From Subsistence to Sustainability: Treating Drug Abuse in Alaska
By Melissa Capers
A village elder leads a tour of a remote
southwest Alaska village. As the small group of substance abuse
counselors and program administrators walks along the unpaved streets,
the elder points out "healthy homes"—those with
substantial woodpiles, fish hanging from drying racks.
—Phoebe Mills, M.S.W.
former Village Clinical Supervisor
Yukon-Kuskokwim Health Corporation
In the traditional subsistence culture of the Yup'ik and
Cup'ik Eskimo people of the Yukon-Kuskokwim Delta of Alaska,
the well-being of an individual or family can be measured, at least
in part, by the capacity to prepare for the Alaskan winter. Survival
depends upon the ability to work cooperatively with others in the
village in order to take advantage of seasonal food supplies and
to assure adequate provisions for each person, family, tribe, and
Within this context, "substance abuse renders individuals incapable
of taking care of themselves or their familieswhich in turn
affects the well-being of the entire community," says Kenneth Robertson,
Team Leader of the Targeted Capacity Expansion Team within SAMHSA's
Center for Substance Abuse Treatment (CSAT).
Founded in 1993 through CSAT's Rural, Remote, and Culturally Distinct
Populations Program, and expanded through a CSAT Targeted Capacity
Expansion grant, the Village Services Program of the Yukon-Kuskokwim
Health Corporation (YKHC) has put into practice a clear understanding
of the relationships between Yup'ik and Cup'ik individuals and their
tribes, between survival and well-being, subsistence activities
and healing. Through successfully integrating traditional subsistence
activities with Western substance abuse and behavioral health treatment,
YKHCwith CSAT supporthas established a system of services that is proving to be both
financially viable and culturally competent.
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History of the Village Services Program
Prior to 1993, the nearest substance abuse treatment programs available
to Yup'ik and Cup'ik villagers were located in Bethel, AK, 150 air
miles from the nearest targeted Yup'ik and Cup'ik village. Villagers
who made the trip to Bethel were separated from family, tribe, and
community, and often worked with service providers who had little
understanding of Yup'ik and Cup'ik traditions.
In 1993, CSAT (through its Rural, Remote, and Culturally Distinct
Populations Program), the state of Alaska Division of Alcohol and
Drug Abuse, and YKHC entered into a cooperative agreement to create
the Chemical Misuse, Treatment, and Recovery Services program. The
a welcome alternative to Bethel by offering access to established
village-based, culturally competent substance abuse services in
three target villages with a combined population of just over 2,000.
After the cooperative agreement expired in 1998, CSAT awarded
YKHC a Targeted Capacity Expansion grant that allowed YKHC to "use
and integrate the learning from the previous cooperative agreement,"
according to Mr. Robertson. This was done by creating a successor,
the Village Sobriety Project, later renamed the Village Services
Program. The Program, now nearing its 10th anniversary, is providing
services to more than 50 villages across the Yukon-Kuskokwim Delta,
and has proven self-sustaining in that effort for the past 3 years.
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The fledgling Village Services Program faced several challenges
in reconciling the needs of each partner organization with the needs
of the population the Program is intended to serve. In some instances,
the needs of each partner were complementary. CSAT required that
the Program establish a Policy Steering Committee in each village.
These committees, comprised of village elders and leaders, as well
as YKHC service providers, contributed expertise and direction to
the Program and served as a bridge between service providers and
the village community.
Other issues required greater effort and understanding from all
parties. For example, to assure cultural competence, wellness counselors
from each target village were recruited, hired, trained, and certified
as level I substance abuse counselors. Providing ongoing supervision
to these new counselors and assuring their compliance with reporting
requirements necessitated the use and development of new technologies.
Miles of tundra separated wellness counselors from one another and
from the Bethel-based village clinician, while a traditional oral
culture impeded the counselors' embrace of written recordkeeping
systems. Teleconferencing allowed for weekly case management meetings
between all parties. Some of the first commercially available personal
digital assistants (PDAs) and software developed in conjunction
with Program staff and steering committee members facilitated the
data entry and coordination necessary to meet the requirements for
reporting, evaluation, and reimbursement.
Other strategies were used to address the discomfort villagers
and clients felt toward written instruments and records. For example,
videos and focus groups were used in program evaluation, and informal
procedures were established to provide services to clients unwilling
to fill out the paperwork required by various agencies and organizations.
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Members of the policy steering committee worked with state Medicaid
officers to identify traditional practices, analyze the potential
healing aspects of each practice, and correlate those aspects to
Medicaid service categories. According to YKHC Clinical Administrator
Sandra Mironov, L.P.C., R.N., Alaska Medicaid officers "really understood...the
advantages of working with native populations in culturally competent
ways, and showed us how to move [through the state system]."
"When we submit billing," continues Ms. Mironov, "we submit billing
for family counseling, individual counseling, and so on. We provide
the same counseling you could receive in an office. We just provide
that counseling in the most appropriate format [for Yup'ik and Cup'ik
In traditional Yup'ik and Cup'ik culture, elders serve as the
human repositories of practice and wisdom. In cooperation with the
Village Services Program, the State of Alaska established a Traditional
Counselor Lifetime Certification, thus identifying—and legitimizing
to funding agencies—those individuals recognized by their
local communities for their knowledge of traditional practices.
These traditional counselors serve as teachers and resource persons
to clients and the Village Services Program.
Just as the health of a household might be measured by the presence
of fish drying outside the home in traditional Yup'ik and Cup'ik
culture, the healing of a household might occur through participation
in a fishing trip. As Ray Watson, YKHC Certified Clinical Supervisor
puts it, "[traditional counseling] hasn't been documented, but it
has been going on for centuries. Traditionally, grandpa would sit
down and teach you to make fish baskets. And, in passing on that
tradition, he would pass along some wisdom, too."
The successful integration of traditional and Western treatment
modalities ultimately came to rest on the willingness of partner
organizations to embrace the traditional context in which this treatment
is provided. Wellness counselors of the Village Services Program
"go and do things [with clients] that are part of their lifestyle
and part of their lives," says Ms. Mironov. She adds, "this approach
shows people how to apply the therapy [in their day-to-day life]."
And, Mr. Watson asserts, the traditional activity "brings another
piece to the treatment plan." When a counselor goes on a fishing
trip with a client, "you get something from the treatment," says
Mr. Watson. But "maybe another outcome is the fish." The fish, the
berries, the woodpile—concrete benefits of treatment provided through traditional activitiesbuild
clients' confidence in themselves and their community.
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According to Mr. Watson, providing services through traditional
activities also makes services more accessible to Yup'ik and Cup'ik
villagers. A client's reluctance to be seen entering a clinic or
a wellness counselor's homewhether that reluctance stems from
discomfort about treatment or concern about rumors starting in the
villagecan be overcome when the wellness counselor instead
meets a client at a village-wide seal bladder festival, or accompanies
a client on a tundra walk.
The willingness of all parties to recognize and assure the equivalence
of treatment provided in Western and traditional contexts has allowed
the Village Services Program to become self-sustaining. Training,
certification, and ongoing supervision of wellness and elder counselors,
as well as the development of written treatment plans, allowed the
Program to receive Medicaid reimbursement.
Local tribes provided a remarkable show of support for the Program
by passing resolutions identifying YKHC as their health care provider
and identifying substance abuse issues as a funding priority. As
a result of these local actions, YKHC's Village Services Program
receives funding for staff positions from the Indian Health Service.
Evidence suggests the Village Services Program is providing effective,
culturally competent treatment services. Community health aides
in one of the demonstration villages report fewer alcohol-related
injuries, and public safety officers report fewer incidences of
disturbing the peace, assault, domestic violence, and possession
of alcohol during holidays.
Mr. Watson observes that "people have gotten over the stigma attached
to counseling. It used to be that any time you went to counseling,
it was a bad thing. Now it's seen as a good thing." In the three
demonstration villages where wellness counseling has the longest
tradition, wellness counselors have the highest client load, suggesting
that the perceived openness to services is real.
According to Ms. Mironov, villagers also acknowledge that they
used to see public drunkenness as a source of amusement.
Now, they see it as serious issueand see less of it. "They
tell me it's no longer the norm," she reports, "which means their
children are no longer exposed to it." Instead, through the Village Service Program, Yup'ik and Cup'ik children and adults
have ever greater opportunities to be exposed to the strength and
healing of their traditional culture.
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