NCI - HBS Detox/Treatment Model

Best Practices Model:  - Theoretical  Guidelines

The National Institute of Drug Abuse(1999) defines the ‘Principles of Effective Treatment” as follows:

1. No single treatment fits everybody.

2. Needs to be readily available.  [ Hence, the City’s desire for expansion.] 

3. Attends to multiple needs of the individual, not just abuse issues. [NCI Model addresses co-occurring disorders and is multi-faceted.] 

4. Continual assessment and plan modification as person changes.[ NCI re-assesses clients  every two weeks.]

5. Stay in treatment for an adequate period of time. [Hence City’s need for Phase-extended  program as the beginning of a “life-long” wellbriety  path .]  

6. Significant counseling (indiv./or group) and other therapies are critical components.  [Hence City/ NCI’s  need for effective staff numbers.]

7. Medications are essential for many patients. [NCI’s expansion will improve medical ability.]

8. Co-existing mental disorders should be addressed at same time.[NCI’s expansion will   improve mental health services –increased nursing department .]

9. Detoxification by itself does little to change long-term drug use. [Hence, development of  NCI Wellbriety Path.]

10. Treatment does not need to be voluntary to be effective. [40% of NCI’s HBS relative’s  will be court ordered].

11. Possible alcohol/drug use during treatment is not allowed and must be monitored.    [NCI is a controlled environment, policy and testing.]

12. Assess  HIV/AIDS, hep.B-C, tuberculosis and other infectious disease intervention.   [NCI medical expansion.]

13. Recovery can be a long-term process and frequently requires multiple episodes of   treatment. [Hence the City/NCI’s interest in this new expanded model.]

The above principles are direct reflections of the NCI’s ideal Native American Wellbriety Path  - and also represents a culturally-empowered CRA model.

Culture as Treatment:  In an attempt to design more effective treatment protocols for our target group, several anthropologists stated that successful programs must utilize traditional Navajo and inter-tribal cultural techniques, traditional settings, and traditional self-empowerment programs (French, 1989; Grobsmith & Dam, 1990; Kavlahan, 1985; Manolescu, 1995; Westermeyer & Canino, 1994). A growing number of medical and psychosocial service professionals also insist that Native American cultural values and practices are essential when assisting traditionally-oriented Native Americans (Abbott, 1998: Brady, 1995; Department of Justice, 2000; Farella, 1984; Garrett & Garrett, 1994; Garrity, 1998; Gutierres, Russo, Ubanski, 1994; Mail & Wright, 1989; May; Rankin & Kappy, 1993; Miller & Willoughby, 1997; Mitchell & Patch, 1986; Muldoon –TAP 10, 1999; Room & Makelwa, 2000; Terrell, 1993; Young, 1986, Kelley, 1998; Kelley & Daw, 1999; Quintero, 2000). 

Jilek (1994) also presented a strong case that most community-recognized traditional medicine practitioners are “useful to modern health care programs as an inexpensive therapeutic resource,” especially in important and crippling psychosomatic and psychosocial issues (Jilek, 1994) (p. 219).  He believed that effective intervention must always be relevant to the socio-cultural context from within which the substance abuse occurs.  He also stated that “cultural-congenial practices of indigenous traditional healers” are often the most relevant psychotherapy. 

Jilek (1994) sees these important therapeutic values in many Native American therapeutic /spiritual practices (e.g., sweat lodge, Sun Dancing, social and personal ceremonies, winter spirit dancing, the Native American Church, and other methods of spontaneous induction into relaxed-altered states of consciousness).

In the Southwest, active participation in the Native American Church is considered by researchers to be more effective than the standard 12-step treatment or medical treatment protocols (Albaugh & Anderson, 1994; Hill, 1990; Pascarosa & Futterman, 1976).

Caution, however, must be taken because a single treatment protocol (even within one culture) is likely to be ineffective for all participants.

Active Variables in Native American Practices: When properly done within the right context, Native American therapeutic techniques are often applied more to groups than with individuals (more cost-effective). They also generally involve: (1) the sacred use of culturally validated symbolic acts, words, and objects; (2) the client’s public admission and promise of a behavioral correction; (3) specific internal and external purification (herbs, physical activity, or physiological shifts); (4) enhanced-altered state of consciousness (shifts in neurochemistry – brainwaves). Jilek describes this induced state as “a culture-congenial situation that facilitates psycho-dramatic abreaction and affective release achieved through catharsis triggered by adequate sensory stimulation, or in an altered state of consciousness induced by psychological, physiological, or phyto-chemical means” (p.247).  Cultural setting are also essential. Jilek also points out that the therapeutic effects of practices are usually magnified by the empathy and support shown by ‘kinspeople’ and community members.

When comparing accepted western methods with such indigenous therapies, Jilek believed that (within a proper context) indigenous procedures often have the following advantages: (a) there is absolute cultural-congeniality between client and practitioner (unlike many western relationships which occur between doctor and patient); (b) the personality, “power,” and rapport of the healer is emphasized more than the mechanical technique (a point often down‑played in both medicine and formal psychotherapy); (c) such therapies always integrate psychology, physiology, social, and spiritual components (unlike the trend towards specialization and fragmentation in many western techniques); (d)  traditional healers are generally very accessible, available, and permanent (western health clinics tend to be difficult to enter with frequent changes in location and staff); (e) enhanced-altered states, engaged emotional conditions, and sharply focused awareness are often utilized in conjunction with culturally validated images (in contrast to the general western insistence that behavioral change occurs through intellectual insight and education); (f) therapies usually involve the re-integration of family, kinspeople, and community (unlike the often isolated western clinics which mainly work on individuals outside of their personal context); (g) indigenous therapies tend to be most cost-effective due to their lower overhead and group orientation. Indigenous practitioners may also act as community role models (very unlike the usual aloofness and isolation of western health care providers).

These cultural principles have been verified by NCI’s recent outcome reports (Department of Justice, 2000; Kelley, 1998; Kelley & Daw, 1999; Na’nizhoozhi Center 1997).

Any successful training protocol must also convert the “negative” tough-mindedness of our target population into what we call “positive” warrior tough-mindedness; a mental strategy based on supportive spiritual Navajo “beauty-way” (Farella, 1984; Zolbrod, 1984). The spiritual and philosophical motto of HBS, “Against all odds, I walk in beauty, ” helps illustrated this change. 

Psycho-Physiological-Neurological Homeostasis:  Recent findings in applied psycho-physiology also support (and help explain) the use of traditional Native American therapeutic practices within modern treatment settings (Kelley, 1998; Shellenberger & Green, 1989).

It is likely that many traditional Navajo medicine and Native American Church procedures (such as sweat lodge, "blessing-way,” herb-usage, and a variety of intense ceremonies) produce significant and measurable psychophysiological, stress-relieving benefits.  For example, numerous researchers believe that intensive training in biofeedback (applied psychophysiology or self-regulation training) may offer the abuser a healthier self-regulating, physiological method of feeling good when sober (neurological normalization).  Such measurable benefits triggered by biofeedback techniques seem to encourage the stress inoculation-like homeostasis required for comfortable “wellbriety”(Bodenhamer-Davis & deBeus, 1995; Fahrion, 1995; Kelley, 1998; Peniston & Kulkosky, 1989; Walters, 1992, ).

Select Native American therapeutic practices, for example, may produce quantifiable psycho-physiological changes similar to the positive results found in these studies. Techniques such as the sweat-lodge likely trigger serotonin-releasing mechanisms: a dark and mystical environment where the participants sit almost naked for hours; intense heat; carbon dioxide buildup in the blood causing better oxygen tissue saturation; increased core-body temperature; intense singing/chanting inducing neurological brainwave synchrony; EMG muscle relaxation; intense cathartic release; release of “stuck” negative cognitive-schemas; varied psycho-physiological purifying procedures such as tobacco and cedar protocols; social bonding; cognitive ego re-structuring; singing with joy after purification; and the theta brainwave-based psychophysiological “afterglow” lasting for hours.  Such practices may rightly stretch the boundaries of what we call science-based, “applied psycho-physiological techniques.”     

As indicated by overwhelming participant feedback, select traditional Native American practices may be “normalizing” participant's brainwaves from “heavy-stress, crave-inducing” patterns. Higher amplitude brainwaves (relaxed and disengaged) have been associated as essential for comfortable sobriety (Peniston, 1994; Walters, 1992; Bodenhamer-Davis & deBeus, 1995; Fahrion, 1995; Ochs, 1992; McPeake, Kennedy, and Gordon, 1991; Kelley, 1998;  Rosenfield, 1992; Erickson, 1989; Taub, Steiner, Smith, Weingarten, & Walton, 1994; Peniston & Kulkosky, 1989).

Help from Known Models:  Some of the possible active ingredients shared with this cultural protocols may be (a) induction of the relaxation response; (b) induction of a beneficial neurologically-based altered state of consciousness which produces both chemical balance and emotional satisfaction; (c) the benefits of both Hawthorne and placebo responses combined with the other essential psychological values of faith, expectation, belief, and hope; (d) the new experience of physiological/ psychological self-control in a situation where the client had previously felt helpless; (e) the experience of what the participants commonly describe as a significant spiritual insight; (f) the Reward Deficiency Syndrome and Feel Good Response model (Blum, 1991), the Altered-State Fulfillment model (McPeak et al., 1991), the Natural Mind model (Weil, 1972), and the Tension Reduction/Stress-related hypothesis.

Native American Therapy and the Community Reinforcement Approach: As mentioned earlier, most of the therapeutic principles used in the HBS design are compatible with the Community Reinforcement Approach  (CRA). In an extensive meta-analysis of the efficacy of various treatments the University of New Mexico’s CASAA (Center on Alcoholism, Substance Abuse, and Addictions) complied this multi-modal treatment model (Miller & Hester, 1995). This approach attempts to help the client re-arrange his or her once difficult vocational, familial, and social environment into a positive and encompassing system of positive ‘reinforcers.’ It is hoped that this new life makes it emotionally awkward for the problem-drinker to take time out for drinking. Clients are taught ways ‘to feel good sober’, ‘to make their own medicine’, and to become as self-sufficient as possible. A new life is created - one that is ‘better and more satisfying than drinking’.  The protocols utilized in HBS naturally included most aspects of these CRA components (Miller & Willoughby – TAP 20, 1997).

Therapeutic Community and “Empowered Peer Synergy:” A community that is based on shares peer values, activities, opportunities, ongoing support, and norms is an important part of the “best practices” components of both the Community Reinforcement Approach and Therapeutic Communities approach (Condelli, 1994; De Loen, 1981; Department of Justice, 2000; Hubbard et al, 1998; Wexler, 1997; Zimmerman, 20000 Both the current NCI model and the proposed Native American Wellbriety Path reflect these principles.

Limitations of Cultural Resiliency: Cultural as treatment, of course, also has limits. It is not a panacea. As in western practices, harm and mistreatment can occur. Jilek did maintain, however, (especially in the field of substance abuse where western efficacy is poor and where failure is often  devastating) that even the most drastic indigenous intervention is usually worth the intelligent-risk. Brady (1995) also issued caution against simplistically and automatically considering “culture as treatment.”

In some cases cultural tradition or taboo might actually be counter productive: e.g. intervention into an individual’s affairs; values against expressing emotion; and anti-authoritarian behaviors can sometimes make programs difficult. Traditions of ‘witchcraft blame’, Christian-like external negative forces (demonic) overpowering individuals, and even the traditional AA concept of “powerlessness over alcohol” often distracts from the responsibility of both the individual and society. In cases such as these, Brady recommended that both the strengths and weaknesses of indigenous culture must be assessed and that modification (or avoidance) of certain traditional values may sometimes be necessary. She stated that cultural and spiritual values in themselves are relatively ineffective unless they involve local peer groups or are part of a compelling social message (as developed by Gallup’s NCI-Community Reinforcement Approach modification – Miller, 1997).    

Desperate for Data: The lack of reliable outcome studies among the often highly-mobile, guarded, and rural Native American population was expressed by Grobsmith and Dam (1990). Although Jileck was also discouraged by this vacuum, he also stated that the overall collection of evidence on many different continents and in many different contexts illustrate that many indigenous therapies are generally successful and growing fast (Abbott, 1998: Brady, 1995; Department of Justice, 2000; Farella, 1984; Garrett & Garrett, 1994; Garrity, 1998; Gutierres, Russo, Ubanski, 1994; Mail & Wright, 1989; Manolescuo, 1995; May; Rankin & Kappy, 1993; Miller & Willoughby, 1997; Mitchell & Patch, 1986; Muldoon –TAP 10, 1999; Room & Makelwa, 2000; Terrell, 1993; Young, 1986, Kelley, 1998; Kelley & Daw, 1999; Quintero, 2000).

Participatory Planning Process – Community-Based Response: 

In agreement with Guba and Lincoln’s Fourth Generation Evaluation model (1989) and the principles of “action-oriented” research (Argyris, 1983), both the City of Gallup and NCI has spent a great deal of time gathering stakeholder input to both plan and evolve this proposal. Because standard prevention and treatment approaches have largely failed this population for 50 years, care must be taken to avoid more waste. For this proposal; Consumer, Public,  and other-agency input came from the following;

          Public Forum: three public forum - focus groups largely organized by NCI and it’s associated leadership (Ellis, Gallup Remembers, 1996, Taking the long View 1998, 2000); a 2-day Border-town public forum in  Farmington. NM was attended by more than 370 people. Written reports of these events three events have been released to the public.

Coalition meetings: NCI participates in the Strategic Alliance Against Substance Abuse  (SAASA) in Gallup – both a public coalition tasked with identifying and meeting substance abuse issues. SAASA meets twice per month for two hours. NCI also participates in the monthly McKinley County Health Alliance dedicated to even broader health issues. NCI also hosted a special “residential needs-assessment” forum with all area treatment providers.

            Internal Evaluation: The City has overseen NCI’s two formal outcome evaluations based on a modified Forth Generation Evaluation Model (Guba & Lincoln, 1998). NCI’s current full-time evaluation team consists of three case-workers and one full time Ph.D. level Clinical Psychologist. Monthly advisory reports have been fed back into  HBS program for more than two years.

             Consumer Representative:  A NCI client-relative was appointed by the State of New Mexico to conduct independent, none-controlled consumer surveys. Two were conducted this last year. Client-relatives, graduates, counselors, security staff, and court staff were interviewed in her assessment.

            Client-Needs Assessment: Client-relative need/satisfaction questionnaires and formal interviews are given to all protective custody clients at least twice per year. Additional feedback occurs almost on a daily basis with morning community meetings and counselor/relative interaction.

Matthew Kelley Ph.D.

NCI

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Last modified: May 24, 2005