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Cultural interventions to treat addictions in
Indigenous populations: findings from a scoping
study
Rowan et al.
Rowan et al. Substance Abuse Treatment, Prevention, and Policy 2014, 9:34
http://www.substanceabusepolicy.com/cont ent/9/1/34
RES E AR C H Open Access
Cultural interventions to treat addictions in
Indigenous populations: findings from a scoping
study
Margo Rowan
1
, Nancy Poole
2
, Beverley Shea
3
, Joseph P Gone
4
, David Mykota
5
, Marwa Farag
6
, Carol Hopkins
7
,
Laura Hall
1
, Christopher Mushquash
8
and Colleen Dell
1*
Abstract
Background: Cultural interventions offer the hope and promise of healing from addictions for Indigenous people.
a
However, there are few published studies specifically examining the type and impact of these interventions.
Positioned within the Honouring Our Strengths: Culture as Intervention project, a scoping study was conducted to
describe what is known about the characteristics of culture-based programs and to examine the outcomes
collected and effects of these interventions on wellness.
Methods: This review followed established methods for scoping studies, including a final stage of consultation with
stakeholders. The data search and extraction were also guided by the “PICO” (Patient/population, Intervention,
Comparison, and Outcome) method, for which we defined each element, but did not require direct comparisons
between treatment and control groups. Twelve databases from the scientific literature and 13 databases from the
grey literature were searched up to October 26, 2012.
Results: The search strategy yielded 4,518 articles. Nineteen studies were included from the United States (58%)
and Canada (42%), that involved residential programs (58%), and all (10 0%) integrated Western and culture-based
treatment services. Seventeen types of cultural interventions were found, with sweat lodge ceremonies the most
commonly (68%) enacted. Study samples ranged from 11 to 2,685 clients. Just over half of studies involved
quasi-experimental designs (53%). Most articles (90%) measured physical wellness, with fewer (37%) examining
spiritual health. Results show benefits in all areas of wellness, particularly by reducing or eliminating substance
use problems in 74% of studies.
Conclusions: Evidence from this scoping study suggests that the culture-based i nterventions used in addictions
treatment f or Indigenous people are beneficial to help improve client functioning in all areas of wellness. There
is a need for well-designed studies to address the question of best relational or contextual fit of cultural practices given
a particular place, time, and population group. Addiction researchers and treatment providers are encouraged to work
together to make further inroads into expanding the study of culture-based interventions from multiple perspectives
and locations.
Keywords: First Nations, Cultural interventions, Addictions, Indigenous, Treatment interventions
* Correspondence: colleen.dell@usask.ca
1
Department of Sociology, University of Saskatchewan, 1109 – 9 Campus
Drive, Saskatoon, SK S7N 5A5, Canada
Full list of author information is available at the end of the article
© 2014 Rowan et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Rowan et al. Substance Abuse Treatment, Prevention, and Policy 2014, 9:34
http://www.substanceabusepolicy.com/content/9/1/34
Background
The hope and pro mise of healing from addic tio ns for
Indigenous people are rooted in cultural interventions.
From sweat lodges [1,2] to traditional teachings [3,4],
these regionally diverse interventions a re commonly
located within the context of Indigenous treatment pro-
grams and integrated into existing treatment practices
[5]. They are led by individuals w ho are sanctioned and
recognized by traditional teachers, community members,
and spiritual beings to facilitate cultural activities [6,7]. For
example, in Canada, the 56 National Native Alcohol and
Drug Abuse Programs and nine Youth Solvent Addiction
Program treatment centres emphasize that Indigenous
traditional culture is vital for client healing and wellness
[8]. Both programs run under the auspices of First Nations
communities and support a network of residential treat-
ment and community prevention programs informed by
Indigenous spirituality and origin stories.
Cultural interventions address wellness in a holistic
sense, in contrast to Western biomedical approaches that
focus on the absence of disease and imply mind-body
separation in treating illness such as addictions [9,10]. Key
to understanding the benefit of culturally-focused treat-
ment is recognizing the meaning of Indigenous wellness,
which is understood as one of a harmonious relationship
within the whole person, including mind, body, emotion,
and spirit [11-13]. Wellbeing and health emerge from a
holistic worldview that emphasizes balance among one’s
tradition, cultur e, language, and community. Szlemko et al.
[10] support this notion and suggest that for treatment to
be effective it is important to consider the whole person
rather than only their physical or mental health.
There are few published studies (i.e., meta-analyses,
literature summaries, scoping, or systematic reviews) spe-
cifically examining the type and impact of cultural inter-
ventions to treat addictions in Indigenous populations,
especially with relevance to First Nations of Canada. Many
reviews have focused on health education or prevention of
substance use problems in Native Americans [14-17]. Some
have examined the treatment literature, but have focused
on broad populations, such as racial and ethnic minorities
[18] or young people [19]. Conversely, others have nar-
rowed their search to spe cific populations of i nterest
such a s Native Hawaiians [20], Hispanic adolesc ent s
[21], African Americans [22], or Australian Aboriginals
[23-26]. A few re views have focused on interventions to
treat Indigenous people, but these cited interventions are
not holistically or culturally-based [27,28]. One literature
review considered evidence-based practice in Native
American mental health service delivery, but deliberately
excluded treatments that targeted substance use [29].
Four relevant literature reviews offer some insight into
cultural interventions used, outcomes measured and/or
the quality of the research. An early study by Brady [30]
involved a review of “comparative material” from the
United States, Canada, and Australia on cultural treat-
ments for alcohol addictions in Indigeno us people. She
found that studies were plagued with poor methodology
and lacked clarity about what was actually involved in
treatment. Abbott [31] reviewed 10 studies on traditional
and Western healing practic es for alcohol treatment in
Indigenous populations in the United States between
1962-1996. These studies described prevalence data, and
the healing practices and Western treatment interven-
tions being implemented, yet the reviewers noted a lack
of randomized control outcome studies. An other seven
studies from 1970-1989, focused largely on measuring
reduction in alcohol consumption, with a notable absence
of measuring spiritual and mental functioning. Dell et al.
[9] conducted a systematic review of articles published in
the Canadian Journal of Psychiatry from February 1998 to
June 2008, augmented with a re view of Canadian and
international literatures on treatment and healing of
Aboriginal people for mental health and substance use-
related issues. In the 12 selected articles, the authors
found a significant gap in understanding and practice be-
tween Western psychiatric and Aboriginal culture-based
treatment in three areas: connection with self, community,
and political context. Finally, Greenfield and Venner
[32] conduc ted a systematic review of the literature
from 1965-2011 on substance use disorder treatments for
American Indians and Ala ska Natives (AI/ANs). Re-
sults from twenty-four studies indicated that earlier
ones (1968-1997) lacked cultural inter ventions and
took the form of AI/AN counselors and language inter-
preters. Clinical ratings of improvement were made by
treatment staff or community members. Traditional
healing approaches were more prevalent in later studies
(2000-2011), which also employed formal assessment
measures. This shift was viewed as bringing treatment
outcomes closer to the AI/ANs’ worldviews.
Although these studies appear relevant to understanding
the literature about Indigenous cultural interventions,
none explained how information from studies was ex-
tracted. There were no details on the screening method or
whether multiple reviewers were used to enhance validity
of the inclusion or extraction process. Neither Brady [30]
nor Abbott [31] listed their inclusion or exclusion criteria
so it is unclear exactly which criteria were used to select
their studies. While both Dell et al. [9], and Greenfield
and Venner [32] listed these criteria, neither focused ex-
clusively on studies with cultural interventions. Neither
Brady [30] nor Dell et al. [9] provided a table or summary
of the literature reviewed, but rather weaved the informa-
tion purposefully into narrative discussions to support
their ideas. For example, Dell et al. [9] blended literature
findings with case study stories to compare and contrast
Western and Aboriginal treatment approaches. Finally,
Rowan et al. Substance Abuse Treatment, Prevention, and Policy 2014, 9:34 Page 2 of 26
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Greenfield and Venner [32] focused on historical trends,
and while they considered the types of outcomes collected,
they did not analyze whether these outcomes focused on
different aspects of wellness.
In this article, we report on a scoping study of the
literature that explores the use of cultural interventions
to treat addictions in Indigenous populations. The pur-
pose of this review is to systematically describe what is
known about the characteristics of cultural programs and
interventions and to examine the outcomes collected and
effects of cultural interventions on wellness. Importantly,
the method used for this scoping study draws on evidence
described in peer-reviewed and grey literatures. The
authors understand that Indigenous epistemologies and
other forms of e vidence offer additional, and equally
important ways of understanding inter ventions. Our
approach is grounded in the concept of Two-Eyed Seeing
(Etuaptmurnk), whereby Indigenous and Western knowl-
edges are valued and utilized to generate, understand, and
find solutions [33]. Furthermore, the scoping study is posi-
tioned within the Honouring Our Strengths: Culture as
Intervention project that builds on our core community-
based research team’s history of collectively led projects
and aims to create a valid and reliable, culturally-competent
instrument to measure the effectiveness of First Nations
cultures a s an intervention in alcohol and other drug
treatments [34].
Methods
This review followed the design of Arksey and O’Malley
[35], enhanced by Levac et al. [36] and involved six
stages: Stage 1: Identifying the research question, Stage
2: Identifying relevant studies, Stage 3: Selecting studies,
Stage 4: Charting the data, Stage 5: Collating, summariz-
ing and reporting results, and Stage 6: Consulting with
stakeholders. The data search and extraction were
guided by the “PICO ” (Patient/population, Intervention,
Comparison, and Outcome) method [37], but we did not
require direct comparisons between treatment and control
groups. The population included Indigenous people in
treatment for problematic substance use or addictions.
Cultural interventions were Indigenous spiritual and
healing practices or traditions introduced into residen-
tial or outpatient treatment centres to help achieve
wellness following problematic substance use or addic-
tion. Outcomes included four dimensions of wellness:
1) Spiritual, 2) Physical- Behavioral, 3) Mind- Mental,
and 4) Heart- Social and Emotional. Dimensions and
their definitions were origi nally built on the founda-
tional work of two papers [38,39], and later solidified
during the project by Elder Jim Dumont after conver-
sations with Treatment Centres. Complete defi nitions
can be found on the Honour ing Our Streng ths: Culture
as I nter vention website [34].
A librarian scientist helped to develop the PICO criteria.
She ran and cross-validated the search strategy with a sec-
ond librarian. Up to October 26, 2012, 12 databases index-
ing the scientific literature were searched. These included
EBM Reviews (including The Cochrane Library), Global
health library, MEDLINE, EMBASE, PsycINFO, Bibliog-
raphy of Native North Americans, CIHAHL, Social Work
Abstracts, Women’s Studies International, Anthropology
Plus and Anthropological Literature, Anthropological Index,
and CAB direct. Each database was searched using its
earliest indexing date. Mesh Headings and free text terms
applicable to the PICO criteria were applied separately, or
in combinations using the Boolean operators “AND” and
“OR”. Under “Population” there were 34 “Heritage or
Culture” terms and 24 “Dependence” terms. There were 27
terms under “Interventions” and nine under “Outcome”.
Another 13 databases were searched from the grey litera-
ture. We supplemented this search with articles identified
by or through the research team, relevant websites, hand
searching relevant journals, and reference lists of included
studies. No restrictions were placed on language. Studies
were screened by nine reviewers. An extraction form was
developed and pilot-tested to collect detailed information
about the background, measurement, and results of each
study. Information was then entered into Word and Excel
files, integrated, and summarized in display and written
format.
Results
Yield
The search strategy yielded 4,518 articles of which 19
studies, involving 5,9 49 treatment clients, were included
in the final review. Fourteen of these were from the scien-
tific literature and five were from the grey literature (see
Figure 1). Most often studies were excluded because they
were descriptive, anecdotal, or preliminary; did not report
or collect outcomes; and/or did not report or include cul-
tural interventions. Decisions about article inclusion or
exclusion were resolved through consensus between pairs
of reviewers or between an arbiter and a reviewer.
Characteristics of programs and interventions
Table 1 describes each study by location, type and length
of program, and interventions provided.
Location
All of the 19 studies were from the United States (58%)
and Canada (42%). Most studies (79%) were localized
within a community or communities of one state or
province, part icularly Californ ia or Ont ario. In so me
cases, clients were referred from outside the community.
For example, clients at the Friendship House Association
of American Indians in San Francisco were referred by
Indian health programs in six other states [45]. Another
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program located in the Pacific Northwest, drew young
clients from eight states across the Western region of the
US [41,42]. There were two national level studies. Dell
and Hopkins [43] studied treatment practices and out-
come data from nine Youth Solvent Addiction Program
sites across Canada. Similarly, Kunic [56] evaluated the
effects o f a national program entitled the Aboriginal
Offender Substance Abuse Program sponsored by Correc-
tional Services Canada. Two treatment facilities served as
sites for multiple studies included in this review, one lo-
cated in the Pacific Northwest [41,42] and the other based
in San Francisco [45,50-53].
Type and length of treatment programs
For the most part, studies involved residential programs
(58%) of varying lengths. For example, one of the shortest
residential programs was described by Boyd-Ball [42] as a
7 week treatment for young, tribally enrolled substance
users, involving cultural interventions and family manage-
ment. In contrast, Dell and Hopkins [43] studied a 4-6
month residential program for young solvent users that
combined culture-based interventions with Western-based,
positive psychology programming. Other programs were
community-based (21%), prison-based (11%), or offered at
minimum a combination of residential and outpatient ser-
vices (11%). Most focused on addiction treatment (63%),
three concentrated on treatment for alcohol, and three for
solvent use. Another study by D’Silva et al. [47] focused
exclusively on tobacco cessation.
Interventions provided
All studies (100%) involved integrative treatment programs,
meaning that the site(s) offered the client and possibly
his/her family, Western-based a sse ssment , educ ation,
counseling, treatment, and/or aftercare services along-
side cultural and traditional ser vices. For example,
Boyd-Ball [41] studied the Shadow Project, an 8 week
residential program in which the treatment as usual
(TAU) offered Western ser vices such as group therapy
and life-skills counselling. TAU was supplemented by
traditional cultural inter vent ions , such as sweat lodge
ceremonies and access t o spiritual Elders. The alter-
nate inter v ention included TAU plus family-enhanced
involvement. More re cently, Nebelkopf and Wright
[51] and Wright et al. [53] applied a Holistic System of
Care for Native Americans in an urban setting. This
was a community-focused intervention involving Western
and culturally-based prevention, treatment and recovery
programs.
Seventeen different Indigenous cultural inter ventions
werereportedintheliterature(seeFigure2).The
number of cultural interventions ranged from 1-13 per
study, with a mean of six inter ventions. There were
eight studies with 1-5 cultural inter ventions; nine with
6-10; and two with 11-13. Most studies (68%) included
sweat lodge ceremonies , as highlighted in Gossage
et al. [46]. Also commonly reported were ceremonial
practices (63%), such as sage, cedar, or sweet gra ss
smudges [40,52]; social cultural activities (58%), a s em-
phasized in Naquin et al.’s therapeutic community t hat
treats clients as family [49]; and/or traditional teach-
ings (53%), such as clas ses in the “Red Road” [45].
Dancing w as the lea st common main inter vention
reported in only one study, although it was sometimes
incorporated within other interventions such a s sweat
lodge ceremonies.
Scientific literature Grey literature
Abstracts and papers excluded
through screening
N=3,894
Scientific literature database search
N=3,908
Final papers included
N=14
Grey literature database search
N=610
Reports excluded
through screening
N=605
Final papers included
N=5
Final papers included in
scoping study
N=19
Figure 1 Yield from literature search up to October 26, 2012.
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Table 1 Characteristics of scoping study scientific and grey literature: program descriptions
Author and Location
(Country/Region)
Program type and length
Cultural interventions Western interventions
Scientific literature
Anderson, 1992/CAN/ BC [40] Community treatment centre: 6 week alcohol addiction program.
• Ceremonial practice (some smudging done
each morning, but used more by staff than
clients).
• Group sessions (the entire client population of
six families per 6 week session, meet together
3-5 times a week for half a day. In this "circle,"
communication, listening and attending are
established founded on mutual respect and
unconditional positive regard).
• Land base activities (focus on healing qualities
of the physical site).
• Family counseling.
• Social culture (community and social activities
of community suppers, food shopping, chapel
services, and recreational pursuits such as fishing
and volleyball, helped clients relate as families
and neighbors without alcohol).
• Alcoholics Anonymous meetings.
• Individual and couples counseling sessions
and special work with children a nd young adults.
Boyd-Ball, 2003/US/ Pacific NW [41] Residential: 8 week alcohol and drug addiction program in study known as Shadow Project. Comparison
of (culturally supplemented) Treatment As Usual (TAU) and treatment with family-enhanced intervention.
• Sweat lodge. • Individual therapy.
• Ceremonial practice (a Welcome Home
ceremony involving family and community
support- for the family-enhanced intervention;
naming ceremony).
• Group therapy.
• Land base activities (wilderness outings, a
Welcome Home ceremony involving family
and community support for the
family-enhanced intervention).
• 24-hour supervision.
• Traditional teachings- studied individual
tribal histories.
• Psychiatric and psychological services.
• Singing. • Assessment and referral.
• Cultural instruments (drumming). • Life-skills counseling.
• Story-telling—used in the family-enhanced
intervention only.
• Medical services.
• Art creation (crafts). • Education programs.
• Elders (access to spiritual elders). • Family programs.
• Aftercare planning.
Boyd-Ball et al, 2011/US/ Western
regions (from 8 States) [42]
Residential: 7 week substance use treatment emphasizing traditional practices at the “WAIT” Center. Post-treatment
substance use trajectories were correlated with self-report measure of general American Indian(AI)culturalinvolvement.
• Sweat lodge (“sweats”).
• Family management.
• Other ceremonial practice (not specified).
• Post-treatment social cultural participation
(speculation that perhaps adolescents were
prepared in treatment for greater involvement
in tribal culture & traditions on returning home).
Dell & Hopkins, 2011/CAN/across
Canada [43]
Residential: 4-6 month solvent use program.
• Fasting. • Treatment and support based in resiliency theory.
• Land base activities (land-based cultural camps). • Support for development of emotional intelligence,
personal wellness care practices, and leadership skills
(within a positive psychology framework).
• Traditional teachings (Elders’ teachings).
• Social culture (inclusion of community
members in the treatment centers).
• Natural foods and medicines
(ceremonial feasts).
• Elders (Elder guidance).
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Table 1 Characteristics of scoping study scientific and grey literature: program descriptions (Continued)
Dell et al, 2011/CAN ON [44] Residential: 12 week 1 h per week, Equine assisted learning (EAL) curriculum added
to a 4 month solvent use program at Nimkee NupiGawagan Healing Centre (NNHC).
• Land base activities (Equine Assisted Learning
programs help make a connection to nature
and the h orse(s) within a natural environment).
According to Bresette (2009/2010), NNHC offers:
• Other cultural aspects to the program in
addition to the equine therapy includes:
Bi-weekly sweats, Welcoming Feasts, Full Moon
ceremonies, Memorial Feasts, Spring Releasing
ceremony, Spring and Fall Fasting, Youth Naming
Ceremonies, Berry picking, Rites of passage
ceremonies (i.e., Berry Fast), Pow-wows, Gardening,
1-1 cultural teachings, Traditional healer visits.
• Individual and group counseling therapy.
• Learning centre and work placements.
• Nutrition program.
• Health care.
• Recreation activities, including attending
sporting events.
• Aftercare planning and follow-up.
Edwards, 2003/US/CA [45] Residential: 90 day substance use program and 90 day aftercare program, at Friendship House.
• Sweat lodge. • Individual and group counseling.
• Traditional teachings (the re-traditionalization
process teaches clients about Native American
values and traditions in classes such as "The
Red Road" based on the work of Gene Thin Elk
(1993) and "Native American Family Values").
• Co-dependency group work.
• Singing. • Alcohol, drug, and HIV/AIDS education.
• Cultural instruments (drumming). • Alcoholics Anonymous and Narcotics.
• Talking circle. • Education about historical Native American
traumas.
• Social cultural (Friendship House celebrations,
personal relationships with the Native American
staff members).
• Traditional healers (Medicine people).
Gossage et al, 2003/US/AZ [46] Prison-based: Sweat lodge ceremony offered to prisoners to treat alcohol addiction.
• Sweat lodge. • Alcohol education.
• Group psychotherapy.
D’Silva et al, 2011/US/MN [47] Community-based: 4, 1 hr. individual or group tobacco cessation sessions paired with pharmacotherapy.
Culturally modified the American Lung
Association’s ‘Freedom from Smoking’
program incorporating:
• Community outreach and education.
• Traditional teachings on how to use tobacco
as a sacred item in ceremonies and offerings.
These teachings are designed to help participants
understand the difference between sacred tobacco
use and commercial tobacco addiction.
• Clinical system referrals.
• Story-telling – cultural adaptations were made
to counseling sessions based on suggestions
from key community stakeholders, and included
the addition of Ojibwe stories.
• Individual and group counseling.
•
Language (use of Ojibwe language in
treatment sessions).
• Access to nicotine replacement therapies (NRT)
and prescription medications.
Lowe et al, 2012/US/OK [48] Community-based: Two types of substance use interventions: 1) Cherokee Talking Circle (CTC), a culturally based,
10, 45 min intervention and 2) Be A Winner/Drug Abuse Resistance Education (DARE), 10, 45 min standard sessions.
The Cherokee Talking Circle intervention
incorporated:
DARE education program:
• Language (the manual used both English
and Cherokee languages).
• Promotes a school/law partnership approach
to substances/ drug education.
• Talking circle.
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Table 1 Characteristics of scoping study scientific and grey literature: program descriptions (Continued)
1
Naquin et al, 2006/US/AK [49] Residential: Alcohol addiction treatment program within the Ernie Treatment Centre, under the Cook Inlet
Tribal Council (CITC) called the Therapeutic Village of Care. Treatment is organized into three phases: Orientation,
Stabilization, and Right Living. The length of time in each phase depended on resident’s treatment plan or progress.
• Sweat lodge (steam bath similar to an American
Indian sweat lodge).
CITC offers:
• Ceremonial practice (harvesting moose (road killed)). • Street outreach.
• Social culture (resi dential treatment community
functions as a large extended family: Members
assume the roles of ‘aunties’ and ‘uncles’;mature
members teach and mentor other, newer family
members and help them reconnect with their
family histories and culture by sharing their
knowledge of tribal genealogies; staff
participate as equals, modeli ng appro priate
family roles and relationships. They also serve
as guides, facilitating the healing process
through role modeling and particip ation in,
but not control of, the community).
• Case management.
• Elders (assume traditional role and are a
constant reminder to residents of unspoken
Native cultural norms).
• Screening and brief intervention.
• Art creation (carving). • Assessment and brief treatment.
• Emergency care and detoxification.
• Intermediate residential, outpatient and
continuing care.
1
Nebelkopf & Penagos,
2005/US/CA [50]
Residential, Health Centre, and Outpatient: HIV/AIDS, substance use, and
mental health programs are offered under the Holistic Native Network (HNN).
There were seven projects that comprise the
HNN. Four of these projects focus on substance
use (Native Youth Circle, FH Healing Circle, Urban
Native Youth, and Native Women). The remainder
are concerned with mental health or HIV/AIDS.
Types of cultural interventions and examples are
provided below:
HNN offers:
• Sweat lodge (monthly gatherings where members
of the community where members of the
community come together in a spiritual way).
• Residential treatment.
• Natural foods and medicines (traditional herb
consultations).
• Outpatient counseling (individual, group or family
counseling).
• Cultural instruments (drum group). • Case management.
• Talking circle. • Community outreach.
• Traditional teachings (discuss the Red Road
to Recovery).
• Risk-reduction counseling.
• Art creation (beading class). • Psychotherapy.
• Social culture (Pow-wows, barbecues, dinners,
ceremonies, give-aways, health fairs and other
rituals are planned monthly and with the
changing of the seasons).
• Art therapy.
• Traditional healers (a central component at
community events).
• Home visits.
1
Nebelkopf & Wright,
2011/US/CA [51]
Community-based: Substance use treatment within the Native Men and Native Women Program.
The program is one of three described under
the Family and Child Guidance Clinic (FCGC)
of the Native American Health Center, Holistic
System of Care (HSOC) for Native Americans
in an Urban Environment. The other two are
not of primary interest as they focus on
prevention and children’s mental health.
The HSOC model includes:
FCGC offers:
• Individual, group and family counseling.
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Table 1 Characteristics of scoping study scientific and grey literature: program descriptions (Continued)
• Sweat lodge. • Care coordination.
• Ceremonial practice (seasonal ceremonies,
smudging).
• Psychological assessment.
• Traditional teachings (discuss the Red Road
to Recovery).
• Screening.
• Prayer. • Alcohol and drug prevention programs for
youth and adults.
• Social culture (four-day Gathering of Native
Americans (GONA)).
• HIV/AIDS prevention.
• Story-telling. • Youth Services program: Drop-in centre,
after-school services, tribal athletics, and
substance abuse prevention.
• Talking circle.
Saylors, 2003/US/CA [52] Residential: Substance use treatment provided by the Women’s Circle at two Native American Health Centres.
Cultural interventions often occur at an
individual level, with counselors assessing a
client's desire or readiness to work with
traditional ways. A counselor's initial clinical
assessment contains spiritual/cultural domains
that allow him/her to gauge a client's cultural
affiliation and identification. This helps direct
the development of a treatment plan which
may include:
• Psycho-therapeutic practice.
• Sweat lodge. • Family and Child Guidance Clinic provides
the services of a nurse case manager and
perinatal social worker.
• Singing.
• Cultural instruments (drumming).
• Natural foods and medicines (herbs and
tobacco).
• Traditional healers (Native healers from different
cultural backgrounds a nd traditions are brought
in for several days at a time to work with clients).
• Prayer (some counselors pray with clients at
the client's request).
• Ceremonial practice (sage, cedar or sweet grass
smudges are often incorporated into a
counseling session).
• Talking circles (held regularly at the clinic for
clients and staff).
Wright et al, 2011/US/CA [53] Residential and Outpatient: Mental health and substance use treatment at the Native
American Health Center (NAHC) using the Holistic System of Care (HSOC) service provision framework.
Native American culture is integrated into
treatment in the following ways:
HOSC offers:
• Sweat lodge. • Treatment (mental health, substance use,
medical, and family services).
• Ceremonial practice (seasonal ceremonies,
smudging).
• Prevention (wellness education, positive
parenting intervention, mental health
promotions, addiction prevention, hepatitis
prevention, and HIV/AIDS prevention).
• Traditional teachings (self-directed learning:
Drawing on intertribal similarities, counselors
also work with individuals to develop skills
and use healing practices that includes individual
backgrounds, traditions, practices, and stories).
• Recovery services (employment, housing life
skills, and community service (giving back)).
• Natural foods and medicines (herbs). • Peer support.
• Cultural instruments (drumming).
• Talking circle.
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Table 1 Characteristics of scoping study scientific and grey literature: program descriptions (Continued)
• Social culture (Pow-wows, women’s/men’s/
youth societies, GONA, Positive Indian
Parenting (OIO)).
• Prayer.
• Story telling.
• Traditional healers (Native healers from
different cultural backgrounds and traditions
are brought in for several days at a time to
work with clients).
Grey Literature
Bresette, 2009/ 2010/ CAN/ON [54] Residential: 4 month solvent addictions treatment provided at Nimkee NupiGawagan Healing Centre Inc.
• Sweat lodge (bi-weekly, staff sweats). Centre offers:
• Fasting ceremony (spring and fall fasting). • Individual and group counseling therapy.
• Ceremonial practice (Full Moon ceremonies,
Spring Releasing Ceremony, youth naming
ceremony, rites of passage ceremonies, smudging .
Multicultural and certified staff (Anishnaabe,
Haudenosaunee, Lenni-Lenape) accommodate
specific cultural and healing experiences).
• Learning centre and work placements.
• Land base activities (gardening, equine program). • Nutrition program.
• Traditional teachings (one to one cultural
teachings).
• Health care.
• Social culture (Pow-wows). • Recreation.
• Natural foods and medicines (welcoming
feasts, memorial feasts, berry picking).
• Aftercare planning and follow-up.
• Singing. • Community education and training.
• Cultural instruments (drumming).
• Prayer.
• Language (encourages and reinforces
communication in original language).
• Traditional healers.
D’Hondt, no year/CAN/ON [55] Residential: 21 day cycle substance use treatment cycles at the
Centre for Addiction and Mental Health Addiction Program (CAMH).
• Ceremonial practice (smudging). Document lists the following services for
pilot program:
• Cultural instruments (drumming). • Employmen t and housing for treatment
graduates.
• Aftercare programs.
CAMH, in general, offers a variety of services
(see: http://www.camh.ca/en/hospital/care_
program_and_services/addiction_programs/
Documents/3882ABS_brochurestnd.pdf
Including:
• Intake and assessment.
• Individual, couple and family counselling.
• Talking circles and group work.
• Telephone counselling.
• Training, consultation and capacity building.
• Inpatient and outpatient treatment programs.
• Referrals.
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Table 1 Characteristics of scoping study scientific and grey literature: program descriptions (Continued)
Kunic, 2009/CAN/across
country [56]
Prison-based: Aboriginal Offender Substance Abuse Program (AOSAP)
offered to male offenders involving four modules and 65 sessions.
• Sweat lodge. AOSAP offers contemporary best-practices in
substance use treatment, such as cognitive-
behaviourism, social learning theory, and
relapse prevention.
• Ceremonial practice (sacred sweat ceremonies
plus other ‘traditional ceremonies’ relevant to
the place in which they are conducted, however
no detail as to what these ceremonies are is
provided).
• Traditional teachings (particularly within the
Modules 1 and 4, e.g., power of the circle of
wellness).
• Natural foods and medicines (sacred medicines
introduced in Module 4).
• Social culture (The Western Door (Module 3),
which is 14 sessions in length, focuses on the
history of consequences and the impact of
substance use within Aboriginal communities.
It also explores the devastating effects of
substance use on Aboriginal individuals, families,
and communities, and how changing individual
behavior can result in the restoration of health,
pride and culture). Module 2- Aboriginal spiritual
engagement is facilitated through the introduction
and exploration of the impact of trauma and how
substance use was, and still is, a means by which
Aboriginal people tried/try to cope with its effects).
• Talking circle.
McConnery & Dumont,
2010/CAN/QC [57]
Residential: 5 week alcohol and substance addiction treatment program at Wanaki Centre.
• Sweat lodge. • Cognitive-behavioural therapy.
• Ceremonial practice (letting go ceremony
after Sweat lodge. Have a Closing of the Sacred
Fire ceremony with the Elder that provides
closure for the entire treatment cycle.
Smudging daily).
• Life skills training.
• Land base activities (teaching and experiences
that build connections to creation/nature- clients
go in the forest to collect cedar and balsam for
the Sweat Lodge ceremony. Spending time in
the woods with an Elder).
• Traditional teachings (delivered by an Elder:
Sacred Fire, Pipe Keeper, four medicines, blessing
of the water, teachings for women such as moon
time and women’s dress, teaching of the lodge.
Also have tradi tional Algonquin teachings. Adhere
to the philosophy of 1) Red Road – involves a strict
code of conduct and ethics, the foundation being
respect for oneself and for other people and the
environment in all its forms. 2) Medicine Wheel:
Mental, emotional, spiritual, and physical).
• Social culture.
• Natural foods and medicines (have a cooking
workshop to make traditional foods. A traditional
meal is offered to clients, staff and guests at the
graduation ceremony).
• Singing (songs are used with the Blessing
of the Water teaching).
• Cultural instruments (drumming is used with
the Blessing of the Water teaching).
• Language (use of Algonquin language).
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Study samples, designs and methods
Table 2 summarizes the samples, designs, and methods
of the studies included.
Samples
Samples ranged from 11 to 2,685 clients who participated
in a culture-based treatment program for problematic
substance use. Most studies included both male and fe-
male participants. Two studies involved solely male clients
attending a prison-based intervention program [46,56]
and one included solely female clients of Native American
Health Centres [52]. Another three focused on adult
clients: Two involved youth and one evaluated students.
In studies that reported the average age of clients, the
mean age range was from 14 to 36 years old.
Designs
Many research designs were utilized; none were true ex-
perimental designs. Just over half (53%) of studies involved
quasi-experimental designs. Commonly within these
designs researchers collected data from clients before
treatment or at baseline and then reassessed at multiple
points during or after treatment. For example, Gossage
et al. [46] collected time-series survey data from 190 males
enrolled in a jai l-based alcoh ol treatment program at
Table 1 Characteristics of scoping study scientific and grey literature: program descriptions (Continued)
• Talking circle (Sharing circle—the Eagle Feather
is used here. Healing circles lead by Elder).
• Elders (Elders from the community and abroad
deliver the teachings and traditional components
of the program).
• Art creation (Grieving collage made of pictures
cut out of magazines, representing images that
touched them personally and they present their
collage to the group. Create a family genogram
showing family members who suffered from
addictions. Make dream catchers and grieving
bags).
• Prayer (daily).
1
The Tsow Tun Le Lum Society,
no year/ CAN/BC [58]
Residential: 42 day alcohol and drug treatment program provided at the Tsow Tun Le Lum Society.
• Sweat lodge. • Client outreach.
• Ceremonial practice (traditional food burnings
at least twice per year).
• Community networking and development.
• Land base activities (spring-fed pond for
traditional cleansing).
• AA and NA meetings.
• Singing. • Aftercare.
• Dancing.
• Cultural instruments.
• Elders (Elders lead the morning “Spiritual
Room” session that begins each program day.
Healthy reconnection to “being Indian” is the
goal of the unique Elder component).
• Prayer.
1
Focused on part of study relevant to scoping study only.
Figure 2 Number and type of cultural interventions reported in
the literature.
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Table 2 Study samples, designs, and methods
Study Samples Designs Methods
Scientific Literature
Anderson, 1992 [40] 63 clients: 39 clients were 1-2 years
out of treatment; another 24 clients
had gone through the program less
than a year before.
Qualitative: Ethnographic study whereby
the author and another researcher resided
in the community for two months. They
observed and participated in the 6 week
program.
Mixed methods—Interviews with
clients post-treatment (open-ended,
face-to-face, frequently with multiple
interviews of the same persons and
usually in family contexts), observations
of treatment, personal testimonies and
materials written by staff a nd clients.
Boyd-Ball, 2003 [41] 57 clients (and their families): 31
males; 26 females; mean age:
16 years old.
Quasi-experimental: Non-equivalent
control group. Comparison of (culturally
supplemented) Treatment As Usual
(TAU) and TAU with culturally and
historically family-enhanced intervention.
Surveys—All clients (and their families)
followed up and assessed monthly for
11 months from the day they left
treatment. Follow-ups were also
done the third and final year of
the study.
Boyd-Ball et al, 2011 [42] 57 clients (and their families):
32 males; 25 females; mean
age: 16 years old.
Quasi-experimental: Time-series.
Post-treatment substance use
trajectories were correlated with
self-report measure of general
American Indian (AI) cultural
involvement.
Mixed methods—Surveys, interviews,
and observation. Data were collected
in three waves: baseline, monthly for
11 months post treatment, and at exit
interview 12 months following
treatment.
Dell & Hopkins, 2011 [43] 154 youth. Quasi-experimental: Time-series data
used to provide insights into the
Youth Solvent Abuse Program (YSAP)
treatment program outcomes.
Surveys at 3, 6, 9 and 12 month
intervals.
Dell et al, 2011 [44] 15 youth (two intakes of program):
7 males; 8 females; mean age:
14-15 years old; 6 treatment staff.
Qualitative: Exploratory, phenomenology
study to understand the experiences of
First Nations and Inuit youth participating
in an Equine-Assisted Learning (EAL)
program as part of their healing from
solvent addiction while in a residential
Treatment Centre.
Mixed methods—Interviews with youth
and staff held during last week of program
(semi-structured, face-to-face), researcher
observations, written reflections by
researchers, pr ogram facilitators and
staff of EAL program, and journal
responses by youth during the program.
D’Silva et al, 2011 [47] 317 adults. Quasi-experimental: Time-series. A
single-group design involving an
evaluation of a culturally specific
curriculum for tobacco dependence
treatment.
Mixed methods—Self-reported tobacco
use assessed at baseline, exit, and follow-up
included current smoking behaviours and
quit attempts; seven-day point-prevalence
abstinence measured at exit and follow-up;
and pharmacotherapy data obtained from
program records.
Edwards, 2003 [45] 12 adults: 6 males; 6 females;
age range: 23-51 years old.
Qualitative: Grounded theory study to
understand and document the
experience of substance use recovery
from the perspective of the Native
Americans in treatment.
Interviews—sin gle, face-to-face, conducted
after completion of the 90 day residential
substance use treatment program.
Gossage et al, 2003 [46] 190 males: mean age: 30 years old.
The sample was divided into two
groups: IPsFU and IPsNFU. The size
of each group varied by stage of
measurement but generally there
were equal numbers in both groups.
Quasi-experimental: Time-series and
comparison between inmate/patients
(IPs) who were followed-up (IPsFU) vs.
those not followed-up (IPsNFU) to
advance current knowledge about the
efficacy of Sweat Lodge Ceremony. It
is unclear what follow-up entailed.
Surveys—Four different surveys used at
distinct stages: baseline; multiple times
after sweat lodge experiences; and 3 and
9 months after release.
Lowe et al 2012 [48] 179 students: Intervention #1—92
students: 59 males; 33 females;
mean age: 17 years old; Intervention
#2—87 students; 44 males; 43 females;
mean age: 16 years old.
Quasi-experimental: Non-equivalent
control group. Two condition design: 1)
Cherokee Talking Circle (CTC) and 2) Be
A Winner/Drug Abuse Resistance
Education (SE).
Surveys—Three instruments used to make
comparisons at pre-intervention,
immediate post-intervention, and
90 day post-intervention.
2
Naquin et al, 2006 [49] 399 clients: 203 males; 196 females. Pre-experimental: One-shot case study
examining resident engagement with
treatment process and outcomes at a
single Treatment Centre.
Mixed methods—Time in treatment/
retention rates compared to earlier years
and national averages and Surveys—
post-treatment perception of care; 6 month
follow-up of level of employment and use
of alcohol.
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pretest; multiple times after sweat lodge experiences;
and 3 and 9 months after release. Two other quasi-
experimental studies involved a non-equivalent control
group design, comparing the effe ctiveness of cultural
and Western inter ventions. To illustrate, Lowe et al.’s
[48] two condition design compared survey scores in years
two and three from 87 students of the “Be a Winner/Drug
Resistance Education” and 92 students in the traditional
Cherokee Talking Circle group. Pre-experimental designs
were employed by roughly a third (32%) of studies. These
designs commonly assessed one group before and evaluated
the same group 3, 6, or 12 months after t reatment. For
example, Say lors [52] used this design t o sur vey changes
in 742 females engaged in residential treatment at baseline
and at 12 month follow-up. Finally, three studies (16%)
used qualitative designs employing ethnographic, phe-
nomenological, or grounded theory approaches.
Methods
A total of 16 studies used surveys; nine of these studies
(56%) developed in-house surveys and seven studies (44%)
incorporated a total of 14 standardized instruments to
Table 2 Study samples, designs, and methods (Continued)
1
Nebelkopf & Penagos,
2005 [50]
45 individuals: 39 males; 5 females; 1
transgender.
Pre-experimental: One group pretest-
posttest examining changes in clients’
quality of life as a result of services
received through the Holistic Native
Network.
Survey—Pre-post survey at baseline and
3 months after care.
1
Nebelkopf & Wright,
2011 [51]
490 adults: 142 males; 348 females. Pre-experimental: One group pretest-
posttest involving adult substance
users to assess whether the Holistic
System of Care for Native Americans
is a viable model of treatment.
Survey—Pre-post survey at baseline and
6 months after care.
Saylors, 2003 [52] 742 females. Pre-experimental: One group pretest-
posttest to assess lessons learned and
impact of the Substance Abuse
Treatment Women’s Circle on clients.
Survey—Pre-post survey at baseline and
12 months follow-up.
Wright et al, 2011 [53] 490 participants: 142 male; 348
females; mean age: 36 years old.
Pre-experimental: One group pretest-
posttest to assess preliminary outcome
findings of substance abuse outpatient
and residential treatment services for
urban American Indians and Alaskan
Natives under the Holistic System of
Care model of treatment.
Survey—Pre-post survey at baseline and
6 months after care.
Grey Literature
Bresette, 2009/ 2010 [54] 27 clients: 9 males; 18 females,
mean age: 16 years old.
Quasi-experimental: Time-series to
execute an impact evaluation of the
Nimkee NupiGawagan Health Centre
Inc. pilot project involving treatment
for youth, families, and their communities
who suffer from solv ent addiction.
Surveys—Pre-post survey at 3 and
6 month follow-up.
D’Hondt, no year [55] 12 clients. Quasi-experimental: Time-series to
evaluate a pilot residential substance
use treatment program at the Centre
for Addiction and Mental Health.
Mixed methods—Focus groups, and
interviews and surveys at baseline,
treatment completion, and follow-up.
Kunic, 2009 [56] 2,685 males. Pre-experimental: One-shot multiple
case studies comparing treatment
outcomes among three treatment
groups: 1) the Aboriginal Offenders
Substance Abuse Program (ASOP), 2)
the Nation al Substance Abuse
Program—Hig h Intensity (NSAP -H)
or 3) Moderate Intensity (NSAP-M).
Mixed methods—Comparison of
post-release outcomes over an
18 month follow-up period among
three treatment groups: Biochemical
markers—urinalysis for evidence of
drug use and program records—type
of release and revocation.
McConnery & Dumont,
2010 [57]
15 clients: 10 males; 5 females. Quasi-experimental: Time series to
study the impact of an integrated
addictions treatment program at
Wanaki Treatment Centre.
Survey interviews—Repeated measures
surveys (in person and by telephone) at
baseline, end of treatment, and 3 and
6 months pos t treatment.
The Tsow Tun Le Lum
Society, no year
provided [58]
11 clients: 6 males; 5 females. Quasi-experimental: Time series to
assess the integrated alcohol and
drug treatment program provided
at the Tso Tun Le Lum Society.
Survey interviews
—At admission,
completion of program and 3 months
post treatment.
2
Focused on part of study relevant to scoping study only.
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measure mostly self-reported physical and/or emotional
aspects of wellness (see Table 3). Only Boyd-Ball et al. [42]
reported reliability scores using test-retest scores. There
were six standardized surveys identified to measure alco-
hol or drug use: 1) Behavioral and Symptom Identification
Scale-32 (Basis-32) [55], 2) Global Assessment of Individ-
ual Needs—Quick (GAIN-Q) [48], 3) The Government
Performance Results Act (GPRA) Tool [51,53], 4) Form
90-DI: A Structured Assessment Interview for Drinking
and Related Behaviors [42], 5) Alcohol Dependence Scale
(ADS) [56], and 6) Drug Abuse Screening Test (DAST)
[56]. The American Indian Cultural Involvement Index [42]
and the Cherokee Self-Reliance Questionnaire [48] were the
only instruments that were oriented to Indigenou s culture.
Wellness outcomes collected and main results
Table 4 summarizes the outcomes collected and main
results from the studies identified in the scoping study.
Outcomes collected
Outcomes were collected on four main themes: Spiritual,
Mental, Emotional, and Physical wellness with many
positive results found in all areas. All but two articles
(90%) focused on measuring physical wellness, which in-
cluded five major subthemes ranging from improvement
in physical health to sobriety or abstinence from alcohol,
drug, or inhal ant use. Emotional health was frequently
collected in 74% of studies. It had nine subthemes ran-
ging from self-esteem to non-violence or non-aggr essive
behaviour. Mental wellness was measured by just over half
(53%) of the studies and was captured through knowledge,
skills, and awareness; school achievement; and learning
about Aboriginal spiritual healing. Fewer studies (37%)
measured spiritual health, as identified via spiritual health
practices, awareness and values; feeling connected/belong-
ing; and traditional values practiced. Several studies (42%)
focused on measuring dyad combinations of outcomes,
Table 3 List and type of standardized surveys
Survey [study where used] What it measures Administration: self-report = SR;
caregiver = CG
Behavior and Symptom Identification Scale-32
(Basis-32) [55].
Relationship to self and others, depression and
anxiety, daily living skills, impulsive and addictive
behaviors, and psychosis.
SR
Global Assessment of Individual Needs – Quick
GAIN-Q [48].
Four major scales – General Life Problem Index
(GLPI), Internal Behavior Scale (IBS), External
Behavior Scale (EBS), and Substance Problem
Scale (SPS).
SR
The Cherokee Self-Reliance Questionnaire [48]. Presence of Cherokee self-reliance. SR
The Government Performance Results Act (GPRA)
tool [51,53].
Demographics; drug and alcohol use; family and
living conditions; education, employment, and
income; crime and criminal justice; mental and
physical health problems; treatment/recovery;
and social connectedness.
SR
Child Behavioral Checklist (CBCL) Behavioral and
Emotional Rating Scale [51].
Behavioral and emotional problems in children. CG
Caregiver Strain Questionnaire (CGSQ) [51]. Strain such as feelings of anger and resentment
about the child, disruption of family and community
life, and caregiver feelings of worry, quilt, and fatigue.
CG
Columbia Impairment Scale (CIS) [51]. Global impairment for youth. CG
Behavioral and Emotional Rating Scale
(BERS-2 Caregiver) [51].
Interpersonal, intrapersonal, family, affective, school,
and career strengths.
CG
Quality of Life (QOL) Survey [50]. Gender, ethnicity, education, presence of an AIDS
diagnosis, and quality of life.
SR
Form 90-DI: A Structured Assessment Interview
for Drinking and Related Behaviors [42].
Alcohol consumption and other related problems. SR
The American Indian Cultural Involvement Index
(AICI) [42].
Composite score based on two measures: 1) a child
ethnic identity score and 2) count of traditional
values practiced or believed.
SR
Alcohol severity ratings on the Alcohol Dependence
Scale (ADS) Problems Related to Drinking Scale [56].
Alcohol dependence syndrome. SR
The extent of problems related to drinking as
measured by the Problems Related to Drinking
Scale (PRD) [56].
Alcohol-related problems. SR
The drug severity ratings on the Drug Abuse
Screening Test (DAST) [56].
Severity of problems associated with drug use. SR
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Table 4 Wellness outcomes and main results
Study Wellness outcomes Main results
Spiritual Mental Emotional Physical
Scientific literature
Anderson, 1992 [40] √√• 1/3-1/2 of clients maintained sobriety for at least
1 year post treatment.
• Clients established follow-up circles in their own
community and those involved “do much better
and feel more hopeful than those that are not” (p.11) .
Boyd-Ball, 2003 [41] √√• Family-enhanced group perceived high level of
support of family members (94.2%) and nonfamily
adults (90.6%) and positive peer support (66%).
• % of days abstinent from substance use from month
1 to 12 was high for both (culturally supplemented)
treatment as usual and family-enhanced intervention
groups, ranging from 80-100% days abstinent.
• The highest gain in abstinence was from month
1 to 2 for both groups.
Boyd-Ball et al, 2011 [42] √√ √ √• At 1 year follow-up: 23% relapsed into regular
substance use; 77% showed low levels of substance
use.
• Post-treatment substance use trajectories indicated
that membership in the relapser’s group showed less
engagement in traditiona l cultural pract ices and
identification with their American culture
(mean = -.24) than those classified in the abstainers
group (mean = .17).
Dell & Hopkins, 2011 [43] √√• Half of the youth (49.62%) reported a completely
abstinent lifestyle in 90 days following exit from the
program and half of these youth (51%) reported to
not have the urge to misuse volatile or other
substances during this time.
• At 6 months follow-up, 74% reported not using
volatile or other substances and 68% of these
reported not having to resist drug use.
• More than half of youth who completed the
program (54.2%) reported attending school at
3 month follow-up and at 6 months this rate
increased to 83.64%.
Dell et al, 2011 [44] √√ • Participating in the Equine-Assisted Learning
program provided a culturally relevant space for
youth and thus was beneficial to their healing in
the program.
• Three main themes explained the healing experience:
spiritual exchange (calm presence, being in the
moment, meaningful connection to the horse),
complementary communication (ability to
communicate with horse beyond verbal commands
and helped with patience and leadership in
communicating with others), and authentic occurrence
(females showed compassion for pregnant mares and
foals, inter acting with horse let them experience
healthy to uching and expressing affection).
D’Silva et al, 2011 [47] √ • 63% of participants completed the program.
• Upon completion, almost 1/3 of participants
self-reported 7 day abstinence.
• Of those reached at follow-up, 47% reported
abstinence at 90 days.
• The smoking quit rate was 21.8%.
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Table 4 Wellness outcomes and main results (Continued)
• Continuing smokers cut their daily smoking by
half (from 17-9 cigarettes).
• 88% reported an increase in self-efficacy for their
next quit.
• 44% planned to quit within 30 days.
Edwards, 2003 [45] √√ √ • 73 transformational (healing) experiences towards
re-traditionalization were expressed by graduates of
the treatment program.
• These were categorized into 12 themes (in descending
order): Feeling cared for, spiritua l experiences, insight,
making a commitment, empowerment, releasing
emotional pain, remorse, reconnecting to traditional
values, forgiveness, relief, safety, and gratitude.
Gossage et al, 2003 [46] √√ √ √• IPsFU (Inmate/patients followed-up) drank 1 to 1.5
drinks less per drinking occasion than before intake
(5.4 vs. 6.8), although still considered to be problematic.
• Analysis using the Wilks test reveals significant
improvements in scores over 3 time periods (baseline,
3, 9 months after release) for relating to the animal
world and human world (p < 0.02 and p < 0.03)
respectively.
• Mean social support given to IP by his family
increased before going to jail and at follow-up
(from 6.5 to 8.3).
• One of five indicators of domestic violence (hit or
throw things first, regardless of who started an
argument) improved significantly from before
going to jail to follow-up (x
2
= 4.714, p = 0.030).
• Medical status scores improved before to follow-up
(5.8 to 7.8 on a 10-point scale) and this was statistically
significant (paired t-test, =3.3.16, p = 0.003).
• There was substantial and significant improvement
in marital status (x
2
= 108.127, 45 df, p = 0.000).
• 47% of IPs were rearrested at some point during
the study.
Lowe et al, 2012 [48] √√• Culturally based intervention (CTC) was significantly
more effective for reducing substance use and related
problems than the non-culturally-based intervention
(SE) on the Global Assessment of Individual
Needs—Quick (GAIN-Q) as follows:
• The Total Symptom Severity Score (TSSS) showed
differences between groups increased over time, and
at 3 month follow-up, the difference remained and
the magnitude increased (t = -5.35, p < .001).
• The General Life Problem Index (GLPI) showed
differences between the CTC and SE groups becoming
significant at post intervention (t = -2.63, p = .009) and
3 month follow-up (t = -5.05, p < .001).
• The Internal Behavior Scale (IBS) results show a
significant difference between the two groups at
post-intervention (t = -4.18, p < .001) and 3 month
follow-up (t = -5.45, p < .001).
• External Behavior Scale (EBS) score differences
between the two groups became significant at
post-intervention (t = -3.58, p < .001) and 3 month
follow-up, (t = -4.56, p < .001).
• The difference in the Substance Problem Scale
(SPS) between the CTC and SE groups became
significant at post-intervention (t = -3.89, p < .001)
and 3 month follow-up, (t = -4.69, p = .001).
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Table 4 Wellness outcomes and main results (Continued)
• Cherokee self-reliance scores showed that at
post-intervention, the CTC group had higher
scores than the SE group (t = 2.72, p = .007). At 3
month follow-up, the difference between the two
groups became larger (t = 6.74, p < .001).
Naquin et al, 2006 [49] √ • Rate of residents completing the program rose
dramatically from 2002-2005, from 55% in 2002 to
75% in 2005, and this level of retention is higher
than the national experience of 35% for therapeutic
communities and 33-38% for long-term care (over
30 days).
• At 6 month follow-up, use of alcohol in the last
30 days dropped from 57% at intake to 20%.
• Full-time employment increased from 19.2% to 33.3%.
Nebelkopf & Penagos, 2005 [50] √√• Mixed results in self-reported quality of life results
owing to population that included HIV/AIDS clients,
e.g., “how would you rate your overall health”
decreased between baseline and follow-up (no
data provided) whereas “feeling bad lately”
decreased over that period of time (32% vs. 3%
said “definitely true”; 29% vs. 18% said “mostly true”).
Nebelkopf & Wright, 2011 [51] √√ √• Using the McNemar test:
• 24% reported using alcohol or drugs in the prior
30 days at baseline, with a decline to 5% six months
later (p < .001).
• Experiences of stress, emotion, or activities resulting
from substance use in the prior 30 days also showed
a decreasing rate of change from 47% to 23% (p < .001).
• The number reporting either part or full-time
employment increased from 11% to 20% (p < .001).
• The largest rate of change was seen in enrollment
in school or a training program, moving from 7%
to 17% (p < .001).
• The number reporting being arrested or committing
a crime in the prior 30 days went from 31% to 5%
(p < 0.001).
• Significant reductions were seen in the rates of
non-substance use-related reports of: serious depression
(p < .001), serious anxiety or tension (p < .001),
hallucinations (p < .001), trouble understanding
or concentrating (p < .001), trouble controlling
violent behavior (p < .01), and suicide attempts
(p < .01).
Saylors, 2003 [52] √√• Within pre/post matched sample, alcohol use
decreased 13% after 6 months and drinking alcohol
to intoxication was reduced by 19%.
• Women who reported using other drugs at intake,
such as marijuana and inhalants, reported no use
at 6 months.
• Heroin use was down 93%.
• At 12 month follow-up, the rate of full-time
employment increased from 10% at intake, to 29%,
and the clients who were legally employed doubled.
• There was an increase in the % of participants
claiming good health and decreases of “fair” or “poor”.
•
Positive change in clients’ living situations also
resulted in fewer having contact with the criminal
justice system and more being enrolled in school
or job training programs.
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Table 4 Wellness outcomes and main results (Continued)
• Culture was viewed as important at intake, with
5.7% reporting it was “not important”; 11.5%
responding “important”, and 73% responding that
their culture was “very important” to them.
Wright et al, 2011 [53] √√ √• Using the McNemar test:
• 80.2% decrease rate of change in alcohol and
drug use from 116 (23.7%) in the prior 30 days at
baseline to 23 (4.7%) six months later (p < .001).
• Experiences of stress, emotion, or activities resulting
from substance use in the prior 30 days showed a
decreasing rate of change of 51.8%, from 231 (47.1%)
to 111 (22.7%) (p < .001).
• The number reporting either part or full-time
employment increased from 55 (11.2%) to 100
(20.4%), with an 82.1% rate of change (p < .001).
• The largest rate of change (150.7%) was seen in
enrollment in school or a training program, moving
from 34 (6.9%) to 85 (17.3%) (p < .001).
• The number reporting being arrested or committing
a crime (includes illegal substance use) in the pri or
30 days went from 151 (30.8%) to 26 (5.3%) with an
82.8% rate of change (p < .001).
• Significant reductions were seen in reports of
serious depression (p < .001), serious anxiety or
tension (p < .001), hallucinations (p < .001), trouble
understanding or concentrating (p < .001), trouble
controlling violent behavior (p < .01), and suicide
attempts (p < .01).
Grey literature
Bresette, 2009/2010 [54] √√ √ √Outcome #1: Increased sense of physical and
mental well-being; feeling purpose and self-esteem:
• Self-identity as a Native was much more positive
at the end of treatment.
• 71% of clients stated that they feel very comfortable
practicing their cultural beliefs.
• 93% of clients who entered the program did not
have a spirit name and received one during their
stay in the program.
• 100% of clients stated that they were completely
comfortable using their native language both in
their community and outside their community.
• 63% of clients stated that they had some
connection to First Nations Culture, to family
members or extended family.
• 58% of clients returned to their community and
participated in cultural, social or artistic activities
in their home community.
Outcome #2: Increased knowledge of drug-free
lifestyles including cultural healing strategies:
• Increased knowledge of drug-free lifestyles
including cultural healing strategies, such as
connection with spiritual family through youth
fasting, feasts, ceremonies and learning to help
self with use of the spirit.
Outcome #3: More past clients pursued their
education and/or life learning goals:
• Average grade level improvement in language arts
(.98% grade improvement) and math (.99% grade
improvement).
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Table 4 Wellness outcomes and main results (Continued)
• Upon return to their communities, clients reported
that they continue performing traditional cultural
activities, e.g., smudging, leading prayer, assisting
with dressing the drum, etc.
• 100% of clients stated that they volunteer once
a month in their community.
• 33% stated when they call back to the Treatment
Centre after discharge that they had increased their
social activities.
Outcome #4: Clients have developed positive social
networks and have passed on teachings to help
peers and community members:
• 46% of the clients continued with culture either
alone or with family, friends or community members.
• Clients have connected with peers via the internet
after leaving treatment.
• Clients have identified a confidant (clients calling
the NNHC on follow-up to treatment included 3 or
25% of the youth who were in the program within
the last year. 15.2 hours total spent on the 24 hour,
toll-free line with youth over 104 different contacts).
Outcome #5: Clients encountered fewer occurrences
with the justice system.
• 37% of clients left treatment early, all were female
and 60% left because of charges.
• Serious occurrences (e.g., assaults on staff/clients)
average = 1.5/month vs. 4.75 benchmark.
• Incidents (e.g., physical attack/threats)
average = 1.5/month vs. 6.3 benchmark.
D’Hondt, no year [55] √√• High completion rate at 84.6% and 50.0% of patients
continued to be engaged in aftercare programs at
CAMH and elsewhere.
• Reduced alcohol and drugs use in follow-up
(30 days prior) compared to initial assessment
(90 days prior).
• Pre- and post-treatment results showed a decrease
in BASIS 32 scores, suggesting clinically important
improvements in general mental health and
functioning among the clients.
• At initial assessment (treatment entry), 10 out of
12 individuals (92%) reported having consumed
alcohol to the point of blackout in the past 90 days.
However, at follow-up, only 1 individual of the 9
contacted (11%) reported having drunk until
blackout in the past 30 days.
Kunic, 2009 [56] √ • Those who participated in Aboriginal Offender
Substance Program (AOSAP) were returned to
custody at a lower rate during the follow-up period
than the groups of Aboriginal offenders who
participated in National Substance Abuse Program-
High Intensity (NSAP-H), NSAP-M (Moderate Intensity),
failed to complete a substance use program, or did
not participate in a substance use program prior to
release from custody. Aboriginal offenders who
participated in versions 2 or 3 of AOSAP were
returned to custody at the same rate as Aboriginal
offenders who participated in version 1 of AOSAP.
There was no statistical difference between versions
of AOSAP.
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Table 4 Wellness outcomes and main results (Continued)
• Only 5% of the successful participants of AOSAP- V
2&3, and 6% of the participants of AOSAP version 1
were returned to custody because of a new offence
or charge compared to 16% and 20% of the
successful participants of NSAP-H and NSAP-M,
respectively.
• Exposure to substance use treatment prior to
release from custody was a relatively weak predictor
of relapse to substance use (p = 0.07). However, some
evidence suggested that successful participants of
AOSAP and NSAP-M were less likely to incur a positive
urinalysis result while on release than successful
participants of NSAP-H .
• Those who participated in AOSAP were less likely
than offenders from the other program exposure
categories to test positive for drugs that are
considered dangerous (e.g., cocaine, opioids).
McConnery & Dumont, 2010 [57] √√ √ √Outcome #1: Achieve greater balance in the four
aspects of life (mental, spiritual, emotional, and
physical):
• Not a clear increase over time in all aspects of
wellness; however:
• Mental wellness of clients increased during
treatment and 6 months after their treatment, but
it was noted that there is “too much inaccuracy in
the question to judge if there was a significant
increase” (p.25).
• The only marked finding under spiritual
wellness was the increase of practice and comfort
associated with practicing this type of spiritually
during the program, such as the daily smudge and
praying. The spiritual aspect was mentioned a few
times in the Talking Circle as something that
participants thought would help them to remain
sober once they returned to their community. But
it is noted that “the spiritual aspect does not show
considerable c hanges that could be interpreted as
a general increase for participants, despite the fact
that they name this as an impor tant tool for their
recovery” (p. 25).
• Authors noted: “The emotional aspect shows
more clearly a decrease in feeling of sadness
and crying” (p.25).
• Definite increase in the self-interpretation of
physical good health with time from treatment to
3 months after treatment. There is a slight
decrease between 3 months after treatment and
6 months after treatment. The authors note that
“in the physical aspect there is a more evident
decrease in the feeling of ill health” (p.25).
Outcome #2: Increase self-esteem and cultural pride:
• Slight increase in self-esteem from 6 months prior
to treatment and 6 months after treatment, but
authors note this is not significant.
• Cultural pride is about as high 6 months before
treatment as it is 6 months after treatment.
Outcome #3: Achieve abstinence and influence peers
in communities.
• 50% or more of the participants remained abstinent
during the 6 months after treatment.
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particularly emotional and physical wellness. Just over one
quarter (26%) of studies collected outcomes under all four
themes.
Main results
Results provide evidence about the benefits of Indigenous
cultural interventions to help improve client functioning
Table 4 Wellness outcomes and main results (Continued)
Outcome #4: Decrease the number of occurrences
of client-related family violence:
• Slight decrease in violence from the pre-treatment
to the post-treatment.
The Tsow Tun Le Lum Society [58] √√ √ √Outcome #1: Clients are involved in more activities
that contribute to their being “clean and sober” (at
3 months post treatment):
• 2/3 (7 of 11) kept busy at daily activities every day
or at least 3 times a week.
• Staying in the company of sober people remained
the same as upon admission at 45% (5 of 11).
• 45% (5 of 11) requested help from AA/NA (a slight
increase from admission).
• 64% (7 of 11) put into practice new ways of
reacting to risky situations.
Outcome #2: Clients pride and dignity are empowered
through participating in cultural, spiritual, and artistic
events (at 3 months post treatment):
• 55% (6 of 11) were comfortable self-identifying as
Aboriginal or Inuit (this is a drop from that at
admission of 82%).
• 45% (5 of 11) had participated in cultural or traditional
events (same as six months prior to admission).
• None were uncomfortable with practicing Aboriginal
spiritual practice.
• 45% agreed or strongly agreed that a rich heritage
of knowledge, wisdom, and traditional was passed
to them (an increase over admission (36%) but a
slight drop from the rate at completion (64%)).
Outcome #3: A decrease in demonstration of violent
behaviors towards self and others:
• Significant drop in violent behaviors towards others,
from 73% at admission to 29% at 3 months post
treatment.
• Self-violent behavior dropped from 27% at
admission to 14% at 3 months post treatment.
Outcome #4: Increased client’s self-esteem enhances
their mental, physical, emotional, and spiritual
well-being (at 3 months post treatment):
• 36% prefer to use and stay in the company of
people in recovery every day.
• 36% have requested assistance from resources in
their community (this % was double over the rate
at admission).
• 18% (2 of 11) had difficulty sleeping; 55% (6 of 11)
could sleep without medication; and 64% (7 of 11)
felt calm and rested from sleep (these % were
improvements over rates at admission).
Outcome #5: Increase awareness in communities
around addictions and its impact on people:
• Since leaving the Treatment Centre, clients most
frequently got support from a friend or family member.
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in all areas of wellness, particularly in association with
reducing or eliminating substance use problems as found
in almost three quarters (74%) of studies. It is important
to note, however, that only two studies based on non-
equivalent control groups, directly compared and con-
trasted the effects of Indigenous and Western components
within the same study. Lowe et al. [48] found that a Native
American adolescent culturally-based intervention was
significantly more effective at reducing substance use and
related problems than a non-cultural-based intervention.
The largest significant differences between the groups
for all four major scales of the Global Assessment of
Individual Needs instrument occurred at the 3 month
post-intervention follow-up. In contrast, Boyd-Ball [41]
found no differences between treatment as usual (which
in this setting also incorporated cultural activities), and
family-enhanced intervention groups, both of which had
80-100% abstinence rates over 12 months. Mixed results
were identified for self-reported quality of life, which
Nebelkopf and Penagos [50] suggested are specific to the
population that included HIV/AIDS clients. McConnery
and Dumont [57] saw no clear increase over time in all as-
pects of clients’ wellness; however, there were meaningful
changes in emotional and physical health.
Discussion
This study set out to identify and describe what is
known about the types of cultural interve ntions used
with Indigenous populations to treat addictions, along
with intended outcomes and effect s on wellness in this
context. We examined academic literature, but suggest
that not all of the relevant evidence may be found through
such sources, as much of the knowledge about culture is
still held in Indigenous “worldviews, languages and rituals”
[59]. All stud ies identified were from North America,
and involved community-based, residential substance
use treatment programs of varying lengths. They c