEVEMENT 

Cultural and linguistic competence 

is evident at the system, policy, and 

practice levels and demonstrated 

by system administrators who value 

the cultural strengths and cultural 

resources of the community; 

service policies that clearly state 

that the system values and seeks 

ways to increase partnership with 

cultural resources; and practices 

that routinely include the use of 

cultural resources as part of the 

treatment/care plan, as appropriate 

to the family. 

Continued on next page 

Chapter 2 191 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

AMERICAN INDIAN/ALASKA NATIVE SUSTAINABILITY SELFASSESSMENT TOOL (CONTINUED) 

SOC ELEMENTS AND 

SUSTAINABILITY OBJECTIVES 

KEY INDICATORS 

OF SUCCESS 

PROGRESS 

RATING 

BARRIERS TO 

ACHIEVEMENT 

Social marketing practices ensure 

that messages, images, and 

outreach strategies are culturally 

and linguistically appropriate. 

Systemwide leadership, including 

tribal offcials, is committed to 

continuing the lead for change 

processes that result in culturally 

competent services that families 

respond to positively. 

Cultural and linguistic competence 

is adopted as a personal mission 

for each individual staff person 

and volunteer involved in the SOC 

network. 

Policies are established that ensure 

cultural and linguistic competence 

is the required standard of service. 

Structures are established 

to ensure the planning and 

implementation of culturally and 

linguistically competent services. 

Adequate resources—spiritual, 

cultural, fnancial, personnel, and 

volunteer—to support cultural 

and linguistic competence are 

established. 

The service array is constructed to 

provide appropriate and acceptable 

services tailored for, and responsive 

to, the unique range of families 

served by the SOC. 

Management information systems 

(MIS) are designed to track services 

(with consideration of the cultural 

appropriateness and usefulness 

of counting traditional practices), 

clinical and functional outcomes, 

and service satisfaction based 

on the unique demographics of 

persons served. 

Continued on next page 

192 Chapter 2 
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AMERICAN INDIAN/ALASKA NATIVE SUSTAINABILITY SELFASSESSMENT TOOL (CONTINUED) 

SOC ELEMENTS AND 

SUSTAINABILITY OBJECTIVES 

KEY INDICATORS 

OF SUCCESS 

PROGRESS 

RATING 

BARRIERS TO 

ACHIEVEMENT 

Quality management/quality 

improvement systems are 

designed to measure impact of 

services tailored to the unique 

demographics of the community. 

Cultural competence is infused 

into the core plans and operations 

of agencies, programs, and 

organizations involved in the SOC. 

Diverse cultural and linguistic 

communities are meaningfully 

involved in all components of the 

SOC: planning, administration, care 

coordination, service provision, and 

evaluation, etc. 

Cultural competence is a focus of 

systemwide collaboration. 

Mechanisms are in place to support 

attitudinal change of all members 

of the system (tribal governance, 

executive, tribal and nontribal 

provider, practitioner, families and 

youth, community at large). 

Mechanisms are in place to 

facilitate continual cultural 

knowledge development of 

all members of the SOC at 

institutional, supervisory, and 

individual levels. 

Mechanisms are in place to provide 

linguistic access throughout the 

entire system in compliance with 

Title VI of the Civil Rights Act 

and to others with limitations 

in communication (e.g., limited 

literacy or disability). 

Continued on next page 

Chapter 2 193 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

AMERICAN INDIAN/ALASKA NATIVE SUSTAINABILITY SELFASSESSMENT TOOL (CONTINUED) 

Political and Economic Support 

SOC ELEMENTS AND 

SUSTAINABILITY OBJECTIVES 

KEY INDICATORS 

OF SUCCESS 

PROGRESS 

RATING 

BARRIERS TO 

ACHIEVEMENT 

An analysis has been conducted 

to determine the full range of 

fnancial and other available 

resources that have been, or could 

be, available to sustain the SOC. 

Partnerships at federal, state, tribal, 

and other local levels are developed 

and maintained to effect mutually 

benefcial outcomes. 

Tribal community members have 

been involved in interpreting the 

fndings of their community’s 

evaluation effort, and the fndings 

are integrated in the design 

and implementation of the SOC 

framework. 

Key stakeholders representing 

the diversity of the community 

(including federal, state, tribal, and 

local public offcials) are involved in 

the initiative and are committed to 

sustaining and expanding the SOC. 

Political and policy-level support 

for the SOC approach has been 

generated at the federal, state, 

tribal, and local level. 

Policies have been reformed or 

developed to support system 

change at the federal, state, tribal, 

and local levels to sustain the 

initiative. 

Coalition-building among 

advocates, including those 

representing specifc cultural, 

racial, ethnic, linguistic, religious, 

and other communities, is being 

supported to impact change. 

Strong interagency relationships, 

both within and outside of the 

tribal community, are being 

cultivated or are in place. 

Continued on next page 

194 Chapter 2 
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AMERICAN INDIAN/ALASKA NATIVE SUSTAINABILITY SELFASSESSMENT TOOL (CONTINUED) 

SOC ELEMENTS AND 

SUSTAINABILITY OBJECTIVES 

KEY INDICATORS 

OF SUCCESS 

PROGRESS 

RATING 

BARRIERS TO 

ACHIEVEMENT 

A strong family organization that 

refects and effectively supports 

the diversity of families in the 

community is evolving or in place 

and is supported by the community 

at large. 

The SOC framework and its values 

and principles are infused within 

the broad tribal service delivery 

system. 

Strategic Financing Strategies 

SOC ELEMENTS AND 

SUSTAINABILITY OBJECTIVES 

KEY INDICATORS 

OF SUCCESS 

PROGRESS 

RATING 

BARRIERS TO 

ACHIEVEMENT 

Determination of available fnancial 

resources (known and untapped), 

including matched resources, is 

being conducted. 

A plan for maximizing federal, state, 

tribal, and other local revenue is in 

place and is being implemented. 

Strategies for creating more 

fexibility in existing funding 

streams have been developed and 

implemented. 

Partnerships among the tribal– 

public–private sectors have been 

developed. 

Financing strategies are developed 

that ensure continued access to 

appropriate and acceptable services 

for all demographic groups within 

the community.

 Continued on next page 

Chapter 2 195 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

AMERICAN INDIAN/ALASKA NATIVE SUSTAINABILITY SELFASSESSMENT TOOL (CONTINUED) 

Roster of Participants: 

As members of the community, we actively participated in completing the Sustainability Self-Assessment 

Tool. List all participants, including each participant’s Name, Agency Affliation or Youth/Family Member, 

and Date. 

Name Agency Affliation or Youth/Family Member Date 

Examples of Key Indicators for Some of the Attributes of the SOC Framework 

Service array

□ Services focus on both the individual and the tribe. 

□ Service staff is available during times convenient and acceptable to families. 

□ Services are provided at locations convenient to families and at locations of the families’ choosing 

(e.g., homes, schools, tribal centers, or other community-based settings). 

□ The service array recognizes the value and strength of families’ cultures and includes culture-based 

services. 

□ Transportation is provided. 

□ Childcare is provided. 

□ Families are aware of the referral process and can self-refer into the service delivery system. 

□ Flexible funds are in place to meet unique needs, including traditional practices. 

□ Service plans are individualized according to the child’s and family’s strengths and needs. 

□ Crisis and transition plans are provided as part of the treatment planning process. 

□ Staff, families, and youth have been trained on the process for linking strengths with needs to develop 

service plans and coordinate care. 

Management and coordination

□ Current program leaders are supported by the formal tribal leadership and tribal community and 

report reduced stress. 

□ New generations of leaders are identifed and refect the diversity of the community served. 

□ Training and support of all leaders involved in the effort is being conducted, resulting in decreased 

staff turnover and increased job satisfaction. 

□ Clinical reviews, fscal oversight, management monitoring, and quality improvement processes are in 

place. 

□ A social marketing plan is completed, detailing how the appropriate use of data can positively impact 

state and local policy. 

Continued on next page 

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Interagency planning and coordination

□ Interagency structure is in place and meetings are conducted among tribal and relevant nontribal 

organizations for system-level policy, planning, and coordination purposes. 

□ Training curriculums and materials are developed jointly by cooperating agencies and organizations. 

□ Joint training is conducted with staff of cooperating agencies and organizations. 

□ Staff are shared or coordinated between cooperating agencies and organizations. 

□ Staff are out-stationed or co-located at cooperating agencies and organizations. 

□ Procedures for pooling, blending, or braiding of funds across agencies are established. 

□ Process for cross-system communication is in place. 

□ Interagency service and treatment planning meetings are conducted regularly. 

□ Interagency case/care management and case/care review meetings are conducted regularly. 

□ Joint staff meetings are conducted. 

□ Joint hiring/recruitment of staff is conducted that refects the diversity of the population served. 

□ Professional development and credentialing are a joint effort between tribal organizations and local 

colleges. 

□ Interagency cooperation is in place for shared administrative forms, unifed case records, integrated 

MIS, and joint administrative/system implementation meetings. 

Family and youth involvement

□ Families and youth are hired as part of the administrative team or the service, marketing, evaluation, 

or cultural competency teams. 

□ Families and youth are provided with information, enabling them to actively advocate for policy, 

system, and practice change. 

□ Families and youth are involved in reforming existing policies. 

□ Families and youth are represented on governing and policy bodies and committees. 

□ Family members and youth attend meetings and receive stipends for childcare, transportation, and 

other assistance that enables their full participation. 

□ Family members and youth are involved in developing and providing training to service providers. 

□ Family members and youth are involved in recruiting, interviewing, and selection of agency staff. 

□ Families and youth are involved in data gathering. 

□ Families and youth are part of a process for reviewing outcome and evaluative data. 

□ Families and youth are part of the management team process to review the data for quality 

improvement purposes and to develop services and supports. 

□ Family members and youth are partners in service planning meetings. 

□ Family members and youth may include or exclude the participation of specifc individuals in the 

service planning process. 

□ Family members and youth identify and prioritize problems, concerns, or challenges and develop goals. 

□ Youth and families have been trained to understand how data can be used effectively to advocate for 

programs and services. 

□ Youth and families have received training on various topics related to advocacy, funding sources, 

multisystems, governance board participation, policy development, and the evaluation process. 

Continued on next page 

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TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

AMERICAN INDIAN/ALASKA NATIVE SUSTAINABILITY SELFASSESSMENT TOOL (CONTINUED) 

□ Youth groups and family organizations have marketable skills needed by community organizations 

that sustain their involvement. 

□ Youth groups and family organizations have partnered with community organizations to gain 

fnancial and philosophical support. 

□ Youth are supported by other youth through youth groups and peer mentoring. 

□ Other family members and the family organization support families. 

Cultural competence

□ Tribal people help to plan and implement effective, appropriate, and acceptable services. 

□ Tribal organizations and other tribal community groups are involved in providing services, developing 

the service array, and advising providers. 

□ Recruitment and hiring of staff is conducted in a way that staff ft with the cultural background of the 

children/families served. 

□ Staff training in cultural competence is conducted for all staff and volunteers at all levels on an 

ongoing basis. 

□ Youth and family culture and background are assessed in service planning, including things that 

are important to them such as spirituality, religion, tribal culture/traditions/beliefs, family traditions, 

community defnition of wellness, beliefs about health and illness, and sexual orientation. 

□ Services are adapted to respond to the cultural perspective of each child, youth, and family. 

□ A mission statement is in place that articulates principles, rationale, and values for providing culturally 

and linguistically competent services and supports. 

□ Processes to systematically review policies and procedures are in place to assess how they support 

the consistent delivery of culturally and linguistically competent services to tribal families. 

□ Policies and procedures are in place to periodically review the current and emergent demographic, 

sociocultural, economic, organizational, institutional, and political trends in the geographic area. 

□ Requirements are established that contracting procedures, funding proposals, and requests for 

services include performance criteria for culturally and linguistically competent practices. 

□ Dedicated structures (e.g., committees, task forces, work groups) are in place with the charge to 

facilitate the infusion of cultural and linguistic competence elements at all levels of the organization. 

□ Cultural learning for all staff is designed on an individualized basis to include self-assessment of 

knowledge of the tribal community, guidance and appropriate exposure to the spiritual and cultural 

values of the community, participation in cultural and community events, formal training (e.g., 

workshops, courses, seminars, etc.), and use of cultural brokers, spiritual guides, and other community 

consultants. 

□ Key documents are translated into languages that are predominant in the community, especially 

documents that must be signed or have legal or service access implications (including implications 

for confdentiality). 

□ Marketing materials positively refect the cultural strengths of the community. 

□ Appropriately trained interpreters (e.g., in mental health and interpretation) are on staff or on call for 

face-to-face and telephone interpretive services. 

□ Leadership toward change is evident at policy, administration, practice, community, and family levels. 

Continued on next page 

198 Chapter 2 
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AMERICAN INDIAN/ALASKA NATIVE SUSTAINABILITY SELFASSESSMENT TOOL (CONTINUED) 

Political and economic support

□ Process to assess the current and future economic health of the community, including job viability for 

families, is in place and considered as services are developed. 

□ Strong and positive relationships exist between SOC leadership and key tribal, state, and federal leaders. 

□ Tribal, state, and U.S. congressional elected offcials respect and know the tribal SOC. 

□ Process to assess leadership decision-making and power styles of stakeholders and the impact on the 

tribal SOC is in place. 

□ Tribal, state, and national election dates are known, and the impact on the tribal SOC is considered. 

□ Tribal SOC models: self-determination; equal partnerships between nontribal and tribal partners; 

leadership welcomed from all levels of the community; and the tribal community demonstrates that 

it buys in to the SOC. 

□ Tribal institutional leadership is stable and supportive of SOC principles. 

□ Tribal institutions have structures, policies, and procedures that match the cultural norm (tribal 

institutions are in sync with tribal values). 

□ Quality improvement process is in place for administrative and program practices and used on a 

regularly scheduled basis. 

□ Clinical and fscal utilization management is in place. 

□ Quality assurance is managed through a process incorporating families and youth. 

□ Social marketing plan is in place, utilizing data as a means to impact policy change. 

Strategic fnancing strategies 

Assessment:

□ Determination of all available (known and untapped) funds and matched dollars assessed. 

□ Full understanding of the fnancial strengths and challenges of an SOC developed within a clinic 

setting, as opposed to a nonclinic setting. 

□ Ability to redeploy funds is assessed as is the potential impact of redeployment on the community’s 

well-being. 

Partnerships:

□ Relationships developed with other child-serving system leaders to start discussion of the benefts of 

pooled resources to expand the fscal base and leverage funds. 

□ Relationship with the state mental health authority in place. 

□ Relationship with the state Medicaid offce in place. 

□ Relationship among tribal–public–private leadership at state and local levels is established and fosters 

fscal investments in children and families. 

Readiness:

□ Leadership understands the licensing requirements and state-negotiated service categories needed 

to seek Medicaid or Title IV-E waivers. 

□ Programs are operated more effciently by cutting costs and reinvesting funds. 

□ Plan for training, licensing, and credentialing of staff in place, per Medicaid reimbursement 

requirements. 

□ Process in place for peer-to-peer fund development advice from other tribal SOC communities. 

Continued on next page 

Chapter 2 199 
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AMERICAN INDIAN/ALASKA NATIVE SUSTAINABILITY SELFASSESSMENT TOOL (CONTINUED) 

Action:

□ All administration and program staff take responsibility to ensure reasonable program expenditures. 

□ Reinvestment is accomplished by allocating funds that can be “saved” through redeployment, 

refnancing, or reductions in spending, or using in-kind resources. 

□ Diversifcation of funding is accomplished. 

□ Federal revenue is leveraged by taking advantage of programs that provide funding contingent on 

state, local, or private fnancing. 

□ Grants are written and submitted on a regular basis. 

□ Funds are pooled, blended, or braided to create unifed funding streams. 

□ Categorical funding across agencies is coordinated and aligned to support community services. 

□ Devolution or de-categorization of funding streams is completed to remove narrow eligibility 

requirements and rules and to expand array of supports and services currently unavailable to families. 

□ Medicaid or Title IV-E waivers are being sought and implemented. 

□ Technical assistance is provided to public and private agencies to increase their understanding of 

what is needed to create and sustain SOC services and supports. 

Source: SAMHSA, CMHS, & Child, Adolescent and Family Branch, 2003. Adapted with permission. 

The tools presented in this chapter can help you, 

your staff, and your community build a sustainable 

program and system of services designed to meet 

the behavioral health needs of American Indian 

and Alaska Native clients. As an administrator or 

program manager, you are in a central position 

to know which of these tools will best serve your 

mission and how best to adapt them to your 

organization’s and community’s particular needs. 

Let us put our minds together and 

see what life we can make for our 

children.” 

—Sitting Bull (1831–1890), Hunkpapa 

Lakota 

200 Chapter 2 
TIP 61 BEHAVIORAL HEALTH SERVICES FOR 

AMERICAN INDIANS AND ALASKA NATIVES

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212 
Index 

TIP 61 BEHAVIORAL HEALTH SERVICES FOR 

AMERICAN INDIANS AND ALASKA NATIVES

A

access to services. See increasing access to services 

acculturation, 30–31, 35, 56–57, 140 

active listening (also referred to as refective listening), 61, 

74–75, 77–78 

Addiction Technology Transfer Center (ATTC) Network, 

133, 140, 142, 144. See also Substance Abuse and 

Mental Health Services Administration: National 

American Indian and Alaska Native Addiction 

Technology Transfer Center (NAI & NA ATTC) 

administrative challenges, 130–137. See also solutions, 

paths to 

adverse childhood events, 23. See also child abuse 

Alaska Commission for Behavioral Health Certifcation 

(ACBHC), 177 

Alaska Federation of Natives, 16, 19 

Alaska Native Allotment Act, 16 

Alaska Native Claims Settlement Act, 16, 19 

Alaska Native Program, 19. See also Trans-Alaska Pipeline 

System 

alcohol 

death rate from, 29 

myths, 26 

use disorder and other substance use disorders, viii, 

6, 26, 47, 52, 65. See also vignette 1 

American Indian/Alaska Native Behavioral Health Briefng 

Book, 47 

American Indian/Alaska Native Sustainability SelfAssessment Tool, 186, 186–200 

American Indian and Alaska Native Culture Card: A Guide 

to Build Cultural Awareness, 142 

American Indian Religious Freedom Act of 1978, 15 

American Speech–Language–Hearing Association’s SelfAssessment for Cultural Competence, 42 

ancestry, 24, 24, 31–32 

anonymity/confdentiality, 48, 49, 55–56, 60, 66, 78, 99, 

131, 150, 191 

assessment/assessing 

American Indian/Alaska Native Sustainability SelfAssessment Tool, 186, 186–200 

community prevention and education, 178 

cultural identity, 9, 30, 34–36, 56–57, 57, 87, 147, 149 

Native American Cultural Assessment Survey, 

159–160, 160–171 

using scales, 84 

values, 36, 37–39 

assimilation, 16, 17–18, 30, 30, 137, 141 

attitudinal competencies, 153 

authenticity, 50, 59, 78 

B

Becoming a Culturally Competent Health Care 

Organization (2013 report), 126 

behavioral health services 

barriers, 49 

preferences, 48, 48–49 

Behavioral Health Services for People Who Are Homeless 

(TIP 55), 27 

biculturalism, 30, 30, 56 

Black Elk, 11, 22 

blood quantum, 24 

boarding school(s), 14, 16, 17–19, 20, 49, 60, 71–72, 

74–75, 79, 83, 86, 108, 117, 118, 137, 143, 151, 171. 

See also Carlisle Indian School 

Brave Heart, Maria Yellow Horse, 20 

Bureau of Indian Affairs (BIA), 14, 132 

C

canoe journey, 23, 133–134, 178, 184 

care integration. See integrating care 

Carlisle Indian School, 18. See also boarding school(s) 

case management, 54, 152 

Center for Mental Health Services (CMHS), 186 

Center for Substance Abuse Prevention’s (CSAP’s) 

Prevention Fellowship Program, 139 

Centers for Disease Control and Prevention’s (CDC’s) 

Public Health Training Fellowships, 145 

child abuse, 22, 28. See also adverse childhood events 

circle model. See key elements for providing culturally 

responsive care for American Indians and Alaska 

Natives in behavioral health services 

clinical supervision 

conducting a cultural awareness self-evaluation, 147 

six areas of competence as a culturally competent 

supervisor, 146 

supervision and client experiences: the infuence of 

culture, 148 

supervision dynamics, 147–149 

Clinical Supervision and Professional Development of the 

Substance Abuse Counselor (TIP 52), 145 

Cobell v. Salazar, 15, 19 

213 
TIP 61

176 

Behavioral Health Services for American Indians and Alaska Natives 

cognitive–behavioral therapy (CBT), 61, 63–64, 75, 79, 84, 

colonization, 13–15, 20, 67, 140. See also historical trauma 

commonalities among American Indian and Alaska Native 

cultures, 31–33 

community 

-based interventions/approaches, 60, 62, 67, 101 

collaborating with, 136 

connections, 65–67 

cultural and subsistence skill development, 178 

differences, 127 

effective behavioral health practices for. See First 

Nations Behavioral Health Association (FNBHA) 

Catalog of Effective Behavioral Health Practices 

for Tribal Communities 

engaging with, 127, 128–129 

event(s), 46, 48, 58, 65–66, 67, 99, 180. See also 

Gathering of Native Americans (GONA) 

healing, 67, 128, 180. See also Gathering of Native 

Americans (GONA) 

importance of, 32, 134 

involvement, 9, 126–127, 150 

leaders, 45, 65, 127, 131, 142–143, 153 

liaison, 127, 155, 155, 158 

members, 32, 41, 52, 56, 58, 60, 65–67, 126, 

127–128, 131–132, 137, 138, 155, 194 

prevention and education, 178 

readiness model, 137, 138, 178. See also 

dimensions of readiness 

reinforcement approach (CRA), 63 

screening tools, 179. See also Native H.O.P.E. 

strengths, 129 

competencies. See provider competencies 

consensus panel, 5, 8, 10, 69, 69, 95, 112, 117, 125, 130, 

133, 144 

continuing care planning, 96, 121 

creation, 11, 13, 31, 33, 73, 101, 180 

Cree proverb, 34 

culture/cultural(ly) 

American Speech–Language–Hearing Association’s 

Self-Assessment for Cultural Competence, 42 

Becoming a Culturally Competent Health Care 

Organization (2013 report), 126 

conducting a cultural awareness self-evaluation, 147 

connecting/reconnecting with, 29, 43 

cultural activities, 29, 31, 41, 47, 49, 58–59, 

134–135, 142, 142 

cultural advisors, 142, 142, 164 

cultural awareness development. See developing 

cultural awareness 

cultural camps, 54, 54 

Cultural Competence Health Practitioner 

Assessment, 42 

cultural identity, 7, 9, 12, 30, 34–36, 56–58, 57, 60, 

61, 87, 127, 140, 147, 149, 171 

cultural immersion events, 178 

culturally adapted treatment. See examples of 

culturally adapted treatment approaches 

culturally appropriate communication, 128, 156 

culturally responsive counseling with American 

Indians and Alaska Natives, 95 

culturally responsive relationships. See culturally 

responsive relationships: provider guidelines 

and considerations 

culturally specifc, 12, 28, 49, 50 

cultural trainer(s)/training, 140–143, 143–144 

developing a culturally competent and responsive 

workforce, 136. See also workforce and 

organizational development 

establishing a cross-cultural supervisor–supervisee 

relationship, 146–147 

Georgetown University’s National Center for 

Cultural Competence, 42 

importance of, 129, 141 

Improving Cultural Competence (TIP 59), 8, 23, 

34, 41, 50, 125, 141, 147, 149. See also How To 

Engage in Self-Refection: A Tool for Counselor 

Training and Supervision 

improving your cultural competence, 41–42 

improving your knowledge of American Indian and 

Alaska Native cultures, 41 

infuence of, 148 

Leaving Footprints: Cultural Training, 144 

loss of, 7–8 

mainstream, x, xii, 7, 8, 10, 14, 18, 26, 30–32, 35–36, 

39, 42, 43, 44, 46, 56 

organizational benefts of culturally responsive care, 

126 

providing culturally responsive care. See key 

elements for providing culturally responsive 

care for American Indians and Alaska Natives in 

behavioral health services 

role of, vi, 9, 29 

six areas of competence as a culturally competent 

supervisor, 146 

Tlingit cultural values, 106 

culturally responsive relationships: provider guidelines and 

considerations 

knowing yourself, 50–51 

making introductions as a provider: frst meeting, 

55–56 

remaining fexible and embracing new 

opportunities, 52–55 

supporting communication, 51–52 

cycle of 

assimilation and reconnection, 30, 30 

historical trauma, 21 

214 
TIP 61

 

Index 

D

data use and analysis, 130–131, 131. See also evaluation 

capacity 

Dawes Severalty Act (also known as the General Allotment 

Act), 14, 18 

Department of the Interior, 14–15, 27, 173 

Department of the Treasury, 15 

depression, 46, 48, 50, 64, 96–97, 99, 100, 134 

developing cultural awareness 

step 1: awareness of cultural differences, 34–36 

step 2: self-assessment of your values, 36 

step 3: understanding the effects of cultural 

differences, 36, 40 

traditional American Indian and Alaska Native 

values and beliefs, 37–39 

developing native evidence-based practices (EBPs) 

culturally adapted treatment. See examples of 

culturally adapted treatment approaches 

effective behavioral health practices for tribal 

communities. See First Nations Behavioral 

Health Association (FNBHA) Catalog of 

Effective Behavioral Health Practices for Tribal 

Communities 

Native American Motivational Interviewing: 

Weaving Native American and Western 

Practices—A Manual for Counselors in Native 

American Communities, 61, 74 

Oregon Addictions and Mental Health Division 

Evidence-Based Programs Tribal Practice 

Approval Form, 181, 181–185. See also 

integrating care 

diagnosis, viii, x, 8–9, 36, 39, 44, 46, 48, 52, 87, 100, 111, 

137, 138, 149 

Diagnostic and Statistical Manual of Mental Disorders 

(DSM–5), x–xi, 100 

dimensions of readiness, 138. See also Community 

Readiness Model 

Diné. See Navajo 

discrimination, racism, and prejudice, 10, 34, 36, 39, 47, 

49, 60, 72, 74, 89, 110, 112, 141, 151, 153, 171 

domestic violence, 19, 29 

double-sided refection(s), 80 

Dr. Duane Mackey “Waktaya Naji” Award, 144. See also 

Mackey, Duane 

dream(s), 86, 88–89, 89, 172. See also visions 

E

economic and social conditions of American Indians and 

Alaska Natives 

child abuse, 28. See also adverse childhood events 

domestic violence, 29 

education, 27 

housing and homelessness, 27. See also vignette 4 

income and poverty, 26–27 

physical health, 29 

trauma (rates of), 27–28 

unemployment, 27 

violent crime, 28 

education. See training and education 

1884 Organic Act, 16 

elders 

learning from, 66, 117 

message on suicide prevention, Inuit, 117 

traditional, 22, 23, 23, 32, 38, 41, 45, 46, 58, 59, 66, 

73, 82, 104, 109 

enculturation, 30 

etiquette, 55, 66, 127 

evaluation capacity, 131. See also data use and analysis 

evidence-based practices (EBPs) 

developing for tribal populations. See developing 

native evidence-based practices (EBPs) 

examples of. See examples of culturally adapted 

treatment approaches 

examples of culturally adapted treatment approaches. See 

also evidence-based practices (EBPs) 

behavioral therapy, 64 

cognitive–behavioral therapy (CBT), 63 

community reinforcement approach (CRA), 63 

family therapy, 62 

Matrix Model, 64 

mindfulness-based interventions, 63 

motivational interviewing, 61 

trauma-informed treatment, 62 

Exxon Valdez oil spill, 19, 20, 108 

eye contact, 35, 36, 37, 39, 51, 55 

F

Facebook, 120. See also social media 

family 

and youth involvement, 190, 197 

recovery crest, 102, 105 

session(s), 52, 96, 98–99, 101–102, 102–103, 

104–106. See also vignette 3 

structure, 32–33 

therapy/treatment, 60, 62, 69, 90, 105, 145, 179. 

See also vignette 3 

fellowship(s), 139, 145, 145, 180. See also internship(s) 

First Nations Behavioral Health Association (FNBHA) 

Catalog of Effective Behavioral Health Practices for 

Tribal Communities 

American Indian and Alaska Native 12-Step 

meetings and fellowship, 180 

Circles of Care, 178 

Community Readiness Model, 178. See also 

dimensions of readiness 

cultural immersion events, 178 

215 
TIP 61

 

Behavioral Health Services for American Indians and Alaska Natives 

equine-assisted therapy, 180 

Gathering of Native Americans (GONA), 178 

Healing Forest, Wellbriety, Sons and Daughters of 

Tradition, 180 

Honoring Children, 179 

Native American Church, 180 

Native H.O.P.E., 179 

Positive Indian Parenting, 179 

Sobriety Campouts, 180 

sobriety pow wows, 180 

sweat lodge ceremonies, 180 

talking circle, 179 

To Live To See the Great Day That Dawns, 179 

Wraparound in Indian Country, 179 

First Nations Behavioral Health Association (FNBHA) 

Listing of Native Workforce Development Programs. 

See also workforce and organizational development 

Alaskan rural human service program, 176 

consultation model with traditional healers, 176 

HHS, mental health technicians, counselor aid 

positions, 176 

Project Making Medicine, 176 

funding, 129, 131–133, 136, 153, 173, 200. See also grants 

G

Gaalee’ya Project, 35 

gathering 

of Native Americans, 67, 67, 178 

of strengths, 90 

General Allotment Act (also known as the Dawes Severalty 

Act), 14, 18 

Georgetown University’s National Center for Cultural 

Competence, 42 

Gottlieb, Katherine, 23 

grants, 26, 129, 131, 136, 200. See also funding 

H

harmony and balance, vi, 9, 11, 22, 29, 31, 33, 33, 37, 43, 

46, 69, 73, 74, 106, 133 

healing and medicine, traditional, 7–11, 23, 29, 31, 40–49, 

44–45, 54, 56–57, 58, 59, 59–61, 64, 69, 73, 94, 105, 

108–109, 129, 176–177, 181 

health, concepts of, 43 

historical trauma. See also colonization 

benefts of focusing on, 23 

cycle of, 21 

defned, 20, 20 

effects on American Indians and Alaska Natives 

today, 21, 21–23 

effects on parenting, 22 

importance of, vi, 8 

symptoms of historical trauma response, 57 

traditional cultures and, 20 

holistic view of health and healing, vi, 8, 43, 67 

homebrew, 98, 98 

honoring 

children, 55, 104, 179 

traditional ways. See vignette 1 

hopeful language, 52 

housing and homelessness, 27. See also vignette 4 

How To Engage in Self-Refection: A Tool for Counselor 

Training and Supervision, 149. See also Improving 

Cultural Competence (TIP 59) 

hozhq, 33 

humor, 52–53, 53. See also laugh(ter) 

I

Idaho State Loan Repayment Program, 145 

identity 

cultural, 7, 9, 12, 30, 34–36, 56–58, 57, 60, 61, 87, 

127, 140, 147, 149, 171 

native, 30, 31–32 

illness, concepts of, 43–44, 43–44, 55, 60 

Improving Cultural Competence (TIP 59), xi, 8, 23, 34, 

41, 50, 125, 141, 147, 149. See also How To Engage 

in Self-Refection: A Tool for Counselor Training and 

Supervision 

income and poverty, 26–27 

increasing access to services, 132 

Indian Child Welfare Act of 1978, 15, 19, 143 

Indian Citizenship Act (also known as the Snyder Act), 18 

Indian Civil Rights Act of 1968, 19 

Indian Gaming Regulatory Act, 19 

Indian Health Services (IHS) resources 

Externship Program, 145 

Loan Repayment Program, 145 

New Hire Quick Reference Guide, 155, 156–158 

Indian Health System, 130 

Indian Relocation Act, 15, 18 

Indian Removal Act, 14, 17 

Indian Reorganization Act, 15–16, 18, 173 

Indian Self-Determination and Education Assistance Act of 

1975, 15, 137 

intake, 56, 56, 77, 80, 85 

integrating care, 132, 181, 181–185. See also Oregon 

Addictions & Mental Health Division Evidence-Based 

Programs Tribal Practice Approval Form 

intellectual property, 66 

intergenerational trauma. See historical trauma 

internship(s), 136, 139, 145. See also fellowship(s) 

introductions, 55, 87 

J

216 
Index TIP 61

K

key elements for providing culturally responsive care 

for American Indians and Alaska Natives in behavioral 

health services 

cultural awareness and competence (south), 12, 

34–35, 34–36, 37–40, 40–42, 42 

cultural knowledge (east), 12–13, 13–16, 15, 17–30, 

20–34, 32–34 

culturally specifc and responsive skills and practices 

(north), 12, 49–61, 50–57, 59–67, 64–68 

cultural perspectives on behavioral health (west), 12, 

42–45, 42–49, 47–49 

knowledge competencies, 151 

L

label(ing), 36, 40, 43–44, 44, 50, 52, 87 

Lakota, 20, 144, 160 

laugh(ter) 52, 53, 89, 91, 91. See also humor 

Leaving Footprints: Cultural Training, 144 

loan opportunities 

Idaho State Loan Repayment Program, 145 

Indian Health Service (IHS) loan repayment 

program, 145, 145 

National Health Service Corps (NHSC) Loan 

Repayment Program, 137, 145, 145. See also 

Spokane Tribe Health and Human Services 

Behavioral Health Program 

SHARP-II: Providing Support-for-Service to Health 

Care Practitioners, 145 

loss of language, viii, 20, 88 

M

Mackey, Duane, 144. See also Dr. Duane Mackey “Waktaya 

Naji” Award 

mainstream 

culture/society, xii, 7–8, 10, 14, 18, 26, 30, 30–32, 

35–36, 46, 56 

treatment/models of care, 6, 10, 42–44, 43–44, 46, 

48, 52, 54, 59, 61, 63, 69, 74, 100, 106–107, 

132–133, 137 

mascots, 26, 39. See also microaggressions 

master provider notes in vignettes, 69, 70. See also 

vignettes 1, 2, 3, and 4 

Matrix Model, 64 

Mead, Margaret, 110 

mental disorders, 7–9, 21, 21, 46, 48–49 

mentoring, 133, 136, 136, 149, 149–150 

Meriam Report, 15 

metaphor(s), 81, 134 

methamphetamine, 47, 48, 86–88, 88–90, 91, 135 

microaggressions, 39. See also mascots 

military service, 15 

mindfulness, 63, 91 

Mining Act of 1872, 16 

motivational interviewing, 57, 60, 61, 74, 145. See also 

Native American Motivational Interviewing: Weaving 

Native American and Western Practices—A Manual for 

Counselors in Native American Communities 

mutual help, 65. See also 12–Step 

myths and facts about American Indians and Alaska 

Natives, 25–26 

N

National Drug Court Resource Center, 85 

National Evaluation of the Comprehensive Community 

Mental Health Services for Children and Their Families 

Program: Exploratory Description of Financing and 

Sustainability in American Indian and Alaska Native 

System of Care Communities, 135 

National Health Service Corps (NHSC) Loan Repayment 

Program, 137, 145, 145. See also Spokane Tribe Health 

and Human Services Behavioral Health Program 

National Indian Child Welfare Association (NICWA), 

178–179. See also Positive Indian Parenting 

National Resource Center on Child Sexual Abuse, 14 

Native American Center for Health Professions, 136. See 

also We Are Healers 

Native American Cultural Assessment Survey, 159–160, 

160–171 

Native American Curriculum for State Accredited, NonTribal Mental Health & Substance Abuse Programs in 

South Dakota, 144, 159, 177 

Native American Motivational Interviewing: Weaving 

Native American and Western Practices—A Manual for 

Counselors in Native American Communities, 61, 74 

Native American Rehabilitation Association of the 

Northwest, Inc. (NARA), 142 

Native H.O.P.E., 179 

nature, 8, 31, 37, 39, 90, 101, 117 

Navajo, 33, 45, 63, 88 

Navigating Life Curriculum Sessions, 134–135 

Neihardt, J. G., 11 

New Hire Quick Reference Guide, 155, 156–158 

nonverbal communication, 40, 51 

Northwest Ordinance, 14, 17 

O

Oglala Sioux, 11 

open-ended questions, 57, 80 

Oregon Addictions & Mental Health Division EvidenceBased Programs Tribal Practice Approval Form, 181, 

181–185. See also integrating care 

organizational development. See workforce and 

organizational development 

217 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

P

Pan-Indian, 31, 56, 65, 173 

partnering with tribal governments to meet the mental 

health needs of American Indian/Alaska Native 

consumers, 132 

paths to solutions. See solutions, paths to 

personifcation of illness, 43 

physical health, 29 

planning 

continuing care, 96, 121 

treatment, 9, 54, 56–61, 94, 129, 196 

plastic shamans, 45, 108. See also shamans 

Poitra, Betty, 147 

Positive Indian Parenting, 179. See also National Indian 

Child Welfare Association (NICWA) 

pow wow(s), 31, 47, 67, 165, 168, 173, 180, 185 

practice-based approaches, 10–11, 13, 61, 61–63 

prayer(s), 22, 28, 46, 73, 76, 107, 172, 185 

prejudice. See discrimination, racism, and prejudice 

Pretest for Non-Native Counselors. See Sample Pretest for 

Non-Native Counselors 

pretreatment, 70, 86–87, 91, 94. See also vignette 2 

professional development. See workforce and 

organizational development 

Project Homeless Connect, 111 

provider competencies 

attitudinal, 153 

knowledge, 151 

skill, 152–153 

understanding, 151–152 

Q

questions 

about beliefs and values, 37–39 

to assess cultural identity, 56–57, 57 

Qungasvikm, 101 

R

racism. See discrimination, racism, and prejudice 

reconnection, vi, 9, 29–30, 30–31, 43, 58, 86–95 

Red Road, 65, 92, 175 

refective listening (also referred to as active listening), 61, 

74–75, 77–78 

RESPECT: a mnemonic for culturally responsive attitudes 

and behaviors, 40 

S

Sacred Hoop of 100 Eagle Feathers, 22 

sage, 75, 76, 109, 168 

Salish, 42, 65 

Sample Pretest for Non-Native Counselors, 159, 172, 

172–175 

Santee Sioux, 139, 144 

scale(s), 57, 83, 83–84, 147, 163–166, 170–172, 186 

sculpting, 54, 55, 62, 117 

settlers. See colonization 

sexual violence/abuse, 7, 14, 16, 21, 28, 57, 62, 72, 75, 97, 

97, 111 

shamans, 45, 108–109. See also plastic shamans 

SHARP-II: Providing Support-for-Service to Health Care 

Practitioners, 145 

skill competencies, 152–153 

S’Klallam, 134–135. See also Suquamish 

smudging ceremony, 46, 76, 85, 92 

Snyder Act (also known as the Indian Citizenship Act), 18 

social media, 120. See also Facebook 

social supports, 64–65 

socioeconomic conditions. See economic and social 

conditions of American Indians and Alaska Natives 

solutions, paths to, 130–137. See also administrative 

challenges 

South Dakota Urban Indian Health (SDUIH), 28. See also 

trauma: Beyond Trauma support group 

spiritual beliefs, 33, 39, 174 

Spokane Tribe Health and Human Services Behavioral 

Health Program, 137. See also National Health Service 

Corps (NHSC) Loan Repayment Program 

stacking questions, 77 

staff training. See training and education 

stages of change, 61, 87, 92, 93, 95. See also motivational 

interviewing 

Stand Down, 111 

storytelling, 51, 90, 101–102, 135 

strengths 

-based practice, 89–90 

gathering of, 90 

of tribal systems of care, 129 

Substance Abuse and Mental Health Services 

Administration (SAMHSA) 

American Indian and Alaska Native Culture Card: A 

Guide to Build Cultural Awareness, 142 

Minority Fellowship Program, 145, 145 

National American Indian and Alaska Native 

Addiction Technology Transfer Center (NAI & 

AN ATTC), 133 

Tribal Training and Technical Assistance Center, 133 

Substance Abuse Treatment: Addressing the Specifc 

Needs of Women (TIP 51), 29 

suicide 

prevention, 33, 63, 67, 101, 115, 117, 128, 176, 

178–179 

statistics, 6, 25, 97 

supervision. See clinical supervision 

218 
TIP 61

 

Index 

Suquamish, 134–135. See also S’Klallam 

sustainability, 132–133, 135–137, 186, 186–200 

sweat lodge, 22, 35, 46, 58, 73, 92, 129, 133, 163, 172, 

180, 184 

T

talking circle, 46, 58, 60, 90, 107–108, 146, 179 

Tanana Chiefs Conference Old Minto Family Recovery 

Camp, 54 

Termination Era, 18 

therapeutic relationship(s), 39–40, 54, 60, 74, 139 

Through the Diamond Threshold: Promoting Cultural 

Competency in Understanding American Indian 

Substance Misuse, 177 

Thurman, Pamela Jumper, 141 

timeline of signifcant events in Native American History, 

17–19 

Tlingit cultural values, 106 

tobacco (ceremonial/religious use), 46, 73, 109, 165, 

168–169 

To Live To See the Great Day That Dawns: Preventing 

Suicide by American Indian and Alaska Native Youth 

and Young Adults, 115, 179 

traditional 

American Indian and Alaska Native values and 

beliefs, 37–39 

culture(s), 20, 20, 29, 30, 35, 43, 46, 50, 92 

healing and medicine, 7–11, 23, 29, 31, 40–49, 

44–45, 54, 56–57, 58, 59, 59–61, 64, 69, 73, 94, 

105, 108–109, 129, 176–177, 181 

practices in recovery. See vignette 4 

ways, 28, 46, 54, 56, 58, 70, 82–84, 87–88, 94, 96, 

98, 100–101, 101–102, 104, 106, 106–108, 134 

Trail of Tears, 14, 143 

training and education 

arranging staff cultural training, 142 

attitudinal competencies, 153 

identifying potential cultural trainers, 142–143 

knowledge competencies, 151 

Leaving Footprints: Cultural Training, 144 

Native American Curriculum for State Accredited, 

Non-Tribal Mental Health & Substance Abuse 

Programs in South Dakota, 144 

providing educational resources, 144–145 

selecting training materials for cultural training, 

143–144 

skill competencies, 152–153 

staff opportunities, 144–145 

training competencies, 150–151 

understanding competencies, 151–152 

Trans-Alaska Pipeline System, 19. See also Alaska Native 

Program 

trauma 

Beyond Trauma support group, 28. See also South 

Dakota Urban Indian Health (SDUIH) 

historical. See historical trauma 

-informed care/treatment, 23, 62, 99, 125, 128, 128, 

141, 145 

rates of, 27–28 

Trauma-Informed Care in Behavioral Health Services 

(TIP 57), 23, 28, 57, 128 

Treatment Improvement Protocols (TIPs) 

Behavioral Health Services for People Who Are 

Homeless (TIP 55), 27 

Clinical Supervision and Professional Development 

of the Substance Abuse Counselor (TIP 52), 145 

Improving Cultural Competence (TIP 59), 8, 23, 

34, 41, 50, 125, 141, 147, 149. See also How To 

Engage in Self-Refection: A Tool for Counselor 

Training and Supervision 

Substance Abuse Treatment: Addressing the 

Specifc Needs of Women (TIP 51), 29 

Trauma-Informed Care in Behavioral Health Services 

(TIP 57), 23, 28, 57, 128 

Using Technology-Based Therapeutic Tools in 

Behavioral Health Services (TIP 60), 52, 58, 140 

treatment planning, 9, 54, 56–61, 64–98, 94, 129, 196 

Tribal Healing to Wellness Courts: The Key Components, 85 

tribal systems of care, 129 

trust 

gaining, 11, 28, 35, 40, 53, 55, 64, 66–67, 70, 75, 

78, 85, 109, 117, 126, 127–128, 137, 147–148 

lack of, 5–6, 7, 22, 49, 56, 74, 88, 105, 128, 137 

(legal), 15, 17–19, 24, 25, 30 

12–Step, 42, 64, 65, 92, 180. See also mutual help 

U

understanding competencies, 151–152 

unemployment, 27 

Using Technology-Based Therapeutic Tools in Behavioral 

Health Services (TIP 60), 52, 58, 140 

V

values, Alaska Native, 32, 37–39 

vignette 1—Vicki: Establishing Relationships, 

Acknowledging the Past, and Choosing Treatment, 

74–85 

court orders and mandates for treatment, 83 

listen for the meaning: cognitive–behavioral 

strategies, 79 

master provider notes, 76–85 

objectives for vignette 1, 75 

refective listening (also referred to as active 

listening), 77 

smudging ceremony, 76, 76–77, 85 

219 
TIP 61 Behavioral Health Services for American Indians and Alaska Natives 

using metaphor in counseling, 81 

using scales in counseling, 84 

Vicki’s case history, 74−75 

wellness courts, 83, 85 

vignette 2—Joe: Addressing Methamphetamine 

Dependence, Reconnecting With Family, and 

Recovering on the Reservation, 86–95 

culturally responsive counseling with American 

Indians and Alaska Natives, 95 

Joe’s Case History, 86 

loss of language, 88 

master provider notes, 87–89, 91, 94 

objectives for vignette 2, 86–87 

vignette 3—Marlene: Facilitating Support, Creating 

Family Connections, Honoring Traditional Ways, and 

Recovering in Remote Alaska Villages, 96–109 

Alaska Native villages: current challenges, 97 

family session(s), 96, 98–99, 101–106, 102–106 

family therapy: using a systems approach, 105 

homebrew, 98, 98 

Honoring Children, Making Relatives, 104 

how to fnd traditional healers, 108–109 

Marlene’s case history, 96–98 

master provider notes, 99–100, 102–103, 105–106 

objectives for vignette 3, 98–99 

subsistence: living traditional ways, 101 

suggestions for working with individuals who 

practice traditional ways, 107 

talking circle, 107–108 

Tlingit cultural values, 106 

Yuuyaraq: The Way of the Human Being, 106 

vignette 4—Philip: Making Connections Between Losses 

and Alcohol Use, Using One-Stop Outreach and Case 

Management Services for Homelessness and Treatment 

Service Needs, and Building Relationships Using 

Traditional Practices in Recovery, 110–121 

continuing care planning, 121 

detoxifcation counseling session, 113–114 

group treatment counseling session: welcome 

home, 116–120 

homelessness in Alaska, 111 

individual treatment counseling session, 115–116 

Inuit elders’ message on suicide prevention, 117 

is it a cultural belief or is it a diagnosis?, 111 

learning from the elders, 117 

master provider notes, 113, 116, 118–120 

objectives for vignette 4, 113 

Philip’s case history, 110, 112–113 

To Live To See the Great Day That Dawns: 

Preventing Suicide by American Indian and 

Alaska Native Youth and Young Adults, 115 

use of social media to connect Alaska natives who 

are homeless with their families, 120 

Welcome Home: Boarding School Exercise, 118 

vignettes, 69–121 

master provider notes, 69, 70. See also vignettes 1, 

2, 3, and 4 

vignette summary table, 71–72 

Violence Against Women Reauthorization Act, 19 

violent crime, 28 

visions, 22, 35, 45, 49, 73, 74, 89. See also dream(s) 

W

“Waktaya Naji” Award. See Dr. Duane Mackey “Waktaya 

Naji” Award 

Waukazoo, Martin, 153 

We Are Healers, 136. See also Native American Center for 

Health Professions 

Wellbriety, 22, 65, 180 

wellness courts, 83, 85 

withdrawal, 72, 87–89, 88–89, 91, 91–92, 94 

workforce and organizational development 

American Indian/Alaska Native Sustainability SelfAssessment Tool, 186, 186–200 

Center for Substance Abuse Prevention’s (CSAP’s) 

Prevention Fellowship Program, 139 

education. See training and education 

integrating care, 181, 181–185. See also Oregon 

Addictions & Mental Health Division EvidenceBased Programs Tribal Practice Approval Form 

listing of workforce development programs. See 

First Nations Behavioral Health Association 

(FNBHA) Listing of Native Workforce 

Development Programs 

loans. See loan opportunities 

mentoring, 133, 136, 136, 149, 149–150 

Native American Cultural Assessment Survey, 

159–160, 160–171 

New Hire Quick Reference Guide, 155, 156–158 

provider competencies, 150–153 

Sample Pretest for Non-Native Counselors, 159, 

172, 172–175 

supervision. See clinical supervision 

sustainability, 132–133, 135–137, 186, 186–200 

training. See training and education 

worldview, 8–9, 12, 31, 59, 92, 129, 133, 140, 147 

Wounded Knee Massacre, 20 

X

Y

Yup’ik, 25, 101 

Yuuyaraq: The Way of the Human Being, 106 

Z

220 
SAMHSA Knowledge Application Program Resources 

TIPs may be ordered or downloaded for free from SAMHSA’s Publications Ordering 

webpage at https://store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 

(1-877-726-4727) (English and Español). 

To receive monthly updates about TIPs and other SAMHSA Knowledge Application 

Program (KAP) resources on substance misuse and addiction treatment, subscribe to 

the KAP Email List by going to https://eepurl.com/dyBY3n. 
HHS Publication No. (SMA) 18-5070 

Printed 2018 

U.S. Department of Health and Human Services 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment