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January
2002 Na’nizhoozhi
Center Inc. (NCI) Hi’na’ah
Bitsos Society (HBS) Gallup New Mexico (505) 722-2177 Project Summary
- December 2001: In
1998, as the country’s largest substance abuse service provider, the
Na’nizhoozhi Center Inc (NCI) initiated one of America’s most intense
traditional Native American therapeutic environments. The program,
HBS (Hi’na’ah Bitsos’
or “Eagle Plume Society”), refers to the feather worn by a warrior to
maintain (or bring back) “life.” Built
outside of the 150 bed NCI detox facility, this project’s new, fully-secured
ceremonial ground includes: four types of sweat lodges; four Navajo Hogan’s;
two tipi sites; a storage shed; sheep corral; a garden area; a Pow Wow dance
arbor; a cook house and barbeque; and a highly qualified team of Native American
medicine, security, nursing, and administrative staff.
The project served 2,206 “unduplicated” “Relatives” (for residential treatment ) in less than three years (we call our Clients “Relatives” in respect to Navajo Dine’ Ke’ clanship), Our 23.5-day program completion rate was 95%. In addition, almost 40% of these graduates re-entered the program several times at their own request. Outpatient services were more difficult to track because they are largely community events held in the ceremonial grounds; gourd dances, pow wows, shoe games, family ceremonies, workshops, and prevention activities. This project has become the most significant Native American “culturally-based” residential treatment center in the southwest. It now serves as a community center for Native American substance abuse related issues. 85% of the HBS curriculum is based on Native American therapeutic practices (a mix of Dine,’ Native American Church, and Inter-tribal practices). All line-staff speak their indigenous Native American language. 17 of our 23 clinical people are traditional medicine practitioners. Once America’s “Drunk” City: As the primary trade center for America’s largest, rural-based Native American population, the City of Gallup has always faced a disproportionate occurrence of substance abuse problems. From 1975-1986 Gallup recorded the worst drinking-related social indicators in America. The national press labeled Gallup as America’s “drunkest city,” reflecting a drinking mortality rate 19 times the National average (with 13 people dieing on the street each month). Although
McKinley County only has a population of 78,000, as the commerce center for a
vast surrounding rural area, the city’s working population is actually closer
to 250,000 people. 73% are Native
Americans. Unemployment is 75% with
70% of families managing on less then $10,000 annually. 49% live without indoor
plumbing or telephone service. Surrounding human services are limited and
generally fragmented (Maternal and Child Health Council, 2000; New Mexico,
1997). According to a recent county epidemiological survey 71% of Gallup-area families “urgently” wanted drug or alcohol residential treatment and don’t’ know were to get it - or aren’t accepted due to lack of available space (Maternal and Child Health Council, 2000). 76% of local families also voiced the “urgent” need for alcohol services. 53% also voiced the “urgent” desire for more prevention events. Lessons We’ve Learned
Staff: The quality of the staff “makes or breaks” any program. Because
traditional Native American practices involve small communities, family, and
friendship ties, and frequent “after-hour” medicine services, the Western
concept of avoiding “dual” relationships was heavily modified. Although
ultimately more rewarding, a traditional cultural program is much more complex
than a relatively sterile “western” design. We
also believe that cultural practices are more “personality” and
“leadership” dependent than common “Western” practices. Western
techniques can often function along “on-some-level” regardless of who runs
them. Native American techniques, on the other hand, function well only when the
spiritual credentials of the practitioners are accepted by the community – the
practitioner must be seen to “walk their talk” even when at home and
“off-duty.”
Our
low staff pay-scale is always stressful. Most of our experienced staff members,
even those having undergone a life time of spiritual training, raise their
families on 6-10$ per hour with few benefits and no retirement program.
Staff members of high volume, low cost models like ours are living below
the poverty line. As a result we
have more transportation, health, morale, family, and turnover stresses than
that typically found in better paid urban areas. In
another area, because we are a multi-spiritual based program (complimented with
some Western and medical techniques) we spend time maintaining a tolerant
attitude between Christian, Navajo Traditional, Native American Church, and
Inter-tribal traditions. Other local agencies have been ruined by this natural
stress so we don’t take these efforts lightly. As a whole, however, NCI/Gallup
is remarkably multi-cultural, multi-gender, multi-spiritual, and multi-racial
operation. One
of our most difficult challenges now involves New Mexico State regulations. New
Mexico has recently passes strict licensing laws which will eliminated more than
250 experienced Native American, Hispanic, and “lay” counselors from our
rural areas, prisons, half-way houses, and indigent shelters - without any
chance of replacement (this represents 2/3 of all rural counselors Statewide).
The majority of our current counselors are field and workshop trained rather
than formally educated. Although they are actually fairly professional and
follow strict ethical standards, our counselors will not be able to return to
school to meet the new University requirements. Although we encourage everyone
to get more education, it’s our
belief that multi-cultural “lay” counselors are an essential part of our
professional team. This movement
towards eliminating all “lay-counselors” was organized by the urban academia
community without input from rural areas. (NCI has written an essay which
address this coming crisis in detail.) We
find no scientific rational for this arbitrary decision. We would like to have a
three tiered system where “lay,” spiritual-medicine people, and college
graduates all contribute as a team. So many of our “lay” counselors have
“essential” experiences, knowledge, spirit, and natural ability that
Universities can’t duplicate. In addition, very few rural, indigent-serving
programs can afford to hire an exclusive
staff of College graduates even if they were available, bi-lingual, and
culturally competent (which they
usually aren’t). Although
we are striving toward rigorous accountability the size of the resource pie
remains fixed. Unfortunately the expenses of thorough outcome assessment may
decrease client service (and even decrease outcome result) if not handled
properly. For example, the State requires us to conduct a long ASI assessment
every six months. CSAT requires us to also do a GPRA on the same clients.
Neither instrument asks the relevant clinical questions we need
so we then must throw in our own, long local assessment.
The whole process overwhelms, and even antagonizes,
both client and therapist. [We know one large tribe who’s multi-million
dollar program was unintentionally sabotaged by the six hours of various
questionnaires required in every assessment. Although the administrators
initially felt satisfied, counselors started avoiding clients. When the
counselors did see people their assessment questions were so hurriedly done
they lacked validity and proved irritating to
the clients. Lack
of bed space and adequate numbers
of staff still radically limits our performance.
Although the CSAT grant did expand our capacity, we’re still
busting at all seams. As a large volume facility, our Security, Nursing,
Administrative, and Counseling staff are still inadequate for 7/24 hour
coverage. Now that the three year CSAT-TCE program is complete, extensive
cutbacks have been necessary. Full sustainability is more of a pipe dream than a
reality. State money is very
limited. Manage Care dollars only pay for children and pregnant women -thus
eliminates 95% of our adult
population. Limited
co-occurring disorder treatment: More than 30% of our population goes
through treatment without significantly addressing their co-occurring disorders:
depression, anxiety, bipolar conditions, ADHD and learning disorders, head
injury, malnutrition, war PTSD, Domestic and childhood PTSD, deep grief/trauma
issues, and insomnia. Psychiatric
help is available only for the most extreme case and only briefly. Medication
management (if we can get it) is short term or non-existent. Aftercare follow-up
is rare. The
Community: As mentioned above,
we rapidly developed logistical problems with
after-care case management due to the long distances and the mobility of
the Client-Relatives, so we focused our attention to community prevention and
policy change. Because we are a Boarder Town agency rather than a part of Tribal
Government, our influence on the huge Navajo Nation is only indirect. We
have, fortunately, been able to
co-organize five area-wide community forums and have become a principle player
in the design stage of the President’s Office area-wide Boarder-Town Health
Authority – a difficult concept with tremendous potential. We have also
co-organized the Strategic Alliance Against Substance Abuse, the McKinley Health
Alliance, and re-organized Northwest New Mexico Fighting Back. Gallup/NCI also
hosts the Red Ribbon Sobriety Run, numerous summer pow wows,
the New Year’s Sobriety Gourd Dance and Pow Pow,
and many multi-agency meetings. The State of New Mexico has also asked us
to design a package of culturally empowered assessment tools to be utilized in
the state-wide system. Cultural
Empowerment: In
the years before this CSAT-TCE project, our pilot studies indicated that
cultural empowerment was the most essential unmet-need for 75% of our
population. We have now established the largest, and one of the most intense,
residential Native American healing centers in the country. Our
Client-Relative feedback and outcome assessment now constantly verifies that
cultural practices are loudly appreciated. An essay on “Culture as
Treatment” is available on our web site. Evaluators repeatedly hear that
longer, more intense programs are needed. Client-Relatives also report that they
want to come back for more services. Evaluators
and Evaluation: In an attempt to follow Guba’s model of “Fourth
Generation Evaluation, we designed a rigorous system of customized assessment
tools. Ten critical life areas were measured: physical, emotional, family
support, environment, livelihood, spiritual/cultural, self-concept, purpose,
triggers, and motivation. Usage dynamics were also measured.
We
found our Evaluators to be culturally sensitive and helpful.
Because of the lack of a
significant aftercare system in the area, our Evaluator’s are often the only
officials a Client-Relative might see after they graduate. Evaluator’s are
largely welcome, and frequently asked to provide immediate counseling and
traditional medicine way intervention. On
many occasions Evaluators were asked to intervene in some kind of
crises. Some of the
challenges they faced included the logistically difficulties of finding people,
delays in their gas reimbursement, private car problems, a shortage of
computers, and the lack of significant services they could offer people.
Qualitative feedback from clients was generally excellent. Client’s constantly voice appreciation for their easy access to traditional practices. Sweat lodge, NAC drumming, community events, and TNT modules appears to be the most enjoyed. On the downside, Client-Relatives voiced a need for a longer program, more individual attention, and a stronger aftercare system. Quantitative evaluation has been complex, disappointing, and may lack scientific validity due to some design implementation problems. An extensive re-analysis and modification is underway but this will take more time. There is a confusing discrepancy between the consistent strong subjective feedback we hear from Clients and their families; and the more empirical, data we gathered from pre and post measurement. This discrepancy may indicate problems in our evaluation design, it’s application, the validity of our questions, the validity of the way we asked them, or possibly even our own expectation of what results we should have. Due to the high cost of long distances and a migrating population, only 104 graduates were interviewed at 6 months and only 69 were interviewed at 12 months. This low percentage of pre-post comparison is also confused because these contacts are not necessarily the same people (people seen at 6 months vs people seen at 12 months). In addition, this low percentage of follow-up contacts may not represent a statically valid sample (they may have been the easiest to find - rather than those doing better and moving away, or doing worse so were harder to find). Initial outcomes scores so far do show a significant change in alcohol usage. Currently, our other psych/social/environmental factors do not indicated a significant change over time. The range of possible conclusions at this early stage are: (1.) the program’s had little effect; (2) the strength gained in treatment did not last long in the field; (2.) our current sampling and statistical procedure is not valid so skews the data; (3) our assessment instruments are not valid or reliable enough; (4) the outcome results have not yet been analyzed or understood enough to be useful. As
already mentioned, the preliminary results of our first 100 graduates show the
following “one year” DSM-IV outcome trends; 35%
are now in “early full remission;”
15% are now improved but still “alcohol abuse;” 22%
are now in “early partial remission;” 28% are still in “alcohol
dependency;” 72% have shown significant improvement in their lives all-around
even when they may still be struggling. Limited Treatment Time and No Aftercare Support: Evaluators have found that 73% of our HBS graduates either wanted the program to last longer, want to come back to learn more, need more support in the field, or felt that a periodic re-fresher is essential to their sobriety. [45% of the graduating Relatives actually stay on for another session. Due to limited bed space we are sometimes forced to encourage them home before they are ready.] More
Individual Counseling and Attention: Both
the Evaluation Team and our Consumer interviews also point out the overwhelming
request for more “one-on-one” counseling rather than the more cost-effective
group approach. Due to current budget limitations, relatives are only provided
two, one-hour individual sessions in 23.5 days. Most of the Client-Relatives ask
for at least six. Hard Core, Low Motivation: Although the current HBS program has helped to reduced the number of “protective custody” relatives who are chronically recycling through our detox system from 17,550 per year to 15,500 (many of these are repeaters) we are still falling far short of our organization’s full goal. The majority of these chronically recycling detox clients are identified by DiClemente’s Stages of Change as trapped in “Stage 1 - pre-conceptual” (HBS calls this stage “Quiet Darkness”). A deeper-reaching and more enhanced HBS program (using motivational, medical, and legal methods) must be developed for these “hard-to-reach” people. (see attached “Warriors; Wellbriety Path.”)
Other Misc.
Lessons We’ve learned: A. The concept of “one-time” treatment is misleading and unrealistic for most Client-Relative’s at this economic/social level. A life-long path of support and encouragement is needed. B. The lack of continuing, quality aftercare services is tragic. Integrating a HBS graduate back into a jobless, drinking community will wear down all but the most determined. Graduates constantly ask for more outside help, for longer programs, and for easier return-access. C. NCI-HBS is overwhelmed with requests from courts, prison, Behavioral Health Services, urban centers, and other tribes. We could easily fill a 100 bed program. D. Our next program should be longer; should be divided into progressive stages of growth and need. E. More radical, deeper-level, engagement is needed: minor Dine’ ceremonies, some of the major ceremonies, and full Native American Church meetings would improve the program. F. Access to psycho-tropic medication for co-occurring disorders is essential. A culturally empowered relaxation, biofeedback, psycho physiological training component still needs to be implemented as an alternative to drinking. G. Native youth issues have been largely ignored. A large, culturally-based youth program must be developed. H. More help from the Community and other Agencies is required; presenters, spiritual leaders and medical specialists are especially requested. I. We are often forced to juggle too many projects (usually out of necessity) and begin to loose focus. Most of these projects do relate to our ultimate goals but also distract and spread us out too thin. J. A vocational job-creation, half-way environment must ultimately be established. Evaluation
Methods: Due to
the large number of graduates each year, home-visits on each one of them is
unrealistic. As mentioned above
each home visit cost us at least $250. Due to the long, rural driving distances,
the lack of phones, the mobility of our population, and the low income levels
less than 40% of the Client-Relatives can be found.
Those we do contact are obviously the easiest to find for some reason;
they may be using more services, may be less able to move to the city, or may be
drinking more, or drinking less. It
is currently unknown whether this population is representative or not.
Our
next evaluation will involve more representative sampling techniques
(possibility accounting for at least 90% of the graduates within a practically
defined area.) V.
Dissemination of Information. NCI
has already established itself as a change catalyst in several areas; (1)
Reservations Boarder-Town policies; (2) Culturally reliable and valid instrument
design; (3) Culturally empowered treatment practices verified by rigorous
outcome evaluation; (4) State liquor retail policy; (5) State DWI law and
enforcement; (6) Inter-agency organizational models. Although far from complete, the evolution of the Gallup – NCI - HBS model has already made modest but significant contributions to the field. Some of these papers on available on the NCI web site: www.wellbriety-NCI.com. All manuals, curriculums, policies, forms, and videos are available to any interested agency. Two video have been produced: “The Spirit of NCI,” and “Alcohol is Not Our Medicine.” Close to 600 “Spirit” videos have been given out. We are currently looking for $3,000 to copy 1000 “Not Our Medicine” videos. The following papers are a direct result of this project; or the preparatory work we did leading up to the project. Barry, K. L., (1999) Brief Interventions And Brief Therapies for Substance Abuse. Treatment Improvement Protocol (TIP) Series 34 DHHS Publication No. (SMA) 99-3353 Ellis, B. H., and associates. The Latest View: an updated report on substance abuse-related social indicators. Prepared for Northwest New Mexico Fighting Back Inc. Gallup, NM (1999) Ellis, B. H. (1994). Talking the Long View: A review of substance abuse-related social indicators in McKinley County, New Mexico. Prepared for Northwest New Mexico Fighting Back, Inc.1994. Daw, R., Mosher, H. (1995) The Bridges of McKinley County: Building Rural Recovery Coalitions. Treating Alcohol and Other Drug Abusers in Rural and Frontier Areas . Technical Assistance Publication Series 17 DHHS Publication No. (SMA) 95-3054 Department of Justice, US . (2000), Na'Nizhoozhi Center, Inc, Promising Practices and Strategies to Reduce Alcohol and Substance Abuse Among American Indians and Alaska Natives. August. Holmstrom, D. (1997). Indian Traditions Help ‘Drunk Town’ Shed Its Image. Christian Science Monitor. Monday, July 14, 1997. Kelley,
M. J. (1995). Brain wave
biofeedback for Native American substance abuse. Journal of Neurotherapy,
(2-3)3. Kelley,
M. J., Daw, R. (1999). Outcome and program evaluation of a substance abuse
treatment protocol based on traditional Native American therapeutic practices.
Na’nizhoozhi Center Inc. (NCI) Gallup, N. M.. Manolescu,
K. (1995).
K’e: Cultural
Resiliency in Action. Paper
presented at the Society for Applied Anthropology Annual Meetings March 27-31,
1996, Baltimore, MD. Miller W. R., Willoughby, K. V. (1997) Designing Effective Alcohol Treatment Systems for Rural Populations: Cross-Cultural Perspectives Bringing Excellence To Substance Abuse Services in Rural And Frontier America. Technical Assistance Publication (TAP) Series 20, DHHS Publication No. (SMA) 97-3134 Na'Nizhoozhi Center, Inc, (2000), Promising Practices and Strategies to Reduce Alcohol and Substance Abuse Among American Indians and Alaska Natives. U.S. Department of Justice, August, Na'Nizhoozhi Center, Inc, (1999). “Ocean” Awareness Project. Unpublished report. Na'Nizhoozhi
Center, Inc. (1997).
Six Months Outcome Evaluation of Hiinaah Bits’os Society.
Unpublished report. Outcomes
Measurement Outcome
results must be kept in context. You must understand both the target population
and the environment they live in to understand results. TARGET
POPULATION The City’s target priority is current 15,500 Native American intoxicated people brought to NCI last year, approximately 3,000 people ("chronic repeaters") represent about 50% of our total admission. This "high-risk" group is the first specific target for NCI’s expansion. This underserved and largely homeless group contributes to nearly half of our expenses and time. This chronic group also makes up a significant portion of local emergency hospitalizations, Gallup police incidents, petty-crimes, area-wide injuries and accidental deaths. Nine years ago, approximately 10-15 of these clients would die each month from alcohol-related causes; accidents, illness, homicide, suicide. Although we've lowered this quota to about 3 street deaths per month, the personal and public cost of this existing situation demands an expanded response (Na’nizhoozhi, 2000). Although
the complexity of our relative’s problems are sometimes immense (often beyond
available resources) more than 60% of these clients will respond positively to
"intense" culturally-sensitive/life-skill intervention (Na’nizhoozhi,
2000). The
simplified table below has been constructed from a DSM-IV mental health analysis
of randomly selected relatives in our target group. Due to space only the most
common problems were included. Modified NCI-DSM-IV analysis of target population (very simplified) N=41 Age,
average
44%
Anxiety
18%
Cognit.Diso
25%
Witchcraft Trau.
41% Education
8%
Fears
82%
SeverStress 59%
Head Injury
59% Married
12% PTSD
63%
Chron.Fatg. 25%
Seizures
18% No
Family 82%
Sleep Disor. 25%
Self-esteem 88%
Malnutrition
29% Unemployed
88% ADD-learnDis.
12% Child
Abuse 50%
DeepPoverty 88% Trad.Culture
77% Bipolar-AFE
7% Adult
Abuse 46%
Environment. 88% Pref.
Dine’lang. 71%
Alcohol depen. 94%
Family Abuse 41%
Toughminded 47% Depression
59% Cultural Trauma
24% Inst.Depend.
65% Hopelessness
41% Dementia,
alco 29%
Spirt.Trauma
35% Poor coping
64% 75%
of our Phase I HBS relatives report that our program is too short and that they
require further life-wellbriety skills. Unlike
the predominant treatment model of “single” residential intervention, the
NCI model sees wellbriety (comfortable and healthy sobriety) as a lifelong
process of training, ongoing support, and giving back. Of course, when HBS graduates return to their home environment many things still work against them; problems are still there, drinking friends, lack of education and opportunity, joblessness, depression, poverty, boredom, pressure to drink, etc.. [Those treatment centers targeting relatively effluent people in job-rich areas may better succeed with the “single” residential intervention model.] Meaningful
and Relevant Results: When
the City of Gallup first conceived the high volume, low cost,
detoxification/crisis center nine years ago, the eventual development of a
rigorous, science-based model was identified as a priority. Three
years ago, with CSAT enhancement, NCI began developing culturally sensitive
tools, conducting expensive home-site outcome-interviews, applying
“consumer”-feedback systems, and provided leadership in Native American
methodology development on both the State and National Level. Current One Year Outcome Indicators: Although NCI’s current finding are not yet ready for publication, the preliminary results of the first 100 graduates show the following “one year” outcome trends; 35% now in “early full remission” 15% now improved but still “alcohol abuse,” 22% now in “early partial remission,” 28% still in “alcohol dependency,” and 72% significant improvement in their lives. Because
other variables are even more “telling” indicators than just measuring
“sobriety,” NCI also tracks these “critical” psycho/social/environmental
indicators: (1) DSM GAF; (2) psychological health; (3) Self-Concept; (4)
Life Purpose; (5) Spiritual Interest; (6) Self-Care; (7) Physical Functioning;
(8) Dangerous Behavior; (9) Social Functioning; (10) Interpersonal Functioning.
Examples of early outcomes are available on the NCI web site or from NCI
directly ( Kelley & Daw, 1999; Manolescuo, 1995). Pre-treatment scores
average from 50-60 while Post-treatment scores average 60-75. Usefulness of Local Finding: As mentioned above, both our consumer-questionnaires and our follow-up tools have pointed out the following problems. We are attempting to develop solutions. A. The concept of “one-time” treatment is misleading and unrealistic for most Client-Relative’s at their economic/social level. A life-long path of support and encouragement is needed. B. The lack of continuing, quality aftercare services in our area is tragic. Integrating a HBS graduate back into a jobless, drinking community will wear down all but the most determined. Graduates constantly ask for more outside help, for longer programs, and for easier return-access. C. NCI-HBS is overwhelmed with requests from courts, prison, Behavioral Health Services, urban centers, and other tribes. We could easily fill a 100 bed program. D. Our next program should be longer; should be divided into progressive stages of growth and need. E. A more radical, deeper-level, engagement is needed: minor Dine’ ceremonies, some of the major ceremonies, and full Native American Church meetings would improve the program. F. Access to psycho-tropic medication for co-occurring disorders is essential. A culturally empowered relaxation, biofeedback, psycho physiological training component still needs to be implemented as an alternative to drinking. G. Native youth issues have been largely ignored. A large, culturally-based youth program must be developed. H. More help from the Community and other Agencies is required; presenters, spiritual leaders and medical specialists are especially requested. I. We are often forced to juggle too many projects (usually out of necessity) and begin to loose focus. Most of these projects do relate to our ultimate goals but also distract and spread us out too thin. J. A vocational job-creation, half-way house environment must ultimately be established. ***********
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