K A M I L L A V E N N E R , P H . D .
A S S I S T A N T P R O F E S S O R
U N I V E R S I T Y O F N E W M E X I C O
C E N T E R O N A L C O H O L I S M , S U B S T A N C E A B U S E , A N D A D D I C T I O N S
Considerations for Culturally Tailoring Treatments with American
Indian/Alaska Native People to Improve Engagement and Effectiveness
Intro
Copper River Fish Wheel
Overview
Substance use and race/ethnicity
Debates around Cultural Adaptations
Reasons to Culturally Adapt
Assessment and Case formulation
Adaptations to Motivational Interviewing (MI)
Adaptations to Community Reinforcement Approach (CRA)
Currently: adapting Community Reinforcement and Family Training (CRAFT)
NSDUH Alcohol use 2013
Balance of Strengths & Weaknesses
Percent Alcohol Dependent in Past Year
Spicer et al., 2003
0
2
4
6
8
10
12
14
16
2+ races AI/AN AfricanAm
White Hispanic Haw/PacIs
Asian Am
%
%
Past Month Illicit Drug Use by Ethnicity 2012NSDUH
Percent Abstaining in Past YearSpicer et al., 2003
Within group differences are noteworthy… (Spicer et al., 2003)
10
0
10
20
30
40
50
60
70
US Population Northern PlainsNative
Southwest Native
% L
ife
tim
e A
bs
tain
er
s
Male
Female
Alcohol and Substance Use Disorders11
19.2
14.4
14
13.6
10.6
6.5
7.2
7.2
7
5.9
5.1
3.3
3.3
3
2.5
7.7
3.9
3.9
3.3
2.2
0 5 10 15 20 25
AI/An
Black
White
Hispanic
Asian
Past 12 Months
Severe Moderate Mild Any AUD
Prevalence DSM-5 AUD
0 5 10 15 20 25 30 35 40 45 50
AI/AN
Black
White
Hispanic
Asian/PI
Lifetime
Severe Moderate Mild Any AUD
Debate about Cultural Adaptations
Exactly as Developed
Scientific process
If efficacious, provide to other groups and test efficacy or effectiveness
Etic approach of universality of human behavior
If adapt, may lose key ingredients or reduce efficacy or effectiveness
If adapt, not sure if any observed differences are due to new population or to altering method
Cost
Argument against EBTsGone, 2008
Subtle form of colonization – wipes out culture
Detracts from cultural preservation and revitalization efforts to maintain traditional healing practices
Emphasis on secular rather than sacred (i.e. Calabrese, 2008)
Dyadic rather than communal (i.e. Calabrese, 2008)
Stigmatized services vs admired participation
Lack of acknowledgment and value of indigenous ways of healing
4 Directions for Culturally Appropriate Treatment (Eap & Hall, 2007; Venner & Bogenschutz, 2008)
Deliver evidence based
treatment (EBT)
Acculturated
Deliver culturally based
intervention (CBI)
Traditional
Integrate EBT and CBI Bicultural or Multicultural
Develop new intervention Bicultural, Multicultural,
Traditional
EBT Fidelity Continuum
Exactly Retain
as Developed Underlying
Mechanisms
Reasons to Adapt
6 Reasons to Culturally AdaptBurlew et al., 2013
1. EBT less effective REMAS was less effective with African American men than
with the non-Hispanic White men (Calsyn et al., 2012)
2. EBT harmful EBT provided to new population (“deviant youth”) iatrogenic
in a group format and deviance increased (Dishion et al., 1999)
3. EBT unacceptable EBT secular; NA healing sacred
EBT in dyads, immediate family; NA healing could be individual, family , or community
EBT often stigmatized; NA healing revered (Calbrese, 2008)
Tribal SUD TX agencies express concerns (Novins, 2011)
6 Reasons to Culturally Adapt (cont.)Burlew et al., 2013
4. an adaptation would increase attractiveness, engagement, retention, and outcomes
After cultural adaptations to REMAS, African American men’s outcomes were significantly higher than had been in the unadapted version (Calsyn et al., 2013)
5. Acknowledges that cultural traditions influence behavior
6. More respectful to the ethnic cultural group knowledge and worldview
Aids in promoting cultural revitalization & preservation
Tripartite Model informs adaptations
Every Person is:
Like All Other People (Universal)
Biological, Common Experiences
Like Some Other People (Group/Cultural)
Culture, ethnicity, race, gender, social class
Belonging to a group can be major part of identity
Like No Other Person (Individual)
Individuals are unique
Do not stereotype, more differences within group
Dimensions for Cultural Adaptations(Bernal et al., 1997)
1. Language
2. Persons: client and therapist (e.g. ethnic matching)
3. Metaphors: symbols and concepts (e.g., sayings)
4. Content: cultural knowledge, values, traditions
5. Concepts: treatment (e.g. dependence; assertiveness)
6. Goals: related to positive and adaptive cultural values
7. Methods: (e.g. modeling, cultural reframing, formality)
8. Context: (e.g. phase of migration, acculturative stress)
22
Case Formulation & Assessment
Assessing Causal Model
Development
Cause of problem
Distress/unwellMethod to address
problem
Restoration/Healing
Biopsychosocialspiritual
Spiritual
Social
Psycho
Bio
Collision of Two Cultures
Kleinman’s Interview Questions
1. What do you call this problem?
2. What do you believe is the cause of this problem?
3. What course do you expect it to take? How serious is it?
4. What do you think this problem does inside your body?
5. How does it affect your body and your mind?
6. What do you most fear about this condition?
7. What do you most fear about the treatment?
Kleinman’s Suggestions
“First, get rid of the term ‘compliance.’ It’s a lousy term.
Second, instead of looking at a model of coercion, look at a model of mediation. Go find a member of the Hmong community, or go find a medical anthropologist, who can help you negotiate. Remember that a stance of mediation, like a divorce proceeding, requires compromise on both sides. Decide what’s critical and be willing to compromise on everything else.
Third, you need to understand that as powerful an influence as the culture of the Hmong patient and her family is on this case, the culture of biomedicine is equally powerful. If you can’t see that your own culture has its own set of interests, emotions, and biases, how can you expect to deal successfully with someone else’s culture?”
Kleinman case formulation (2006)
Step 1: Ethnic Identity
Step 2: What is at Stake
Step 3: The Illness Narrative
Step 4: Psychosocial Stresses
Step 5: Influence of Culture on Clinical Relationships
Step 6: The Problems of a Cultural Competency Approach
DSM-5
Cultural Case Formulation
16 questions
Semi-structured interview
Cultural definition of the problem
Cultural perceptions of cause, context, and support
Cultural factors affecting self coping & past help seeking
Cultural factors affecting current help seeking
Cultural Concepts of Distress (examples)
Ataque de nervios
Dhat
Kufungisisa
Case Conceptualization Aboriginal
Kilcullun & Day 2018
Language
If more than one language is spoken, how might our services be impacted or adapted?
Which language was spoken first? Spoken in the home? Preferred in therapy?
Language spoken determined proximity when conversing
Which language helps client access emotions?
What associations does the first language spoken bring up?
Strengths
1. Well-being,
2. Coping with daily hassles,
3. Social support,
4. Former coping within crises,
5. Recent experiences boosting self-esteem,
6. Personal strengths and skills,
7. Interpersonal relationships, and
8. Commitment to personal growth
Bern Resource Inventory (BRI; Trösken & Grawe, 2003)
Cultural Identity
Assessing cultural identity and salience
Avoid stereotyping by assessing cultural identity
Acculturation Strategies
Integration
Separation
Assimilation
Marginalization
Measures
https://www.ncbi.nlm.nih.gov/books/NBK248425/
Spirituality & Community
Spirituality
May be nuanced and complicated
Native American Spirituality Scale
Community
Community connectedness
Awareness of Connectedness Scale
Resource
Stress
Meaning
Collectivism
People place relatively more emphasis on collective goals: specifically of their ingroup
Decision making
Conformity
Arranged marriage
Classes of schoolchildren being promoted together regardless of performance of individual children
Motivated more by failure (Japan)
Children sleeping with their parents
Companies compensate employees on how long employed (not individual merit)
Extended families living under one roof
Connectedness
Secularization?
Secularization theory: Perception among many that as the world progresses, there will be less reliance on religious explanations of the world around us.
This trend is culturally constrained, with religiosity rising in some regions of the world.
© 2016 by W. W. Norton & Company
Religious belief
© 2016 by W. W. Norton & Company
Pew Research Center, 2009
Belief in God by age group
Pew Research Center, 2014
US Pew Research Center 2018
© 2016 by W. W. Norton & Company
Historical Trauma
Warfare
Forced removal from ancestral lands
Boarding SchoolsImpact on family functioning, parenting, attachment, trauma
Prohibiting traditional spirituality
Prohibiting use of native language
Genocide
Current thoughts about historical traumaLoss of land
Loss of language
Etc.
Discrimination
DiscriminationInterpersonally mediated
Intrapersonally mediated/Internalized
Structurally mediated
MicroaggressionsMicroassaults
Microinsults
Microinvalidations
Measures
https://scholar.harvard.edu/files/davidrwilliams/files/measuring_discrimination_resource_june_2016.pdf
Indigenist-Stress Coping Model
How do you adapt treatment for your specific populations?
Racio-cultural
Gender orientation
Sexual orientation
Socioeconomic status
Religion/Spirituality
Nationality
Immigration, refugee, asylum seeking statuses
Areas for Adapting
Muñoz and Mendelson (2005) recommended writing manuals to adapt ESIs for diverse populations with involvement from the community.
In addition, they encouraged the consideration of the impact of factors such as:
cultural values,
religion and spirituality,
acculturation and
racism
Adapting MI with Native Americans
Motivational Interviewing
Treatment for individuals in various stages of change
Particularly helpful for clients in the contemplation stage of change
Why MI
Interest from AI/AN
AI/AN people resonate with MI
“I believe the concept of MI is already within our culture.”
MI spreading around the world
Cross-cultural aspects
Resonates with many AI/AN
Why MI with AI/AN?
Better outcomes with Motivational Enhancement Therapy than with Twelve Step Facilitation Approach (Villanueva, Tonigan & Miller, 2002)
Meta-analysis found that the effect size of MI doubles for ethnic minority clients (0.79) vs NHW (0.26)
MI Trainers and Translations
Afrikaans Arabic Bulgarian Cantonese Catalan Creole (Haiti) Croatian Czech Danish Dutch English Estonian Finnish Fon French
Serbian Sesotho Sign (U.S.) Slovenian Sotho Spanish Swedish Tamil Tswana Turkish Urdu Ukranian Xhosa Zulu
Gaelic German Greek Hebrew Hindi Italian Japanese Korean Mandarin Norwegian Persian/Farsi Polish Portuguese Punjabi Romanian Russian
Native American Motivational Interviewing:
Weaving Native American and Western Practices
A Manual for Counselors in
Native American Communities
Kamilla L. Venner, PhD (Alaska Native)
Sarah W. Feldstein, MS
Nadine Tafoya, MSW, LISW (Mescalero Apache)
http://casaa.unm.edu/nami.html/
May need to adapt MI if…
The setting may not seem welcoming
Maybe no signs of AI/AN culture
Maybe no AI/AN providers
The person may not feel comfortable talking about AI/AN culture
Person not sure if anyone will understand them
Adaptations may help make MI make more sense, more culturally relevant
Help person connect motivations to culture, spirituality, family, etc.
How might we adapt MI?
Aspects of the setting
Décor, AI/AN staff, questionnaires, resources
Asking Open-ended questions about culture
Reflections including culture
Understandings of the problem
Motivations to change the problem
Ideas for how to change the problem
Cultural supports for the change
Explore interest in traditional healing
As one Pueblo elder recommends,
“Pray in your way, whichever way you know how.”
Guide me to be a patient companion
To listen with a heart as open as the sky
Grant me vision to see through her eyes
And eager ears to hear her story
Create a safe and open mesa on which we may walk together
Make me a clear pool in which she may reflect
Guide me to find in her your beauty and wisdom
Knowing your desire for her to be in harmony –
healthy, loving, strong
Let me honor and respect her choosing of her own path
And bless her to walk it freely
May I know once again that although she and I are different
Yet there is a peaceful place where we are one
Engaging
Focusing
Evoking
Planning Bridge to Change
Strategic Centering
Four Fundamental Processes* of MI
*Replaces prior Phase 1 & Phase 2
Relational Foundation
Transition to MI
Engaging Process: Introductions
Greet the spirit in each person
Introduce self in terms of heritage, clans
Figure out clan relationship and call client by the relative term (e.g., father, mother, son etc)
Honor each person
“We have to honor the wisdom in the client and then to be able to not see a person that’s an alcoholic, but see that person in the community that’s a grandmother or grandfather, honoring them for who they are, and everyone has wisdom, to bring that honor to them and (to allow) their wisdom to come out.”
~ Navajo female participant
Engaging Process: OARS
Open-ended questions
Affirmation
Reflection
Summary
Open questions to understand culture
What do you think caused this problem?
What is the best way to improve/heal?
How might stressors such as poverty or discrimination affect your health?
How important is your Native American heritage/culture/identity to you?
How important is spirituality to you?
Focusing Process
Agenda setting
Providing information
Drugs
Alcohol
Housing
Diet/Food/ Exercise
Discrimination
Physical health
Cultural Identity
Spirituality
Taking Care of Self
Elicit-Provide-Elicit (EPE)
Providing information in an engaging manner
Elicit: What do you already know about (topic)
Provide: Research shows_____________
Elicit: What do you make of that?
E: What do you know about Native Americans and drinking?
P: Native Americans have both higher rates of alcohol use disorders and higher rates of abstinence.
E: What are your thoughts about that?
Evoking Process: Elicit culture
How person thinks the problem began
Cultural beliefs about how to heal
Explore strengths and values of culture
Personal characteristics (warrior, leader, role model)
Family, clan, religious society, community support
Role in community: role model, member of religious group or society, dancing, preparing food, etc.
Open questions
How might spirituality affect your health? How might spirituality help you with this problem? How is this problem affecting your family? How might your family support you?
Rulers
0. . .1. . .2. . .3. . .4. . .5. . .6. . .7. . .8. . .9. . .10
ExtremelyNot at all
64
On a scale of 0 to 10, how important is it for you to make this change?
…how confident are you that you could make this change?…how ready are you to make this change?
Adapted Version
It is not important to make a change
You are unsure about making a change
It is important to make changes
It is extremely important to make changes
You haven’t prepared the ground for planting
A seed is in the soil but hasn’t been watered
Your plant just broke through the soil
Your plant is ready to be harvested
WHEN IS IT NOT A GOOD IDEA TO INCLUDE
RELIGIOSITY/SPIRITUALITY ?
WHAT ARE IMPORTANT CONSIDERATIONS IN
INCLUDING SPIRITUALITY/RELIGIOSITY IINEVIDENCE BASED TREATMENT?
How might you include spirituality or religiosity with clients?
Adapting CRA
First CRA Therapist Manual
Community Reinforcement Approach
Based on Operant behavioral principles
Substances are reinforcing
CRA helps clients build a sober life that is more rewarding than substance use
Rewards sober behaviors
Skills building approach Coping with Urges; Sobriety Sampling
Job seeking; Relationship building
Originators: Nate Azrin, Robert Meyers & Jane Ellen Smith
MICRA
CRA Forms
Happiness Scale
Arts and Crafts 1 2 3 4 5 6 7 8 9 10
Spiritual and Cultural 1 2 3 4 5 6 7 8 9 10
Extended Family 1 2 3 4 5 6 7 8 9 10 Relationships
Health and Wellness 1 2 3 4 5 6 7 8 9 10
Communication Skills
Many of these adaptations based on Native American counselors from the same reservation
Discussion around drug refusal and assertiveness skills
Acceptable to be assertive in ways similar to mainstream U.S.?
Acceptable to escalate firmness of communications to refuse substances from others?
“Community” in CRA
In small communities and Native American communities, each person has a role(s) to play
Very important to well being of the community and individual for each person to fulfill their role and live in harmony and balance
Reconnected with community: extended family, church, religious societies, community dances, feast days, NA religious observances
Native American Spirituality Scale
I believe life is sacred
I value my life and everyone’s around me
All things are related to one another
I wake up early and pray to creator/ancestors
In the evening I express thanks
I find strength in my faith and spirituality
I watch the tribal dances and feel a greater sense of wellbeing
I participate in cultural/faith related activities
I am spiritually touched by participating in my faith
I believe everything is alive with a spirit
I feel thankful for my understanding of my faith & beliefs
I want to learn more about my tribe’s protocol and way of life
Conclusions
Two evidence-based treatments were well-received within this SW pueblo community
Adapted MI and CRA appear effective in:
Increasing Percent Days Abstinent from alcohol (d=.68)
Improvements on 5/7 ASI subscales (except Job & Family)
Decreasing psychological distress (d =.75)
Small decreases in hopelessness (d=.37)
Small increases in self-efficacy (d=.20)
Increases in spirituality
Currently: Adapting CRAFT
CRAFT
Works with loved ones (concerned significant others; CSOs)who are worried about a person (identified patient; IP) with substance use problems who refuses to seek treatment
Based on operant behavioral principles
Goal of CSO rewarding sober behavior in IP
Help CSO withdraw rewards when IP using substances
Improve communication skills to focus on positive interactions
Invite IP to enter treatment
Help CSO improve own life; increase pleasant activities
Efficacy and effectiveness About 70% IP enter tx; CSO improved mental health functioning
Potential Adaptations
Infusing spirituality throughout intervention
May include traditional NA healing as a positive outcome (vs only SUD treatment programs)
Culturally congruent communication styles
Brainstorming who may be the most effective and appropriate person(s) to invite IP to enter treatment/healing (e.g., gender, age, religious leader)
Culturally congruent pleasant activities
Culturally congruent explanations of SUDs in terms of etiology and treatment/healing
Forms; measures
First Nations Ontario
Elder woman
We women don’t always take good care of ourselves
When I walk, I want to look at the beauty of the plants. When I was small, we would sit together and watch the full moon.
We need to have good words for each other.
Our job is to take care of each other. Harsh words hurt; positive words help/heal
Next: Culturally Center Medications for OUD
AI/AN as original pharmacists
Model of addiction
How do people recover
View of medications for infection, chronic illness like diabetes or cardiovascular disease
Summary
There is no one treatment that is superior to all other treatments and not one treatment fits all
There are many reasons to culturally adapt EBTs and growing evidence in the literature
Tension between fidelity to EBTs and cultural adaptations Cultural adaptations are individualized to the client to
avoid stereotyping and ignoring important group level identities
Cultural adaptations should be considered for assessment, case conceptualization, treatment choice, treatment delivery, and measurement of outcomes among others
Cultural adaptations may improve the treatment for mainstream populations as wel
Kleinman quote (2006)
This is much different than cultural competency. Finding out what matters most to another person is not a technical skill. It is an elective affinity to the patient.
And its main thrust is to focus on the patient
as an individual, not a stereotype;
as a human being facing danger and uncertainty, not merely a case;
as an opportunity for the doctor to engage in an essential moral task, not an issue in cost accounting.
Tsin ‘aen
