According to the 2020 Census data, 9.7 million people identified themselves as Native American or Alaska Native alone or in combination with another race. Native Americans or Alaska Natives comprise approximately 2.9% of the population of the United States (U.S. Census, 2021). Of this population, seven of 10 American Indians reside in urban settings (Urban Indian Health, 2022). The 574 federally recognized tribes in the United States are each ethnically, culturally, and linguistically diverse (Indian Affairs, U.S. Department of the Interior, 2022) with distinct governments that strive to ensure tribal sovereignty (Native American Caucus, 2022). Many states have an American Indian and Alaska Native (AI/AN) population that is the largest racial or ethnic group after Whites.

The U.S. Census Bureau (2021) uses the term "AI/AN" in their data gathering and reporting process. Readers are often confused about the correct terms to use when describing Indigenous people. The authors use the term Indigenous; however, Native American and American Indian are acceptable terms and are used by many authors that are referenced in the article. Providers should determine the language their patient is most comfortable using and use it in communications about their culture. Recognizing that Indigenous people are not a homogeneous population is paramount. The Department of Economic and Social Affairs of Indigenous People (2022, para. 1) states that "Indigenous peoples are inheritors and practitioners of unique cultures and ways of relating to people and the environment. They have retained social, cultural, economic, and political characteristics that are distinct from those of the dominant societies in which they live."

HISTORICAL CONTEXT OF LIMITATIONS OF EFFECTIVE TREATMENT/HEALING

Reconsidering the use of the term "treatment" has value as Indigenous populations may respond better to the term "healing" rather than "treatment." Indigenous healing is a holistic approach/practice that focuses on treating the imbalances of the person's mind, body, spirit, and emotions. To be effective in this approach, healthcare providers must incorporate a trauma-informed approach. Inclusion of the voice of Indigenous people, in a historical context, is critical as a framework for greater knowledge and skill development among treatment providers.

Perpetuating inaccurate history is another form of oppression and the continued colonization of Indigenous populations (Wilson, 2000). Don Warne describes the importance of expanding our understanding to address historical inequities stating, "If we are ever going to get to equity, we have to walk through truth, even when it's unpleasant, even when it makes us uncomfortable" (Sandoiu, 2020, para. 42). Unfortunately, addiction treatment providers, like the rest of the population of the United States, have been exposed to educational materials that include the "majority/colonizers rendition of history" that is largely inaccurate. Correcting this history requires reeducation about the genocide perpetrated by government entities toward Indigenous people. It also requires a commitment by educators to prepare the future workforce with an understanding of racism, trauma, and colonization.

Colonialization is defined as "the act or practice of appropriating something that one does not own or have a right to" (Merriam-Webster Dictionary, n.d.). Facing History and Ourselves (2022) defines it as "the process of assuming control of someone else's territory and applying one's systems of law, government, and religion." Settler colonialism, for example, has the sole purpose of replacing the Indigenous population with new settlers through the adoption of invasive tactics. The outcome was the removal and erasure of Indigenous people so settlers could take and use the land in perpetuity (Morris, 2019). This process is evident today when schools do not teach about AI/AN past or present and, when they do, the information is often inaccurate or canceled out. Sovereignty is "denied through stealing land for private corporations to use for drilling, mining, fracking, farming and more" (Morris, 2019, para. 11).

The colonization of North America decimated the Indigenous people through federal policies, war, forced relocation, and disease. When the strategy of war became too costly, cultural genocide became the new strategy. The approach was clearly stated: "Kill the Indian, save the man." For this strategy to be effective, boarding schools were used to educate the children outside their homes and communities. The boarding school era took Indigenous children from the ages of 4-5 years from their homes, typically for 8 years. During that time, the children were unable to visit their families and they were inculcated with the dominant cultural practices. Many experienced physical, sexual, and psychological abuse in boarding schools. In addition, the forced removal of children through the Indian Adoption Project intentionally placed Indigenous children in the care of White adoptive families. All these policies contributed to the near destruction of the extended family system and are the root of many of the destructive crises currently occurring in Indian country with the family system.

The impact of these traumatic events has been explored as part of historical trauma theory pioneered by Maria Brave Heart in her work with Lakota communities in the 1980s: "This theory purports that some Native Americans are experiencing historical loss symptoms (depression, substance dependence, diabetes, dysfunctional parenting, unemployment[horizontal ellipsis]) as a result of the cross-generational transmission of trauma from historical losses" (Brave Heart et al., 2011; Brown-Rice, 2013, para. 1).

Three elements exist when people experience historical trauma: (a) It is a cumulative emotional and psychological wounding, (b) it is shared by a group of people rather than being the experiences of an individual, and (c) it spans across multiple generations and impacts the current members of the group although they were not present for all the past traumatic events (Boyd, 2020). "Historical unresolved grief accompanies that trauma" and is described in Brave Heart's (1998) early work at Smith College.

Epigenetic researchers find that the impact of historical trauma is passed genetically. Epigenetics is the study of how your environment and behaviors can create changes in your genetic makeup and how these changes can occur before birth and impact your health (Centers for Disease Control and Prevention, 2022). This research began with the studies of survivors of the holocaust. As a result, a person's genetic makeup can carry memories of trauma from the ancestors who experienced trauma. In turn, this influences how the next generation reacts to trauma and stress (Pember, 2016, p. 3; Sandoiu, 2020). The Harvard University Center on the Developing Child (2010) underscores that "environmental influences can affect whether and how genes are expressed. That means negative fetal and early childhood experiences lead to physical and chemical changes in the brain and can last a lifetime" (p. 5). Coping skills and behaviors are dependent on how much the trauma was acknowledged or is "hidden" in their families, in the communities, and by the government that imposed the practices of colonization. Historically, prohibitions existed against the open practice of ceremonies and spiritual practices that were positive coping practices for Indigenous peoples.

Sandoiu quotes R. Dale Walker: "Historical trauma is like generational post-traumatic stress. The trauma is held personally and transmitted over generations[horizontal ellipsis]and the symptoms extend to future generations with anxiety, depression, reduced coping mechanisms, and impulsive behaviors. Substance use disorders and suicide incidence are increased" (Sandoiu, 2020, para. 25). Additional symptoms are exhibited on a spectrum ranging from subtle to disabling that present as negative physical and emotional outcomes. This includes low self-esteem, anger, difficulty recognizing and expressing emotions, and the internalization of self-hatred based on racism, negative stereotypes, and biases. The historical, multigenerational, and transgenerational trauma is still being felt by individuals, families, and communities (Lajimodiere, 2021). Effective health and behavioral health healing require an understanding of trauma and historical trauma. An example of the impact of trauma is the result of the abuse of Indigenous people at the boarding schools, which resulted in a negative view of education today, even unconsciously. Therefore, the principles behind critical theory that underscores the importance of the underlying assumption the prevent participation in the democratic process, and ultimately impede democratic values, must be examined (Bohman, 2021). The history of boarding schools, and other colonization efforts, underscores the need to deconstruct the history of oppression and domination of Indigenous populations. This requires an understanding of how the social, historical, and ideological power structures created this harsh inequity.

THE CONSEQUENCES

Dyke and Warne (2021) underscore the myriad negative outcomes for American Indians including the higher incidence of comorbid conditions. Indigenous populations experience the most significant health disparity of any ethnic population in the United States. This includes a decreased life expectancy, decreased quality of life, and an increase in the prevalence of chronic diseases (Adakai et al., 2018) including substance use disorders (Bagalman & Heisler, 2016). They have the highest rates of suicide of any ethnic/minority population in the United States (Leavitt et al., 2018). In 2019, suicide was the second leading cause of death among AI/AN between the ages of 10 and 34 years (Office of Minority Health, n.d.). In addition, Indigenous populations have the highest poverty rate of any ethnic minority in the United States at 25% (Muhammad et al., 2018). This underscores the limitations in access to basic support including adequate housing, food, and safe drinking water.

The higher rates of substance abuse among Indigenous populations in the United States are noted throughout the literature. However, Indigenous Americans' binge and heavy drinking rates were similar to or less than those of Whites. In addition, Indigenous people are more likely to abstain from alcohol use (Cunningham et al., 2016). These findings, gathered from researchers at the University of Arizona, challenge readers to take a closer look at the stereotypes about alcohol use among Indigenous populations that are being perpetuated.

A 2018 National Survey on Drug Use and Health (McCance-Katz, 2019) states that (a) 10% of Native Americans have a substance use disorder, (2) 4% have an illicit drug use disorder, and (3) 7% have an alcohol use disorder. It is also important to state that Native Americans are more likely to report drug abuse in the past month or year than any other ethnic group (Kaliszewski, 2022), which could mean that the numbers reflect the fact that they are being more honest about their use.

THE ROLE OF CULTURE IN HEALING

The authors postulate that the problem is the lack of awareness, knowledge, and use of culturally relevant assessments and interventions to address this problem of substance use disorders. This converges with the limited cultural humility among providers who serve this population. Let us explore several primary barriers to effective assessment/evaluation and treatment.

Limited Cultural Humility and Knowledge

Providers of addiction services in the United States are typically not members of diverse societies, which results in "a treatment gap" in cultural approaches to care (Hoage et al., 2013). The significant limitations in access to care by Indigenous members are noteworthy with workforce shortages on tribal lands. That shortage includes access to advanced practice, registered, and licensed practical nurses who are Indigenous. The National Academies of Sciences, Engineering, and Medicine (2021) in their Future of Nursing 2020-2030 report describe the critical workforce shortage of nurses to serve the Indian Health Service. The pipeline is not strong with the American Association of College of Nursing (2019) finding that 0.7% of the population of registered nurses are AI/AN. Their report underscores the need to recruit academic leaders and instructors who support diversity, equity, and inclusion. Advancing student knowledge in preservice programs of the impact of colonialization is paramount in these efforts.

The field of social work also notes a significant workforce shortage of Indigenous populations. The 2019 data summary of the Council on Social Work Education, the accreditation agency for social work programs, found that only 1.1% of the students enrolled in bachelor in social work programs and 0.8% of the graduates were AI/AN. The master's in social work enrollment of AI/AN students was 0.9%, with 0.7% who graduated (Council on Social Work Education, 2020). The authors noted the stigma toward the profession of social work because tribal members have past negative experiences/traumatization with social work professionals removing children from their homes. The American Psychological Association estimates in 2006 that there were fewer than 200 PhDs in psychology in the United States who were AI/AN and there are a limited number of training programs to advance the workforce (Benson, 2003). Like many treatment providers, faculty in higher education are often unwilling to adapt their educational practices to meet the needs of Indigenous students, largely because faculty share the same inaccurate history of colonialization, with limited understanding of critical theory, as providers of services. This adaptation would require less rigidity in program articulation and enhances flexibility and mentorship, for example. It also occurs in the field of addiction by expanding content on substance abuse disorders.

Limitations in Access to Workforce and Funding

In 2016, the IHS budget was 4.8 billion dollars and was meant to serve 3.7 million AI/AN, which translated to $1,297 per person, compared with an estimated $6,973 per inmate in the federal prison system (Siddons, 2018). The lack of access to primary care providers is significant: A 25% provider vacancy rate exists in the already underfunded IHS system. Providers in Montana had a vacancy rate closer to 46%: "The shortage occurs across all provider types such as physicians, psychiatrists, psychologists, nurses, nurse practitioners, certified registered nurse anesthetists, social workers, and pharmacists" (Heath, 2018; Siddons, 2018).

Stigma

"Stigma and lack of awareness of what is culturally appropriate mental health care, by mental health providers, create barriers to seeking treatment and using services by Native American individuals with mental illness" (Roessel, 2017, p. 3). Connected to this is a distrust of non-Indigenous providers because of past discrimination. Providers often hold those same stereotypes that exacerbated problems in effective and meaningful therapeutic engagement.

Invisibility

The "Something Else Phenomenon" or "Asterisk Nation" makes Indigenous people invisible in data outcomes. The use of an asterisk is a racial and ethnic data point that acknowledges possible errors that can affect statistical significance or the limitations of a sample size for comparison. This reflects how consistently Indigenous populations are left behind and/or left out in data collection and analysis. Inaccurate and indistinct data among AI/AN prevent policymakers from making data-driven decisions with confidence. This also results in Native American communities, especially those in rural areas, not having opportunities for funding support. Although there are many needs and challenges among Indigenous populations, a narrative of dependence is unhelpful in guiding support and healing. The focus instead should be on the positive values and strong relationships and on building risk and protective factors.

Lack of Evidence-Based Practice

Historically, few if any evidence-based practices (EBPs) have been culturally appropriate for Indigenous persons. Many providers implement EBPs to provide care that is based on science. However, EBPs are more acceptable when they are community driven and culturally grounded. Historically, EBPs implemented throughout the mental health services delivery system have not been culturally appropriate for Indigenous persons (Fox et al., 2020).

RECOMMENDATIONS

Sixteen recommendations, based on the needs identified, to guide administrators, practitioners, medical professionals, educators, peer specialists, and all critical stakeholders in beginning to address these disparities are provided below.

1. Actively engage in cultural humility: This is something all providers of substance use disorder services should undertake. Tervalon and Murray-Garcia (1998) underscore that cultural humility involves entering a relationship with another person to honor their beliefs, customs, and values. This includes a willingness to learn from others. Leaders must support this effort by giving employees time to learn and relearn how to engage in healing practices with cultural humility. This requires an educational and training process to educate all on historical trauma with the capacity to also educate clients to provide a framework for self-understanding. Understanding the link between historical trauma and substance use in the American Indian population when offering clinical services for substance use is paramount (Skewes & Blume, 2019). A host of resources exist that are in the public domain through the Administration for Children and Families (n.d.) to guide practitioners, the Substance Abuse and Mental Health Services Administration, and IHS, which were written by authors who are indigenous.

2. Adapt the Western approach to medicine, which is part of addiction science, for care among the Indigenous population. Moghaddam and Momper (2011) provide a paradigm for support for "integrative recovery programs" that tailor their services to incorporate cultural healing practices involving spiritual healers along with Western medicine practices. This supports efforts to integrate health and behavioral health care.

3. Expand funding to ensure access to care by addressing the availability and accessibility of care (Hogan, 2003). Along with the lack of cultural humility, there is a general lack of available services causing many families to have to travel hundreds of miles to seek care. This is problematic in rural communities as well as in tribal areas.

4. Focus on building resiliency within the individuals and the communities you serve. Learn about the 7 Cs (competence, confidence, connection, character, contribution, coping, and control) of resilience and help children, teens, and their parents develop a resilience plan (Gindsbug & Jablow, 2020).

5. Explore the concepts of the Circle of Courage: belonging, mastery, independence, and generosity. It is based on the medicine wheel model of wellness, balance, and healing. This is an effective tool to advance healing in practice and can be adapted easily.

6. Build protective factors instead of focusing on deficits. Be mindful of language that does not support resilience. McLean (2021) states, "Mainstream medicine and behavioral healthcare typically use nomenclature and paradigms of 'disorders or disease-states' in their terminology" (p. 62) that are often not helpful. Again, ask the person you are serving about the appropriate use of language and be mindful in diagnosis about the role of culture in behaviors that you may not understand.

7. Institutions of higher learning must commit to expanding training and education opportunities to Indigenous people. There are opportunities for collaboration with tribal colleges in expanding access, and money exists to support this work through recent federal funds, including block grant funding to states. Indigenous people must be included in educational content to eliminate the asterisk approach in training future researchers. This content and the study of the history of Indigenous people should be included in all higher education training and educational programs.

8. Seek resources and take the time to learn about the populations and communities you serve. This requires people to step out of their comfort zone and learn about the language, geography, and culture of the person they are serving.

9. Adopt Community-Based Participatory Research efforts designed to engage the community as equal partners in all steps of the research process. Studies have been especially effective in identifying needs through the use of this process to mitigate past problematic research practices (Rink et al., 2020). Include the voice of the people impacted and address their needs by securing a narrative. The title "Nothing About Us Without Us" is a mantra for a civil rights movement that began in the 1990s as an advocacy approach to support the inclusion of persons with disabilities in program development and response (Charlton, 2000). The use of the slogan expanded to support empowerment for other disenfranchised groups, including American Indians.

10. Use the territory acknowledgment statement to increase the awareness of the Indigenous presence and recognize the history and colonialism on the land in which you reside. The land statements do not exist in the past tense and serve as a reminder of your place within that history of colonialism.

11. Storytelling is an essential component of Indigenous communities. Story is medicine (Kopac & Rael, 2014). "When stories seem irrelevant, you need to look for yourself in the story. Examine how it can connect to things in your life. It is also important to consider how to help others make these connections. During this intervention, the individual chooses a story topic from an area of the Medicine Wheel. Encourage people to tell and write down that story. This could be a story about a phase of life (typically included in a Medicine Wheel). For example, childhood, adolescence, adulthood, and Elder. For elders, consider asking them to write a story about what type of Elder they want to be" (Fox et al., 2020).

12. Advocate for equal distribution of services across communities. Work to remove barriers to the provision of integrated behavioral and physical health care in social service settings through empowerment. This includes expanding access to motivational interviewing (National Council on Mental Wellbeing, 2022).

13. Incorporation of drum-assisted recovery therapy for Indigenous people to support healing and self-expression (Dickerson et al., 2012).

14. The need for culturally competent interventions that consider race, culture, and gender is paramount to effective treatment for Indigenous populations (Nahian & Jouk, 2021). Lowe and Struthers (2001), for example, provide a conceptual framework for educators, practitioners, administrators, and researchers in the field of nursing that underscores holistic care that incorporates culture and traditions.

15. Acknowledge the inevitable distrust of government-funded clinics, allowing patients to share their stories; do not assume those who do not speak their language are less Indigenous.

16. Ensure a soft handoff in conducting referrals. That includes providing necessary care management to support the community of healers to serve the broad community and family.

SUMMARY

The goal of this article is to inform the reader about the concept of historical trauma and its continued influence on the Indigenous population when serving people with a substance use disorder. To secure a full picture of how best to serve our Indigenous clients, providers must understand the historical context and its lingering impact across all domains of the individual's life. These 16 steps for consideration to expand access to culturally appropriate care are merely a start. Information about trauma that is culturally informed and based on the history of genocide is essential. Our hope is for better outcomes in the future based on greater understanding.

REFERENCES