Alaska Native (AN) people experience posttraumatic stress disorder (PTSD), alcohol problems, and alcohol-related health disparities at higher rates than the general population (Bassett et al., 2014; Emerson et al., 2017). These are compounded by historical traumas, contemporary oppressions, marginalization, and racialized traumatic stressors. In fact, AN people have a higher 12-month and lifetime prevalence of PTSD in comparison to all other Unites States (U.S.) ethnoracial groups (Goldstein et al., 2016). Trauma has been a reality for AN communities for hundreds of years, with the influx of Russian colonizers in the 1700s and then the sale of Alaska to the U.S. in 1867. This began a long process that continues to this day of Western religious and cultural domination through calculated efforts to simultaneously destroy AN culture and establish and uphold Western culture (Napoleon, 2013). AN tribal groups share a common experience of forced boarding schools, religious indoctrination, and mass death due to diseases introduced by colonialism (Bassett et al., 2014; Napoleon, 2013). It has been posited by both American Indian and AN Elders and thinkers alike that the higher rates of problematic alcohol and drug use among these communities is a symptom and direct result of the cost of oppression and trauma, and quite literally has been referred to as a wounding that is imposed on one’s soul (Duran, 2006). This reflects the continued and intergenerational nature of trauma for AN communities.
Who are Alaska Native People?
AN people comprise over 229 of the 574 federally recognized tribes on the North American continent (i.e., Turtle Island) and have lived for time immemorial in Alaska, derived from the Unangax word for ‘mainland’ or ‘great land,’ alaxsxaq. AN communities represent 20 distinct languages and have documented precolonial systems of government, trade, medicine, ontology, cosmology, and psychology to name a few. The diversity and complexity of tribes and cultures is ubiquitous and yet, AN people share values, practices, and are bound by a collective effort for tribal autonomy, governance, and sovereignty in the face of great change. However, the dominant narrative and colonial mindset does not go farther than to believe that AN people’s mental health and substance issues are prominent, pervasive, and internal. This is just a fraction of the story, and taken alone, is limiting, colonial, and rooted in perpetuating racist and oppressive ideals. This must change.
As a thought exercise, please imagine with me: You and your family reside in a great land that is not only beautiful, but also fruitful and full of natural foods, resources, and elements that comprise the fabric of your life and worldview. You feel loved and deeply connected to your neighbors, friends, and family. Not just your parents, but also your grandparents, aunts, uncles, and cousins feel just as close as your own immediate family. Every sorrow and every joy are shared as a community within a local building, and there are Elders in your community that provide plants as medicine, spiritual guidance, and healing from an ancestral perspective. Scientific knowledge and historical documents reside in the hearts and minds of the people and are carefully passed down generationally. You do not own land or even conceptualize it in this way. Rather, you belong to the land. The community helps you raise your children, shares food, and is a source of self. You understand that change is a part of life, struggles are inevitable, and your community has been able to maintain good relations with neighbor communities. You are raising a family of five children with your longtime partner and life feels good. Then suddenly and inexplicably people invade your homeland, the place you have lived for time immemorial. They do not talk like you, and you cannot understand them. They are rough and take your things. Your partner is forced to leave immediately, and you cannot understand why. They take you and your older children into another room and ravage them to an extent unspeakable. A dark shame takes over. Your younger children are taken and kept from you. All your systems of trade and social structures are rendered useless, and even your Elders and traditional healers have been declared evil. You feel utterly alone. Within several months friends and family that are still around start to get sick, but none of your regular methods help the illness. Three of your children, your mother, your grandparents, and several aunts and uncles die. You feel a sense of grief that almost destroys you. You live in fear and can no longer meet at the gathering house or talk to the traditional healers for help or comfort. Then one evening these invaders give you a strong and bitter drink they call ‘alcohol,’ and for a brief time it allows you to not feel. There is some form of relief in that. You intuitively know that nothing in your life will ever be the same. The next morning you awaken and hope they will offer this drink again.
Alcohol Problems within the Alaska Native Population
Alaska has higher rates of alcohol consumption than the entire U.S. despite having communities and villages that are dry (i.e., the possession or sale of alcohol is prohibited; State of Alaska Epidemiology, 2018). AN people are about 15% of the population of Alaska, and yet they experience 75% of acute-alcohol poisoning deaths and 59% of all alcohol-related suicide and suicide attempts. Further, the AN population is 3.2 times more likely to birth babies with Fetal Alcohol Spectrum Disorder (FASD) and seven times more likely to die of an alcohol-attributable death than non-Native Alaskans. However, research also demonstrates that AN people have higher rates of abstinence from alcohol in comparison to the general population and all other ethnoracial groups (Skewis & Lewis, 2016). Part of the changes that must occur around the narrative of alcohol use also need to account for abstinence rates and the inherent culturally protective factors among the AN population. However, standing starkly in opposition to this is the history of research done on as opposed to done with AN communities. For instance, the Barrow Alcohol Study (1978) resulted from AN community concern about alcohol problems, violence, and death. A group of researchers came in to assess the issues and were supposed to work with the community to understand, interpret, and share the findings. However, upon completion of the study, the researchers released a report without the input or consent of the community, which resulted in the New York Times (1980) running a front-page article entitled, “Alcohol Plagues Eskimos (pejorative).” What follows is an excerpt:
The Inupiat Eskimos of Alaska’s North Slope, whose culture has been overwhelmed by energy development activities, are practically committing suicide by mass alcoholism… The alcoholism rate is 72 percent among the 2,000 Eskimo men and women in the village of Barrow, where violence is becoming the most frequent cause of death as a result of the explosive and self-destructive abuse of alcohol…Offshore oil development is expected to peak in 2010 or 2015…We don’t see the Eskimos surviving till then. This is not a collection of individual alcoholics, but a society which is alcoholic, and therefore facing extinction.
Unarguably, the article is stigmatizing, uses victim-blaming language, declares hurtful accusations, and posits uncontextualized and untrue statements about alcohol etiology and problems among AN people (Skewis & Lewis, 2016). The continuance of marginalizing and racist practices within research and treatment settings requires further examination of the historical and colonial mechanisms that have contributed to these socially accepted beliefs and provides a call to further deconstruct, decolonize, and indigenize the relationship between AN people and alcohol. Moreover, AN voice and culture must be at the forefront of understanding trauma, its impact on problematic substance use, and the ways in which healing can and does occur.
Trauma-Informed Substance Use Treatment among Alaska Native Communities
AN cultural practices, interventions, and worldviews for healing and mental health are inherent and have been used for time immemorial, but they are often overlooked, unseen, and mystified by dominant narratives, approaches, and colonial research paradigms (Wendt et al., 2019). Culturally adapted and trauma-informed alcohol treatments for AN people have been far and few between but are promising for holistic health. As mentioned, it is well-documented that AN people experience high rates of traumas (e.g., lived, historical, racial), however, little has been done to understand the association between trauma and alcohol use disorder (AUD; Bassett et al., 2014). Nevertheless, research demonstrates that an association between AUD and PTSD not only exists for AN people but is more profound in comparison to non-Natives (Emerson et al., 2017). Further, even when age, race, gender, lifetime depression, and education are considered, this association between PTSD and AUD remains. Trauma-informed cultural adaptations to AUD treatment are not only needed, but necessary.
The Naltrexone study was a clinical trial of naltrexone and sertraline for the treatment of AUD among a population of predominantly AN individuals in a rural, southeastern part of Alaska (O’Malley et al., 2005). Through a community-based tribal participatory research (CBPR/TPR) process, the study was conceptualized, supported, and conducted in collaboration with the community. While this was and still is the only trial of this kind among an AN population, it was found that participants who received naltrexone (with or without sertraline) had significantly reduced negative drinking consequences and increased abstinence rates compared to participants in the placebo group. In another example, the People Awaken (PA) Project was a culturally congruent model of alcohol recovery that contextualized AN historical and contemporary trauma (Mohatt et al., 2008). Interventions occur at stages of recovery (e.g., coping, relapse, decisional balance, maintenance) that are offered in culturally relevant ways, such as connection to culture, community, values, family, kinship roles, nature, and recovery that emphasizes healing as an awareness of self in context. Similarly, the Qasgiq Model is an alcohol and suicide prevention/intervention toolbox of cultural activities that are adaptable among the diverse AN tribes and regions (Rasmus et al., 2019). The interventions represent 12 culturally protective factors across the individual, the family, and the community levels. For example, the Maliqnianeq (seal hunt) intervention promotes the AN values and protective factors of spiritual awareness, self-efficacy, and communal mastery. In its totality, culture becomes both the healing from past traumas, through reclamation and revitalization, and the prevention for mitigating future symptoms such as alcohol misuse. Furthermore, these treatments demonstrate that culturally derived and/or adapted forms of treatment for AUD among AN communities must be trauma-informed, and that AN models of treatment can be both distinct from and complementary to Western treatment modalities.
Notably, natural models of AUD recovery are the most utilized among AN people, which highlights the fact that Western models of treatment alone are often unsuccessful. It is important to understand that there exists a gap between trauma-informed, multitargeted AUD treatments and cultural adaptations to treatment that respect and include the unique lived realities of AN people. Prior to colonial contact AN communities thrived and flourished without alcohol or Western forms of health and healing. Yet, the great changes that came suddenly and drastically altered daily lives and tribal realities for generations. The resultant prevalence of trauma, problematic alcohol use, and alcohol-related heath disparities supports the notion that the desecration of cultural values, beliefs, and norms have contributed to these inequities. In turn, the perseverance and survivance of AN people also supports the natural strengths, healing, and power of AN people, culture, knowledge, and traditional practices. After all, it has been said that our existence is resistance.
About the Author
Maria C. Crouch, PhD, is a clinical-community psychologist and a postdoctoral research fellow at Yale University. She is of the Deg Hit’an and Coahuiltecan tribes, and her family is from the Native village of Anvik, Alaska. Her program of research is focused on the intersection of trauma-informed care, evidence-based practices, and practice-based evidence (Indigenous approaches) to address alcohol and drug issues, trauma, and related health impacts of social determinants among American Indian and Alaska Native communities from a cultural, strengths-based approach.
References
Bassett, D., Buchwald, D., & Manson, S. (2014). Posttraumatic stress disorder and symptoms among American Indians and Alaska Natives: A review of the literature. Social Psychiatry and Psychiatric Epidemiology, 49(3), 417-433. https://doi.org/10.1007/s00127-013-0759-y
Duran, E. (2006). Healing the soul wound: Counseling with American Indians and other Native People. Teachers College Press.
Emerson, M. A., Moore, R. S., & Caetano, R. (2017). Association between lifetime posttraumatic stress disorder and past year alcohol use disorder among American Indians/Alaska Natives and Non‐Hispanic whites. Alcoholism, Clinical and Experimental Research, 41(3), 576-584. doi:10.1111/acer.13322
Goldstein, R. B., Smith, S. M., Chou, S. P., Saha, T. D., Jung, J., Zhang, H., Pickering, R. P., Ruan, W. J., Huang, B., & Grant, B. F. (2016). The epidemiology of DSM-5 posttraumatic stress disorder in the United States: Results from the national epidemiologic survey on alcohol and related conditions-III. Social Psychiatry and Psychiatric Epidemiology, 51(8), 1137-1148. https://doi.org/10.1007/s00127-016-1208-5
Mohatt, G. V., Rasmus, S. M., Thomas, L., Allen, J., Hazel, K., & Marlatt, G. A. (2008). Risk, resilience, and natural recovery: A model of recovery from alcohol abuse for Alaska Natives. Addiction, 103(2), 205-215. https://doi.org/10.1111/j.1360-0443.2007.02057.x
Napoleon, H. (2013). Yuuyaraq: The way of the human being. Anchorage Public Library.
Rasmus, S. M., Trickett, E., Charles, B., John, S., & Allen, J. (2019). The Qasgiq Model as an Indigenous intervention: Using the cultural logic of contexts to build protective factors for Alaska Native suicide and alcohol misuse prevention. Cultural Diversity & Ethnic Minority Psychology, 25(1), 44-54. https://doi.org/10.1037/cdp0000243
O’Malley, S. S., Robin, R. W., Levenson, A. L., GreyWolf, I., Chance, L. E., Hodgkinson, C. A., Romano, D., Robinson, J., Meandzija, B., Stillner, V., Wu, R., & Goldman, D. (2008). Naltrexone alone and with sertraline for the treatment of alcohol dependence in Alaska Natives and non-Natives residing in rural settings: A randomized controlled trial. Alcoholism Clinical and Experimental Research, 32(7), 1271-1283.
https://doi.org/10.1111/j.1530-0277.2008.00682.x
Skewes, M. C., & Lewis, J. P. (2016). Sobriety and alcohol use among rural Alaska Native elders. International Journal of Circumpolar Health, 75, 30476. https://doi.org/10.3402/ijch.v75.30476
Sobel, D. (1980, January 20). Alcohol plagues Eskimos. The New York Times, C1, C2.
State of Alaska Epidemiology (2018). Health impacts of alcohol misuse in Alaska (Report No. 2). Alaska Department of Health and Social Services. http://dhss.alaska.gov/dph/Epi
Wendt, D. C., Hartmann, W. E., Allen, J., Burack, J. A., Charles, B., D'Amico, E. J., Dell, C. A., Dickerson, D. L., Donovan, D. M., Gone, J. P., O'Connor, R. M., Radin, S. M., Rasmus, S. M., Venner, K. L., & Walls, M. L. (2019). Substance use research with indigenous communities: Exploring and extending foundational principles of community psychology. American Journal of Community Psychology, 64(1-2), 146-158. https://doi.org/10.1002/ajcp.12363