American Indians and Alaska Natives (AI/AN) living in the United States comprise one of the most diverse ethnic groups living in North America. Although Native Americans constitute less than 1% of the U.S. population, they represent more than 280 recognized tribes (Institute of Medicine [IOM], 1990). Once reduced to as few as 200,000 people in the 1960s, the Native American population has now grown to approximately 1.5 million (National Institute on Alcohol Abuse and Alcoholism, 1994; Christian, Dufour and Bertolucci, 1989; IOM, 1990). Historical and social variations in language, settlement patterns, and tribal values, as well as individual-mediated influences such as reserve residence and level of acculturation, have all contributed to this diversity. In addition, there is wide variation across communities in alcohol and other drug (AOD) use patterns, access to treatment for substance use, and access to other needed health services. This article illuminates the needs of AI/AN women in AOD treatment and the treatment services and community factors that both facilitate and impede recovery.
Alcohol and substance use among Native Americans
AOD use is a serious problem among American Indian and Alaska Native (AI/AN) people. Alcohol is three and a half more times likely than other causes to be implicated in deaths among AI/AN people (Christian et al., 1989) and is responsible for 25% of all deaths for AI/AN women (Leland, 1984). Research has demonstrated much higher levels of morbidity and mortality from alcohol and substance use-related conditions among AI/AN populations as compared with the national population (Lamarine, 1988).
Moreover, alcohol consumption is increasing among women (IOM, 1990; Fleming and Manson, 1990; Leung, Kinzie, Boehnlein and Shore, 1993). Women are more likely than men to use alcohol and/or other drugs alone, while men are more likely to drink socially (Scott, 1993). Although in general AI/AN males drink more than females, females die from alcohol-induced morbidity more often than AI/AN men and the general population (Hisnanick and Erickson, 1993).
The roots of substance abuse in this population can be traced back to the influence of Europeans and the displacement of Natives from their culture and land during the 1800s. In this century the continued attempts to "assimilate" the Native population have led to forced resettlement to urban areas or less productive land, to sending children to boarding schools, and subsequently to isolation, high unemployment and poverty.
The impact of substance use extends beyond its influence on morbidity and mortality rates. Alcohol abuse can affect the AI/AN family in many ways, both directly and indirectly. One of the most direct routes is through alcohol exposure during pregnancy; this can cause fetal alcohol syndrome (FAS), which is caused by maternal alcohol use during pregnancy and can result in severe birth defects and shortened life expectancy (Duimstra, Johnson, Kutsch, Wang, Zentner, Kellerman and Welty, 1993; Masis and May, 1991; State of Alaska Indian Health Service and National Centers for Disease Control and Prevention, 1993).
Alcohol abuse affects the family in other ways as well. One study reported that 85%-93% of all reported child neglect cases on one reservation involved alcohol abuse (DeBruyn, Lujan and May, 1992; Horejsi, Heavy Runner and Pablo, 1992). Among AI/AN women, alcohol abuse may be associated with grief over the loss of family members. However, the unhappy experiences suffered by many AI/AN women have also led to positive, proactive efforts to counter the negative repercussions of alcohol use. For example, many female and community groups are banding together to make their communities alcohol abuse free in an attempt to reduce the incidence of death and pain inflicted by alcohol use (Duimstra et al., 1993; MMWR, 1994; Pauktuuit Inuit Women's Association, 1990).
Despite the serious dimensions of the problem, substance abuse treatment services for AI/AN women (as well as programs for non-Native women) have only recently received much attention in this country, and AOD treatment services for AI/AN women have consequently been targeted by the Indian Health Service (IHS) as a critical area requiring additional resources. …