1. Department of Health and Human Services Substance Abuse and Mental Health Services Admin
Funding Opportunity (FOA) Number SM-16-010: Cooperative Agreements for Tribal Behavioral Health
Historical Trauma: Culturally Sensitive Treatment in Indigenous Communities
Kaitlyn Welch, Sara Cole, Raven Knapp, & Lars Boettcher
University of Washington
June 1, 2016
2. Introduction
There isan extensiveamountof literaturesurroundinghistorical traumaanditseffectson
indigenouscommunities. We will focusprimarilyonindigenouspopulationsandwe will be reviewing
differentapproachestotreatment,suchasthe westernclinical formof treatmentandtraditional
indigenoushealinganditsrole inthe healthof the community.A large bodyof literature hasbeen
writtenonresearchthat showssuccessful preliminaryresultsof indigenoushealingpractices(Bigfoot&
Dunlap,2006; Braveheartet.al 2011, Castledenetal.2007, Gone & Alcantara2007). Withfurther
research,we hope toimprove the efficacyanduse of culturallysensitive treatment.Itisourgoal thatby
investigatingthe currentclimate of culturallybasedtreatmentandevidence basedcare we will finda
more comprehensive interventionmodel.
The social isolation,poverty,andlackof healthcare servicesthatplague the country’s
reservationshave encouragedalcoholism, drugabuse,andalcohol-relatedcrime intheseareas
(Braveheart,2003; Clark2006). Studieshave shownthatIndigenouspeople have a75% higherchance of
beingassaultedintheirlifetime,andthe childrensexual abuse ismore thansix timesthe national
average (Payne,2013). AmericanIndianscontinue tobe confrontedbydiscriminationandracismwhich
has affectednative tribesforhundredsof years,deeplyrootedtothe historical traumathataffectstheir
everydaylives(Braveheartet.al,2011; Gone & Alcantara2007; Sunrise House,2016; Walters,2004).
There are five racial groupsthatSunrise House,atreatmentprogramand a drug rehabcenter
that has beenhelpingpeople foroverthirtyyears,aswell asconductingresearchforbettertreatment
and increasedawareness,focusedtheirresearchonthe populationproportionthatabusedsubstances.
The races that data was collectedonwere AsianAmericans,HispanicAmericans,CaucasianAmericans,
AfricanAmericans,andNative American,Native Americansscoredthe highestat12.3%, comparingto
the secondhighestof 10.5% of AfricanAmericansmore likelytouse substancestocope withtheir
trauma. Fromthisdata, we can deduce thatindigenous populationscurrenttreatmentandhealing
methodsdonot reduce the ratesof substance abuse (Sunrise House,2016).
Eventhoughindigenouspeoplehave highratesof depression,anxiety,andotherformsof
mental illness,the reservationssufferfromalack of mental healthprofessionals(McCabe,2013; Payne,
2007). Mental healthclinicsontribal landsare limitedandhighturnoverratesfortreatmentstaff pose
additional challenges.Addressingtheseproblemsrequiresanational focusonthe healthconcernsof
indigenouspeople,alongwithawillingnesstodevote more resourcestoeducation,prevention,and
rehabfor marginalizedgroupsof people.
NotedscholarPembercomments,“The science of epigenetics...proposesthatwe passalong
more than DNA in ourgenes;itsuggeststhatour genescan carry memoriesof traumaexperiencedby
our ancestorsandcan influence howwe reacttotrauma and stress”(2015). Trauma experiencedby
earliergenerationscaninfluence the structure of ourgenes,makingthemmore likelytoexpress
negative responsestostressandtrauma.Historical traumais a three part process.“Inthe initial phase,
the dominantculture perpetratesmasstraumaona populationinthe formof colonialism,slavery,war
or genocide.Inthe secondphase the affectedpopulationshowsphysical andpsychological symptomsin
3. response tothe trauma.In the final phase,the initial populationpassesthese responsestotraumato
subsequentgenerations,whointurndisplaysimilarsymptoms”(Pember,2015). Accordingto
researchers,highratesof addiction,suicide,mental illness,sexualviolenceandotherillnessesamong
Native peoplesmightbe,atleastinpart,influencedbyhistorical trauma.
There are currenthealthcare provisionsthatindigenouspeoplereceive thatdonoteffectively
improve theirmental health.Modernmedicinefocusesononlythe scientificandothermechanicsof
medicine inthe body(Weiser,2015).The indigenousstyle of healingnotonlyusedherbsandplantsas
medicine,aswell asinclusionof spirituality.Thisiscrucial tohealingthe bodyaswell asimprovingthe
emotional wellnessof apersonand the harmonytheyexperience withtheircommunityand
environment.Indigenoushealingmayhave otherchallengesandlimitations.Forinstance,itisstill
unable tocure some of the diseasesintroducedduringcolonial introductiontothe states.Hospitals,
especiallynearreservations,are startingtobecome more acceptingof the indigenousstyle of healing.
Throughthiscollectedbodyof researchwe will identifythe bestformof treatmentforthese indigenous
groups.LookingintobothWesternmedicineaswell asindigenouspractices,inordertocreate an
effectivetreatmentprogramthatwill positivelyenhancethe outcomesof substance abuse andmental
illnessrecovery.We will thenseektoanswerourresearchquestion:How hasthe efficacyof traditional
healingpracticesbeenmeasured?Whyhasthere beenlimitedstudiesfurtheringeffective indigenous
healingpractices?
Purpose statement
The purpose of thisstudyis to determine the mostbeneficialtreatmentservicesforindigenous
people thathave experiencedhistorical traumaandare currentlyfacingissueswithsubstance abuseand
mental illness.Thisstudywillanalyzeexistingdataonthe efficacyof indigenoustraditional healing,in
comparisonwiththe effectivenessof westerntherapypracticessuchasCommunityBasedParticipatory
Research.Withour findings,we will developanessential preliminarytrainingprogramforcounseling
professionalsworkingwithinindigenous communitieswhichare currentlylacking(Gone &Alcantara,
2007).
Literature Review
Themesthatemergedfromourresearchare traumafrom abuse (sexual andphysical),historical
trauma,substance abuse,mental illness,traumainformedcare,andcommunitybasedparticipatory
researchmethods.Grayshieldet.al conductedone of the firstknownstudiesof itskind(2015).The
authorsof thisresearchstudyare eitherindigenous,aminoritypopulation,orhave astrong connection
to a Native Americancommunity.Importantqualitative dataemergedfromthisNative Americanelder
perspective onwaysinwhichtoheal historical traumaastheyare highlyrespectedmembersintheir
4. community,andmanyof themhave experiencedhistorical traumathroughouttheirlifetime.Existing
researchshowsthathistorical traumahas largelybeencollectedandstudiedfromawesternized
perspective (Grayshieldetal.2015 as citedbyBrave Heart& DeBruyn,1998; Duran, 2006; Whitbecket
al.,2004). The recommendationsfromthe communitythatemergedare:focusonthe positive,
awarenessandeducation,returntocultural andspiritual waysof life,andlanguage learning.Further
suggestionsincludedintegratingastrengthsbasedpsychotherapy“toshiftthe focusof therapyfroma
deficit(e.g.,disordered)modeltoa strengthsmodel”(Smith2006 as cited byWallerstein&Duran)
Thisapproach has similaritiestoa community-basedparticipatoryresearchmodel,whichhas
alsoaddedto the literature of effectivetreatmentandcare withinindigenouscommunities.Community
basedparticipatoryresearch(CBPR) hasgainedmomentuminthe lastfew decadeswiththe “capacityto
reduce or eliminateracial/ethnichealthdisparities”(Wallerstein&Duran2010). Insteadof conducting
researchon a community,CBPRseekstoinvolvethe communitymembersasequal contributorstothe
researchprocess.
A relativelynewwesterntreatmentmethodistrauma- informedcare,thismeansthatstaff are
trainedtobe sensitivetotraumathat patientshave facedinorderto betterserve the needsof these
typesof patients.The Women,Co- occurringDisordersandViolence Study(WCDVS)wascreatedto
quantitativelymeasure the effectivenessof trauma- informedcare forwomencopingwithtrauma,
mental illness,andsubstance use disorders.The resultsshowedthattrauma- informedcare practices
improvedpatient’smental healthoutcomes.
Grayshieldetal.’sstudy onthe possible treatmentsforhistoricaltraumaasrecommendedby
Native Americanelders,provide recommendationsforculturallysensitive treatment,developedby
those affected.Asforthe Women,Co- occurringDisordersandViolenceStudy(WCDVS),trained
professionalstreatingtraumadonot have personal experience withsaidtrauma,therefore the
epistemological frameworksoffercompletelydifferent approaches.The methodologieswe have
analyzedare as follows.Anindigenousstrengthbasedcounselingmodelinwhichcounselorsand
patientsidentifypersonal strengthsandhow touse themwiththemselvesandotherscanprove very
effectiveinindigenouscommunities(Grayshieldet.al).Communitybasedparticipatoryresearchfocuses
on the intersectionof science,communityinvolvementandsocial actiontobenefitequalityof health
care (Wallerstein,2011).Strengthsbasedpsychotherapychangesthe focusfromdeficitsintostrengths
(Smith2006 as citedby Grayshieldetal.2015). Evidence basedpractice strivestodiscoverthe best
treatmentmethodsthatcan be usedto effectivelytreatpatientsandisbasedonthe currentbodyof
knowledge producedbyleadresearchersinagivenfieldof study.Traumainformedcare isatreatment
approach thatfocusesoneducatingtreatmentstaff onthe wide arrayof trauma experience patients
face and howto bestrespondto patient’s needs.
There have beenseveral questionsraisedaswe have reviewedthe literature.Whoisdiagnosing
individualswithco- occurringdisorders?Whatare the challengesof diagnosisinmental illnessesand
substance abuse issues?Misdiagnosiscanpotentiallyoccurandcreate additional barrierstoan
individual’sabilitytorecoverorbenefitfromtreatmentservices.Whatlimitationsconstrainthe
differentmethodologieswe have lookedat?ForInstance,evidence basedpractice islimitedbythe
5. amountof data,both qualitativeandquantitative,incirculationonacertaintopic.Who isbeingleft
out?A considerable questionwe hadinthisprocess waswhetherornot the researchaccountedfor
those whoare tooscared or too proudto come forth abouttheirtrauma or theirsubstance abuse.We
have discussedwhetherornotresearchersleftroomforthose intheirresearchor if theyexcludedthis
populationintheirresearch.Manypeople inthesecommunitieswill be supportive of those theyknow
are sufferingabuse,yetnotconfrontthe situationheadon.Ourcontinuedresearchisdirectingus
towardsfindingamore comprehensive interventionutilizing indigenousperspectivesasthere hasbeen
limitedresearchinthisphenomenological framework(Grayshieldetal.2015). Our desiredapproachis
to upgrade healthcare providerstrainingtoinclude differentculturesandspiritualfixtures.
Methodologyand Epistemological Framework
It isour goal thatthrough thisresearch,we will begintodevelopanextensive trainingprogram,
incollaborationwiththe indigenouscommunityanditsmental healthprofessionalsforcontinued
practice and implementation.In ordertoachieve this,we wanttodevelopapartnershipwiththe
indigenouscommunity.We will be analyzingexistingdataasour methodological approachbyusing
secondarydata analysisandfocusingoncommunitybasedparticipatoryresearch(CBPR).Gone and
Alcantara(2007) foundthe available dataonoutcomesof any numberof culturallysensitive treatments
islimited.IllustratedbyWallerstein&Duran(2010), the continuedpractice of these interventionsisnot
alwayscarriedoutafter studiesare conducteddue tofundinglimitations.
The epistemological frameworksthatourresearchincludesare CommunityBasedParticipatory
Researchandevidence-basedculturallysensitivetreatment.CommunityBasedParticipatoryResearch
(CBPR) isan ideal epistemological frameworkforconductingresearchwithmarginalizedcommunities
and the mental healthdisparitiestheyface (Wallerstein&Duran2010). Castleden,Garvin&Huu-aht-
FirstNation(2008) state that CBPR“attempt(s) todevelopculturallyrelevantresearchmodelsthat
addressissuesof injustice,inequalityandexploitation”.Culturallysensitive treatmentandpractices,
such as the Tribal ParticipatoryResearchmodel,asdevelopedbyFisher&Ball (2003) incollaboration
withCBPR, can strengthenmental healthoutcomesandraise social capital.“CBPRresearchwithina
postcolonial traditionseekstouncoverandhonorcommunityexplanationsandnarrativesof the
conditionof people’slives”(Duran&Duran,1995; Walters& Simoni,2002; as citedby Minkler&
Wallerstein,2008). If implementedsuccessfully,there ispotentialtobe as muchof a communitybenefit
as there isfrom a researchstandpoint.Thispartnershipemploysthe abilitytoradicallychange
communitiesthroughsocial outreach.
Withour evidence based,culturallysensitive practices,we wanttoconducta programthat has
similarcomponentsof the PathwaytoHope Program.AccordingtoPayne et al.,thisprogramhas data
that supportsthe “community-baseddialogueandwisdomof Native eldersandspiritual leaders”paired
withoutpatientcounselorsthatare trainedtowork withindigenouscommunitiesinordertoenact
change for future treatment(Payne etal.,2013).The Pathwayto Hope Programworksat all levels,
6. helpingthe indigenouscommunitylearn,share,helpandheal togetherasa communityinhopesforan
endto the denial andsilence aroundsexualabuse forthe native community.
Conclusion
Loss of indigenousland,culturaltraditions,andtheirpeople has largelycontributedtothe
disproportionateratesof substance abuse andmental illnessamongIndigenouspeople.We have the
chance to buildupona treatmentmodel withpreliminarysuccessthatwill helplowerratesof these
occurrences.Treatmentpracticesthatare culturallyspecificin combinationwithcommunitybased
participatoryresearchare absolutelyimperative.Itwill notonlybe designedtoserve indigenous
communities,butothermarginalizedgroupsaswell will benefitfromCBPRanditsabilitytoaddress
specificgroups’social issues.We anticipate thismodel servingasaprototype forfuture researchersto
builduponandstrengthenasadditional researchisconducted.Byfundingthisstudy,yourorganization
isvalidatingthe livesof millionsof people whohave beenotherwise erasedfromthe hegemonic
structuresinplace.
7. AppendixA. Budget
Personnel (salaries)
ResearchDirector- $60,000/yr
Communitypartner- $60,000/yr
Data analyst- $50,000/yr
ResearchAnalyst- $50,000/yr
Fringe Benefits
$21,840 each
Travel
Hotel and FlighttoRockville,Maryland(SAMHSA Office) ($622 PerPerson- TwoPeople)(twicea
year)
Hotel and FlighttoBethesda,Maryland(NIHOffice)($722 PerPerson- TwoPeople) (twice a
year)
Rental Car inMaryland (about$245 for5 days inMaryland) (twice ayear)
Equipment
CPU ($1500 per person)
Monitor($350 perperson)
Othermaterials(keyboard,mouse andresearchsoftware) ($150 perperson)
Printermulti-purpose($200)
Video/Recordingdevices$600
Supplies
Pens,inkcartridges,coloredink cartridges,paper,etc.($50 per month)
Contractual
Treatmentcenterstaff- 2 outpatientcounselorsprovidingculturallysensitive treatment($150a
day eachperson) ($39K a year) for a six hour day,theywill eachgetpaid$25.00/hr, one working
witha group of patientsandone workingone onone withpatients.
Clinical Psychologist –TBD($69K a year)
KarinaL. Walters,PhD (Director,IndigenousWellnessResearchInstitute) ($75Ka year)
Other
At thistime,inlieuof payingresearchparticipants,free counselingserviceswill be offered.
Total:
8. Salaries:60,000 * 2 = $120,000
50,000 * 2 = $100,000
Fringe benefits:21,840 * 5 = $109,200
Travel:2,488 + 2,888 + 980 = $6,356
Office Equipment:2,000* 4 = 8,000 + 200 + 600= $8,800
Office Supplies:50* 12 = $600
Collaborators:$69K a year fora clinical psychologist(TBD).$75K peryear for consultant
(Walters).
Recruitone graduate studenttoassistin observationandone postdoctoral studenttoassistin
facilitationof treatment.(Total:$69Kper year).
$39K a yearfor treatmentcenterstaff
$596,956 peryear isthe budget
Part 2: Budgetnarrative/planforresearch
The mediansalaryof Social ScientistsinWashingtonState is$66,470 (O*Net,2015). We decided
on $60,000 for the four of us to allotmore funding towardourtreatmentimplementation.
We cappedour fringe benefitsat$21,840 for each employee tohave healthcare and5 days
PTO.
Total travel expenses,notincludingpersonalexpenses,we calculatedtobe about$622 per
personto go to Rockville,MD, (locationof SAMHSA).We will sendtworesearcherstocut down
on cost.Whengoingto Bethesda,MD (locationof NIH) the flightandhotel isabout$722 per
person,withtworesearchersattendingthismeetingaswell.A rental carisabout $245 forthe 5
dayswe are downthere.We will meetwitheachorganizationtwiceayearto reporton research
and our preliminaryfindings.
The equipmentwe willneedinouroffice includesCPU’sforeachperson,whichwill cost$1,500
for eachof us.We will alsoneedamonitorforeach of the CPU’s and a printer,withcopyandfax
capabilities,whichisabout$200.
The suppliesthatwe will needsuchaspaper,pens,paperclips,staplers,will costusabout$50,
thisamountallowingforextrasupplieswhenneeded.
Our researchoffice islocatedinNorthEverett,WA andthe indigenouscommunitythatwe will
be work withisthe TulalipTribe inTulalip,WA thisisabouta 20 minute drive locatedabout12
milesapart.
For our contractual staff,thanksto KarinaL. WaltersPhD.,a notedscholarin indigenous
research,we have createda relationshipwithalocal treatmentcenterthatprovidesculturally
sensitivetreatment.We will payeach(2) outpatientcounselors$39,000 peryear.Walters,who
isthe Directorof the IndigenousWellnessResearchInstitute,hasdone extensive researchinthis
fieldandherexpertisewill helpusdevelopourobjective.Herconsultingserviceswill costus
$75,000 peryear.
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