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SAMHSA News - Volume XI, Number 4, 2003
 

From Subsistence to Sustainability: Treating Drug Abuse in Alaska

     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 village.

Within this context, "substance abuse renders individuals incapable of taking care of themselves or their families—which 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, YKHC—with CSAT support—has 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 Program provided 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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Reconciling Cultures

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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Integrating Services

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 clients]."

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 activities—build 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 home—whether that reluctance stems from discomfort about treatment or concern about rumors starting in the village—can 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 issue—and 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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