“Alcohol is Something That Been With Us Like a Common Cold”: Community Perceptions of American Indian Drinking

Abstract

This study examined tribal members’ perspectives on alcohol, risk factors, consequences, and community responses. Focus groups were conducted with five American Indian tribes between 1997 and 2001. Participants were knowledgeable of the cultural lives of their reservation communities. Although there was agreement regarding the pervasiveness of heavy drinking, participants reported different opinions about the meaning of alcohol and appropriate intervention strategies. Three dilemmas were identified, suggesting that community ambivalence may serve as a barrier to reducing problem drinking. Implications, limitations, and future research directions are discussed. The study was funded by the National Institute on Alcohol Abuse and Alcoholism.

Introduction

Survey-based and epidemiological studies have shown that alcoholism continues to be a major public health problem for many American Indian tribes. Lifetime rates of alcohol dependence range between 1% and 66% for men and 2% and 53% for women (Beals, Manson et al., 2005; Gilder, Wall, and Ehlers, 2004; Koss et al., 2003) with significant variability by tribe (i.e., Beals, Novins et al., 2005; Koss et al., 2003). A comparison between epidemiologic data from two American Indian tribes and the National Comorbidity Survey showed that lifetime rates of alcohol dependence were higher among the tribes than the general population (Beals, Novins et al., 2005). American Indian drinkers are at high risk of experiencing alcohol-related consequences, including chronic liver disease and cirrhosis (Indian Health Service, 1999), driving under the influence (May and Gossage, 2001), legal problems (Robin, Long, Rasmussen, Albaugh, and Goldman, 1998), and physical and sexual violence victimization (Yuan, Koss, Polacca, and Goldman, 2006). From 2001 to 2005, the age-adjusted rate of alcohol-attributable deaths among American Indians and Alaska Natives was approximately two times the rate for the general U.S. population (Centers for Disease Control [CDC], 2008).

As a result of such quantitative research, the prevalence and magnitude of alcohol problems among American Indians are well documented. However, the findings tend to be reductionistic with little or no account of sociocultural influences on individual behavior (O’Nell and Mitchell, 1996). This limitation is highly relevant to research that aims to inform the development of intervention and prevention strategies for Native communities. Since its introduction by European colonists, alcohol use has been associated with the identities of many tribes and the population in general (Duran, 1996). Studies that underestimate or overlook the diverse meanings and contexts of alcohol use tend to reinforce the colonialist image of the drunken Indian and portray American Indians as weak, deviant, and dysfunctional (Quintero, 2001). Such negative stereotypes may have lasting effects on how American Indian drinkers view themselves as well as how their tribal communities perceive them (Quintero, 2001). One approach to resisting colonist ideas and actions is to increase engagement of Native communities in the discourse of alcohol use (Duran, 1996).

Qualitative methods improve the level of discourse and enhance our ability to understand the complex role of alcohol in the lives of Native people (e.g., Spicer, 1997; O’Nell and Mitchell, 1996). Ethnographic studies have depicted American Indian drinking as a simultaneously functional and dysfunctional behavior. Spicer (1997) found that the urban American Indian experience with alcohol was ambiguous and contradictory. He suggested that drinking was tied with both social connectedness and fragmentation. Problem drinkers were concerned about their alcohol use, but were reluctant to quit because of strong social incentives. Alcohol consumption facilitated companionship and reciprocity. However, it was also destructive, contributing to relationship conflict and child neglect. Another ethnographic study documented similar diverse social contexts of drinking among reservation-based American Indian adolescents (O’Nell and Mitchell, 1996). Teenagers in the study reported consuming alcohol to negotiate peer relationships as well as cope with family conflicts. The researchers concluded that pathological drinking was defined by the degree to which alcohol use interfered with gender-specific developmental tasks and cultural values. Biological and psychological processes were less relevant to the construct of adolescent problem drinking.

The study of traditional values and practices through the use of qualitative methods is critical for the development of indigenous models of the etiology and treatment of alcohol abuse. Cultural values are often a source of motivation for American Indians to change their drinking behaviors (Spicer, 1997). Spicer (2001) found that many urban American Indians who had quit drinking sought to reclaim their spirituality and define their purpose in life and in their community. A study of interviews with recovering Lakota alcoholics showed that they had greater acceptance of treatment programs that integrated American Indian culture, traditions, and history of alcoholism into the recovery process than mainstream programs (Milbrodt, 2002). Much of this research has been conducted with current or former American Indian drinkers. Little is known about community perceptions and responses to alcohol and differences across tribes. This is an important area for investigation given that alcohol problems experienced by American Indian individuals and communities are multidimensional and treatment interventions need to be designed by and for entire communities (Abbott, 1998).

The main purpose of the current study was to examine tribal members’ perspectives and experiences with alcohol, risk factors, consequences, and community responses. The second aim was to identify potentially effective alcohol intervention and prevention approaches for reservation-based Native communities. This investigation was part of the larger Ten Tribes Study, a collaboration of Native American Nations and Confederations, the University of Arizona, and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The Ten Tribes Study measured genetic and environmental vulnerability factors of alcoholism among seven geographically diverse American Indian tribes. The present study is based on focus group interviews conducted with five tribes prior to implementation of the main study.

Method

Seven American Indian tribes participated in focus group interviews and main study assessments before funds were exhausted. Tribes were recruited using letters and personal contacts with an emphasis on large tribes with diverse alcoholism rates, cultures, histories, and geographic regions. The inclusion criteria enhanced the representation of the heterogeneity of Native communities. Detailed description of the main study design is provided elsewhere (Yuan et al., 2006).

The goals of the focus groups were to encourage tribal involvement, obtain opinions on alcohol use, violence, and other community problems, and seek input on the main study design and implementation. Six out of seven tribes granted permission to audiotape the focus group interviews. The quality of one tribe’s audio recording was inadequate for transcription. As a result, analyses were conducted with focus group data from five tribes.

Participants

One focus group interview was conducted with each of the five tribes. As part of the signed agreement, the researchers promised to protect the identities of the tribes in all publications. Only regional information is provided in this paper. Three tribes were from the Southwest, one tribe was from the Northwest, and one from the Northern Plains. All participants were living on or near tribal lands, as identified by federal and state jurisdictions, when the interviews were conducted.

Each focus group consisted of 6–11 enrolled tribal members. Applying a community-based participatory research approach, tribal councils and research committees were asked to identify adult tribal residents who were active and knowledgeable of the cultural life of their communities.

Onsite coordinators assisted with recruitment that included formal letters of invitation. Participants were informed that their input would enhance understanding of the unique factors that influence the development of alcoholism, improve the cultural appropriateness of the main study protocol and questionnaires, and strengthen the community-research partnership in general. Purposeful selection of participants was used to obtain a cross representation of the community with regards to gender, age, educational level, employment, and community role. As shown in Table 1, participants had diverse experiences working with their tribes. Some held one or more positions with various tribal offices, departments, and committees during their lifetime, whereas others were well-respected lay helpers. All participants provided written informed consent prior to the start of the study. Individuals were paid $80 per day for participating in the focus group discussions. Data collection began after negotiating Memorandum of Agreement with each tribal government, obtaining clearance from the Office of Management and Budget for research on federal lands, and receiving approval from the Institutional Review Boards (IRBs) of the University of Arizona, NIAAA, and tribes who had IRBs when the study was initiated.

Table 1.

Focus group participant characteristics by tribe

Tribe	Region	Male/Female	Employment/Community role
Tribe 1	Southwest	2/6	Elder, traditionalist, emergency medical services provider, minister, elementary school language assistant, retired heavy equipment instructor, housing authority staff, rancher
Tribe 3	Northwest	2/6	Elder, traditionalist, alcohol prevention provider, community health worker, teacher, historian, community services provider, youth representative
Tribe 4	Northern Plains	3/3	Elder, tribal legislator, health board chairman and member, Head Start teacher, language and culture committee member, Native Employment Works program staff, college student, parent
Tribe 5	Southwest	3/8	Elder, past tribal chairman, alcohol program director, nurse, Bureau of Indian Affairs staff, maintenance engineer, director of planning, tribal employment rights staff, police officer, economic development staff, Council on Aging staff, parent, grandparent
Tribe 6	Southwest	2/9	Chief judge of election board, tribal council members, traditionalist, community health worker, language and culture committee member, water operator, homemaker

Note. Focus group interviews with Tribes 2 and 7 were not included in this study. Several participants reported more than one type of employment and/or community role during their lifetime.

Procedures

Focus group interviews were conducted between 1997 and 2001. The discussions took place at tribal facilities on reservation lands. The group facilitators were American Indians from different tribes than those participating in the interviews. They had previous experience with qualitative research methodology and were supervised by the research team. Native facilitators were used to enhance the participants’ level of comfort in disclosing information on sensitive topics. The facilitators led the discussions using an interview guide. The guide was created by the research team consisting of scientists with training in psychology, social work, and anthropology, and expertise in working with American Indian communities. The set of questions was informed by the goals of the focus groups and the same questions were used with all the participating tribes. Participants were asked about alcohol use, consequences, traditional interventions, interpersonal violence, contemporary community problems, historical trauma, boarding school experiences, main study survey design, data collection methods, and Native language and traditional practices for the development of a tailored cultural affiliation instrument. The focus group interviews took an unusually long amount of time, lasting about 8 hr each day for 3 days. The extended duration was largely due to the amount of time needed to discuss the main topics of interest, review the entire interview protocol, and tailor the cultural assessment to each tribe.

Analysis

The research team conducted the analyses in several stages as recommended by respected qualitative researchers (Patton, 2002).

• Step 1. Verifying Transcription—A doctoral medical anthropology graduate student verified the transcripts by comparing portions of the transcripts to the audiotapes.

• Step 2. Organizing Data—The transcripts were entered into Atlas.ti 5.0 (Muhr, 2005) for data management and analysis. A coding scheme was developed by the research team based on the interview questions, transcripts, and the frequency of appearance of major themes. The graduate student coded all of the transcripts.

• Step 3. Enhancing Credibility (Researcher)—The primary investigator of the current study cross coded the data for one tribe and compared codes with those identified by the graduate student. For responses that were coded differently, they reviewed the transcripts together and discussed the code assignments until agreement was achieved. The primary investigator reviewed the remaining coded data to determine interrater reliability. Both individuals took general notes while separately reviewing the transcripts.

• Step 4. Analysis—Analysis consisted of reviewing notes, the focus group facilitators’ written impressions of each interview, code reports from Atlas.ti, and entire transcripts to generate patterns and themes on alcohol use. Although there were some tribal differences, they were not significant enough to analyze themes with the data from each tribe separately.

• Step 5. Interpreting Findings—The findings were presented to the primary focus group facilitator, who was also the senior field supervisor, to confirm accuracy and refine interpretations.

• Step 6. Enhancing Credibility (Tribe)—In the last stage, a copy of the manuscript was submitted to tribal chairmen and administrators to review, provide feedback, and approve prior to publication, resulting in further validation of the results. One of the five tribes submitted feedback that was incorporated in the final paper.

Results

Participants openly shared opinions, observations, and personal experiences with alcohol, interpersonal violence, and related community problems. The length of responses varied by participant and topic and ranged from a few words to entire paragraphs. Participants used the term “alcohol” to refer to the beverage as well as different types of use, including the one which resulted in negative consequences for individuals, families, and communities. Major topics that emerged from the data included: common drinking patterns, contributing factors, consequences, barriers to community responses, and culturally appropriate intervention and prevention approaches.

Patterns of Alcohol Use

Heavy drinking was common in general across all of the five tribes. Individuals reported that tribal members drank until they were intoxicated, passed out, or ran out of money. There were mixed opinions about whether American Indians engaged in less severe patterns of alcohol consumption. Some believed that light sociable drinking was rare among American Indians. A Southwest man stated, “I would say there is no (Indian) social drinker. They take that booze and they drink it till they get drunk passed out … There is no such thing as a social drinker.” A woman from the same tribe suggested that some adults lacked the ability to control the total amount of alcohol consumed, “I think that’s the understanding that they go out to have just a social drink to begin with, but they can’t handle it.” In contrast, participants from the Northwest tribe observed light and occasional alcohol consumption, particularly among tribal chiefs and adults who were employed or spent most of the day away from home.

Across tribes, canned beer was the most common alcoholic beverage consumed by adults. Cases of canned beer and 40-ounce beers were popular because they were inexpensive compared with other alcoholic drinks. Home brews (home-made beer), which were consumed by past generations and during the prohibition period, were rarely consumed by current tribal members. Participants identified a range of drinking venues, including individual residences, casinos, bars, taverns, breweries, community events, parks, and other outdoor drinking areas. Outdoor drinking spots were often semiprivate and located near specific landmarks, such as bridges, lakes, rivers, and trees. Preferences for drinking settings appeared to vary by tribe and associated with cost and level of privacy. Participants from one Southwest tribe noted that few members drank at the casino because it was expensive. In contrast, individuals from the Northwest tribe identified the casino as one of the most popular drinking venues in their community. Participants across tribes reported that drinking at home was favored because it cost less compared with other settings. For the Northwest tribe, maintaining privacy was considered a primary motivator for drinking at home. One woman from the focus group said, “Another thing is that it’s a small little town, so a lot of the people drinking don’t go to the tavern. You know, they’ll drink at home, privately.”

Consuming alcohol at home did not mean that individuals were drinking alone. Participants from one Southwest tribe described “drinking sprees” in which adults went drinking from one house to another, usually ending up at an elder’s home and staying there until they were sober. Participants across tribes observed drinking as a social activity shared among groups of individuals. They reported alcohol consumption at house parties, community events, national and cultural holidays, and special occasions, including periods of crisis and mourning. A Northwest woman stated, “When people pass away, they get together and some people end up drinking.” Some believed that solitary drinking habits also existed in their communities. A Northern Plains woman felt that some members were “closet drinkers” who consumed alcohol alone and hid their drinking from others.

Contributing Factors

American Indian drinking was influenced by both negative and positive psychosocial and cultural factors. Some participants attributed excessive drinking to lack of opportunities and boredom on the reservation. Adolescents and unemployed adults consumed alcohol to pass spare time. A Northwest Indian commented on adolescent alcohol use and lack of community programs, “A lot of the experiment(ing) … extends from just not having some sort of guidance or activities, things for the youth to do … There’s just not enough to do that keeps them interested.” Similar observations were made of unemployed adults. One Southwest Indian said, “They don’t know what to do with themselves you know, so they just go and drink.” A few participants believed that individuals consumed alcohol in response to financial, social, and psychological problems. A Northern Plains man commented on the lack of healthy coping skills, “I don’t think they learned growing up, they never learned how to face their problems.” One Southwest woman suggested that chronic drunkenness was a strategy used to avoid personal responsibilities and additional disappointments:

Why don’t you want to sober up and face that. You know, maybe they don’t want to face … there’s multiple problems out there that they are facing …. Maybe they don’t want to stay sobered up to get a job. If they sober up, they figure they’ll have to work and they’ll have to start paying child support and then (they’ll) end up in jail (if they don’t pay it).

Risks for alcohol abuse were also presented in broader social and historical contexts. This was highlighted by a Southwest man, “Alcohol has been around for thousands of years, from generation to generation it affects people …. In most cases we were raised in that kind of environment. Our parents drink, make home brews, stuff like that … Alcohol is something that been with us like a common cold.” For some families, there was documented multigenerational transmission and established norms of alcohol use. Some children who observed parents drinking later experimented with alcohol and then developed their own alcohol problems in adulthood. One Southwest woman joked about children carrying on the “family tradition” and pointed to the saturation of alcohol in her community:

Every household is drunk, you know, and it’s-maybe not every household, but most of the people. You go out and you see everybody is drinking. And that’s what my kids used to say when they were kids, “How come everybody drinks and how come they’re doing this?” And when they grew up they were all drinking, too … it’s just all saturated.

In addition to being exposed to poor role models, adolescents also had easy access to alcohol. Participants shared childhood experiences of drinking their parent’s home brew. One Southwest man stated, “And one day, there was some (home brew) lying around there. ‘Hey, why don’t we try? I wonder how it is like.’ ‘Do you wanna try?’We did take it, more and more and later on in time we didn’t know what we were doing.” Many noted that the availability of alcohol remained a risk factor for the current generation of youth. Alcoholic beverages were sometimes left out in the open or made available after adults had passed out from intoxication. Some children stole alcohol from their parents. Others found adults to buy it for them, as one Northwest participant described:

It’ pretty prevalent here, down at 7–11 … Kids will stand on out there, and wait till somebody come in and somebody will buy them booze and bring it out. There’s no real clear standard on that.

Participants across tribes attributed contemporary alcohol problems to continued efforts by Whites to disempower American Indians. They spoke of the negative impact of the drunken Indian stereotype on contemporary Native identity and provided several examples where the stereotype was reinforced. A man from the Northwest tribe noted the irony of a poster stating “Native Pride” located next to the beer coolers in a local pizza parlor. A Southwest man commented on recent news media about an American Indian golfer who was arrested for drunk driving, “Right away they (non-Indians) said, ‘Hey, just another drunk Indian.’ You know, that’s all they said because that image was already created and that’s all they saw.” A few participants felt that promotion of the stereotype of the drunken Indian had gradually led some American Indians to accept it and behave accordingly. One Southwest man stated:

And so they create this image of a drunk Indian and all these years that’s all the image of an Indian has been to the outside world. And so what has happened is that they’ve tried to shape, take us and reshape us and remold us from being who we really are … into the image of being a drunken Indian and eventually as we continued to go through the centuries here, we started to accept that. We accepted that image of being a drunken Indian.

Contrary to these views, participants across tribes also reported favorable aspects of American Indian drinking. Participants identified positive expectancies of the effects of alcohol, including improved mood, relaxation, sociability, and communication. Participants from one Southwest tribe agreed that some parents consumed alcohol to “loosen up and to talk.” A woman commented, “My father was very quiet, spoke very few words, but when he wanted to talk to us he drank and he could easily speak.” Women from a different Southwest tribe also reported positive outcomes of drinking. One woman said, “I see that they’re real happy or jolly or they talk and everything, and I was always quiet. Then I keep thinking, ‘Oh I should do that (drink alcohol). Maybe I’ll be happy too, like them.’ ” A second woman noted, “People just don’t know how to socialize without drinking.” She suggested that alcohol use was a normative behavior for initiating romantic relationships:

They think they have to drink in order to have fun or have a relationship and that’s probably how all relations get started, you know. They meet at a bar. They meet at somewhere. They’re drinking together, but later on they don’t drink no more. Everybody here is like that. They all met when they were drinking.

For some participants, excessive drinking was associated with courage and masculinity. Two tribes described getting drunk as a right of passage to becoming a man. This was evident from such comments as, “Some say you’re not a man until you get drunk” and “Twelve pack then you’re really feeling macho. Then you say, ‘I’m a man.’ ”

Alcohol-Related Consequences

Participants acknowledged the diversity and severity of alcohol-related consequences experienced by individuals, families, and whole communities. Their awareness was attributed to their own drinking experiences and those observed among others. Participants across tribes spoke of the effects of alcohol abuse on diabetes-related health complications and amputations. They also mentioned amputations, injuries, and fatalities due to alcohol-involved car accidents. One Southwest participant commented on the disabled drinkers in his community, “You still see them on the roads with their wheelchairs and a beer … they are so addicted that they still drink even though they’re handicapped.” Other health impacts included liver disease, cancer, HIV, unwanted pregnancies, Fetal Alcohol Syndrome, injuries from fights, and general declines in physical appearance and personal hygiene. Few participants described psychological outcomes. One of the few comments was from a Southwest man who reported that he felt worthless, ashamed, and suicidal after he lost his hand in an alcohol-involved accident. He subsequently engaged in heavy drinking. A man from a different Southwest tribe observed that individuals with alcohol problems lacked “brainpower—ability to think straight.”

Participants described employment, financial, and legal difficulties brought on by alcohol misuse. Some individuals dropped out of high school and others lost work because of alcohol-related absences or drinking on the job. For the Northern Plains tribe, employers were made aware of employees’ alcohol problems as a result of newsletter that published incidents of public intoxication and alcohol-involved accidents. Participants also perceived economic hardships due to borrowing money, gambling, and being robbed when intoxicated. Some individuals with alcohol problems were dependent on General Assistance and social services. Identified alcohol-related legal problems included public intoxication, driving while intoxicated (DWI)/driving under the influence (DUI), traffic accidents, theft, trespassing, vandalism, and providing alcohol to minors. The rules and regulations for incarceration varied from tribe to tribe. The Northern Plains tribe incarcerated individuals for 24 hr when arrested for a DWI/DUI.

Participants from all five tribes recognized the negative social consequences of problem drinking. In response to questions about violence, participants indicated that alcohol-related homicides were rare. Nonfatal forms of aggression, including physical assaults, domestic violence, elder abuse, and child maltreatment, were more common. Participants observed drunken fights and physical attacks against individuals who passed out from drinking. Alcohol-involved intimate partner violence included physical and verbal abuse against women and was documented across multiple generations. One Southwest man recalled childhood memories of watching men getting drunk on Sunday afternoons and beating up their wives. A woman from the same tribe indicated that there was a history of silence about marital abuse:

And that was something (physical abuse) that we didn’t talk about … you stayed with whoever you were with no matter what. That was something that you did back then whether your mom was abused by your father or so forth. That was just kept within the home. You were expected to stay with that family … they always said ‘once you’re married, you made your bed, you stay in it.’

Elders were also vulnerable targets of alcohol-related aggression. Participants voiced concerns about elders who lived with their adult children who returned home from jail or substance abuse treatment. They perceived such households to be at increased risk for family conflict and violence. Members from one Southwest tribe described “squatters” as adults who forced their way into elders’ homes to steal, rob money, or obtain alcohol. “Squatters” typically stayed in an elder’s home until they became sober or were thrown out. One participant noted, however, that it was difficult for elders to throw them out, “The elders can’t physically throw them out. They can yell all they can.”

Adult alcohol abuse was also associated with child abuse and neglect. Women from different tribes reported abusing alcohol while raising their children. A Southwest woman stated:

I became addicted to it for many years and when I was raising my kids I was drinking and abusing and somehow I was still responsible for my children and I raised them and … I have 8 children, and four of them … now they use alcohol themselves and they abuse themselves and they have children and they abuse them.

Many participants voiced concerns that parents with alcohol problems were uninvolved in their children’s lives and did not provide emotional support or assistance with schoolwork and other activities. In some households, there was a reversal of roles between parents and children. One Northwest participant stated, “Those roles get switched around and shoved on these kids and they don’t have their childhood … they get … forced into those responsibilities at a young age. I’m sure it has something to do with some future problems.” Children of parents with alcohol problems were also at risk of being separated from their families. Some were separated when their parents were incarcerated or entered substance abuse treatment. Some children were removed from their homes because of evidence of maltreatment.

Barriers to Community Responses

Participants from all five tribes spoke of community-level barriers to reducing problem drinking. They indicated that law enforcement was ineffective. Complaints about the police included failures to respond to requests for help, enforce laws, and properly complete reports. A Southwest man stated, “Even if you call them, you’re lucky if they come out at all.” A Northern Plains man noted that historically police made arrests for public intoxication, but more recently they escorted individuals home instead. Police also appeared to be negligent about enforcing underage drinking laws. A Northwest participant reported:

The problem with them (sheriff) taking action with MIPs (minor in possession of alcohol) is that if they can’t find parents home, which is usually the case, and there’s no room over the juvie hall, the kid has to ride in the car with them, sometimes all night long while they try to find some place to put them. So what they do is they turn their head with MIPs. They’ll try to do something other than arrest them for MIP.

Incarceration for alcohol-related offenses was rare, even in extreme cases. One Southwest woman reported that individuals who killed someone while driving drunk were not incarcerated. Participants from one tribe attributed the lack of law enforcement to insufficient funds and few police officers on the reservation.

Across tribes, participants recognized that community members played a passive role in the continuation of alcohol problems. They observed that individuals tended to avoid reporting problems and requesting assistance from police because they did not want their spouses and children to get into trouble or go to jail. Pressing charges for alcohol-involved partner violence was rare and police typically only became involved when someone was hospitalized with injuries. One Southwest woman shared negative reactions she received when she made reports to the police:

I think it’s that no one ever calls the police … I used to call the police every time that something like that happened and I was always put down for it and I don’t see no one calling the police so I was the one that had the problem. But no one reports on their family members.

The lack of community involvement seemed to be influenced by cultural values of family cohesion and loyalty. The importance of maintaining cohesion was evident in a Southwest woman’s response:

We have parents abused, and grandmother and grandfather abuse here but we never take it to court because to me, it seems like the Indian families are very close. They don’t like to talk against their grandchildren or their own children sometimes. And it just seems to increase the abuse.

Another woman from the same tribe openly admitted that she remained loyal to her family even though they had beaten and abused her. She said, “I’ll do anything for them and that’s just the way I am.” The strength of these values seemed to be shaped by historical and environmental factors. Participants reported sensitivity to the history of “divide and conquer” tactics used to fragment and destroy American Indian tribes. Current threats of separation included long-distance placements for treatment or incarceration because the services and facilities were unavailable on the reservations. Participants from two tribes were aware; however, that unresolved alcohol problems led to further community disintegration. A Northwest man said:

Also goes back to one of the oldest things of conquering a people … people that are out drinking and then you have those people that aren’t okay with it, so it divides them like that … People stay away from people cause they’re drinking … it starts separating the families and the people.

Another barrier to community responsiveness was the protection of individual privacy. One Southwest participant stated, “They’re afraid, you know, if I go to a AA (Alcoholics Anonymous) meeting and if I say how I really felt, then another person’s going to take that out into the community and then the community’s going to find out about it and then … everybody’s to know.” A participant from the Northwest tribe pointed out that the community was uncertain when to respect individual privacy and when to intervene. Some attributed contemporary alcohol problems to a lack of communication in the community and families not working together. A woman from a Southwest tribe observed, “Sometimes we want to have workshops with parents or people in the community and when they start talking about alcohol and stuff like that, they don’t want to talk about it (alcohol problems).”

Intervention and Prevention Approaches

Participants acknowledged the challenges their communities faced in addressing alcohol use. A Southwest man stated, “We are gonna have a big job ahead of us you know to deal with this (alcohol use).” Frequent use of humor during the interviews did not diminish the seriousness of their concerns. One Southwest woman suggested that laughing, making jokes, and poking fun at drunk individuals served as a coping mechanism:

We laugh about it (everybody drinks), we think it’s funny and he just said that somebody thought it was funny. I don’t know who it was, but it’s not a joke, you know. Everybody coming, funny and laughing and that’s the only way and maybe that’s what we call making it through.

Participants offered different perspectives and recommendations for alcohol intervention and prevention approaches. Many agreed that the initiation and maintenance of abstinence was a difficult process. They spoke of individuals who repeatedly participated in alcohol treatment without successfully quitting drinking. Participants across tribes felt that alcohol cessation was primarily dependent on an individual’s motivation to quit. Quitting was viewed as a personal decision and achievable with self-determination and courage. The role of individual responsibility on alcohol cessation was evident in the quit experiences of two participants from two different tribes. A Southwest man commented, “I’m the only person who made that decision for myself. I said, ‘Today ok, I’ll stop drinking.’ So I did. Nothing helped me but I helped myself. That’s the way in human nature. It’s up to each one of us.” The same person reported that another man was unwilling to provide assistance because he shared the same views on cessation:

I was working at a store at that time and there was an older guy working there and I’d ask him, “How can I get away from this booze? How can I stop it? Can you help me?” He turned around and said, “No, I can’t help you. I can’t tell you how to do it. I’m gonna have to tell you to make your own decision, make up your mind to get away from it. Just fill your mind up to the point to say no to it.”

A man from a different Southwest tribe also stated that quitting was a personal decision, “I’m sick, that’s why I’m drinking, but it’s within me. If I make that decision to quit, that’s up to me and nobody can tell me, ‘You’d better quit.’ I won’t listen to that.” Although he acknowledged that his wife helped him achieve abstinence, his philosophy on alcohol cessation centered on self-reliance:

We have that power to change that image (drunken Indian). It’s up to us individually … Do it from the heart and you can change yourself. Everybody can tell you how to live. Everybody will tell you that drinking is bad for you, but unless you accept it for yourself and place it in your heart, that I want to be this good person, you will never change … You have to start with yourself and that image of a drunken Indian was started by the White man and all we do is fulfill that image throughout the years.

In contrast to the views on alcohol cessation, participants emphasized the important role of community involvement in alcohol prevention strategies. Some expressed a sense of urgency in intervening with youth before more serious consequences occurred. A Southwest woman stated, “I would hope that somehow some of us can get help around here on the reservation for the young kids. Before it’s too late, because there’s so many of them that need help.” Recommendations for alcohol prevention focused on leadership, cultural education, parent training, and community-based youth programs. Participants across tribes believed that strong leadership was necessary for health promotion in their communities. One Southwest woman recalled a period of time when the tribal chairman, council members, and health department were committed to reducing alcohol consumption and improving healthy behaviors among tribal members. The priorities, however, had changed over time and recent efforts were “watered down.” Others from the same tribe commented that the tribe was losing sovereignty and jurisdiction over its members. A man from a different Southwest tribe reflected on the past when clanship was a prominent social structure and the head person was responsible for directing and teaching his people. He felt that contemporary problems were due to the loss of the clanship structure and a breakdown of the traditional ways of life.

Participants across tribes identified the need for increased education of Native history, language, practices, and values. Some participants perceived traditional sweats and other traditional healing practices as effective alcohol prevention approaches. A Northern Plains woman stated, “I feel that it helps a lot being connected. Because I went to my first sweat 17 years ago and ever since then I’ve been dry, so I know it helps.” Discussion about the revitalization of traditional practices included concerns about the selection and accuracy of such practices. Participants from the Northwest tribe and one of the Southwest tribes reported that some contemporary practices were adopted from other tribes and not their own. An individual from a different Southwest tribe indicated that some traditional practices were not being performed correctly and some traditional stories were lost when individuals who knew them had died. Many felt that parents were responsible for educating children about tribal culture; however, they acknowledged that some parents lacked the necessary relationship and parenting skills. Identified areas for parent training included communication skills, disciplinary practices, manners, and respect. A Southwest man suggested that the reintroduction of traditional practices required the rejection of Anglo parenting styles:

I think it’s about time to reintroduce our language, our traditional values, family values to our children instead of our children controlling the parents. The parents should control the children because it’s not our lifestyle. The Anglo’s lifestyle is not ours … we should hang on to who we are.

Individuals from all five tribes agreed that more community-based programs were needed in general. They recommended alcohol education for adults and youth to improve communication and decision-making about alcohol consumption. A Southwest man stated, “Educate them you know, in some way they will too make a right choice, a wise decision, to live their life. I think that will help too you know. We need some kind of program protecting this in our community where we can encourage any new generation.” Some spoke of the benefits of established youth programs including adventure-based programs, leadership programs, sports, special interest clubs, after-school and summer activities, and employment opportunities. The Northwest Plains tribe had a program that required youth to sign written contracts indicating that they would not use alcohol and drugs or get in trouble with the law. Participants across tribes voiced concerns that resources should be directed to all individuals and not solely those who are already exhibiting problem behaviors. A Northwest woman said, “A lot of time the kids that have alcohol problems. They get all the attention in the community. And the good kids that never get in any trouble don’t get to go anywhere.” Similarly, a Southwest woman noted, “The only time we get little provisions is when you get in jail. They say, ‘Go to wellness program. Go to this. Go to that.’ ”

Discussion

This descriptive study reveals the complexity of American Indian drinking as perceived by community members from five geographically diverse tribes. There was general agreement across the focus groups regarding the pervasiveness of heavy drinking and severity of alcohol problems among reservation communities. Participants consistently spoke of the public and social contexts of alcohol consumption, highlighting that tribal members of all ages were likely to be exposed to alcohol-related risk factors and consequences. Different opinions about the meanings of alcohol and culturally appropriate intervention strategies, however, revealed three dilemmas that may contribute to community ambivalence and barriers to reducing American Indian problem drinking. Ambivalence toward alcohol has been documented previously in this population, but only among individual urban American Indian drinkers (Spicer, 1997).

First Dilemma

One dilemma that emerged from the current findings was that alcohol was perceived to both weaken and strengthen American Indian life. This study showed that most participants held negative opinions of alcohol. Consistent with viewpoints held by American Indian prophets (Duran, 1996), some individuals believed that alcohol use represented the assimilation of colonial values and practices. One Southwest man felt that American Indians failed to reject the drunken Indian stereotype and use such empowerment statements as, “I’m not that (drunken Indian). I am a human being and I was here before them and I know a different life than them, which is maybe more supreme than theirs.” Problem drinking was associated with reduced observance and transmission of traditional values and practices to younger generations because of ineffective parenting and poor role models. Many participants felt that the lack of adult involvement and alcohol use were damaging to the general development of Native children and adolescents. Similar findings were documented by a community-based study on youth wellness (Teufel-Shone, Siyuja, Watahomigie, and Irwin, 2006). Adults from a Southwest tribe were described as modeling unhealthy behaviors with the lack of community and parent involvement and substance abuse.

In contrast, a few participants viewed alcohol use as a part of Native life and identity. Some associated Indian drinking with values of courage and masculinity. Members from two tribes described drinking to intoxication as a right of passage to manhood. Some individuals expressed pride in the American Indian’s tolerance for alcohol and drew strength from their own alcohol experiences.

Participants’ observations provided evidence of a developmental trajectory of American Indian alcohol use starting with experimentation in adolescence, leading to heavy drinking in early adulthood, and ending with natural recovery in later adulthood. Consistent with previous studies (Spicer, 2001), a few described cultural and spiritual transformations as a result of quitting drinking. Normalizing alcohol use also seemed to build community unity and form resistance to “Whiteman’s” views that Native drinking is pathological. Participants recognized that colonists used alcohol to control and destroy American Indian communities. Some appeared to reclaim ownership of Native drinking and reject perceived actions by Whites to further control American Indian alcohol behaviors and public perceptions of them. These views were consistent with previous calls for justice against the promotion of colonial ideas that contemporary Indian drinking is deviant (Quintero, 2001).

Second Dilemma

A second contradiction revealed in this study was that alcohol use promoted social connectedness and also fragmented Native communities. Participants described drinking as a shared activity, frequently occurring in social settings. The interviews showed that some participants held positive expectations of the effects of alcohol on sociability and relationship development. Similar positive aspects of American Indian alcohol use have been reported among urban drinkers (Spicer, 1997). Alcohol consumption also seemed to enhance cohesion in that many individuals responded to alcohol problems by becoming more protective of their families and communities and committed to keeping them intact. This contributed to the underutilization of law enforcement and treatment services that threatened to physically separate individuals from their loved ones. In addition, family members, particularly elders, often took individuals into their homes after they returned from jail or completed alcohol treatment. Participants reported willingness to forgive their family members for their problems. Strong family loyalty seemed to be influenced, in part, by beliefs that individual behaviors were shaped by experiences of historical, social, and economic oppression.

Heavy drinking, however, also contributed to conflict and social fragmentation of Native families and communities, as has been previously documented (Spicer, 1997). A Northwest man believed that alcohol recreated a “divide and conquer” phenomenon in his community with conflicts between individuals who drank and those who did not. Those who felt alcohol use was a problem stayed away from those who drank. Other sources of destruction included alcohol-related assault, child abuse and neglect, intimate partner violence, and elder abuse. Many attributed child maltreatment and family dysfunction to parental alcohol use. Family violence was reported among households where parents allowed their adult children to live and drink in their homes. Participants stated that most parents and elders would rather fight with their adult children than force them to be homeless or send them to jail. Communities also suffered devastating losses due to alcohol-related injuries, disabilities, deaths, and legal problems. As one Southwest man said: “I think it’s when our young ones get in a car wreck. I think that’s one of the main things too that affects so many families, due to alcohol.”

Third Dilemma

The third dilemma consisted of two contrasting dimensions: individual versus community and alcohol intervention versus prevention. Whereas participants believed in the importance of noninterference and personal autonomy in alcohol cessation strategies, they emphasized community engagement and collectivism for primary prevention. Values in individual autonomy have been documented in many Native cultures (LaFromboise and Low, 1998). In this study, individuals who had quit drinking, most of whom were men, indicated that self-determination was the key factor in initiating quit attempts. They reported that Alcoholics Anonymous and social support helped reduce their alcohol consumption, but not quit drinking. Participants’ value on self-reliance seemed to be grounded in spiritual beliefs about the relationship between an individual and human nature. They were consistent with views that an individual’s life is dependent on the Creator and the spirit world (Gone, 2007).

In contrast, participants across tribes agreed that the community needed to play an active role in prevention, particularly among Native children and adolescents. Tribal communities were responsible for creating environments that protected and nurtured the younger generations of members. Participants identified several strategies for improving community engagement in alcohol prevention. They included strong leadership and role models, revitalization of traditional values and practices, and community-based youth programs. In general, participants displayed greater interest and commitment to alcohol prevention compared with intervention during the focus group interviews. This finding was unexpected given that some participants worked in health care and administration. It provided further evidence of contrasting values in privacy and self-reliance once alcohol problems have already occurred versus open communication and community involvement before they have started. There seemed to be a disconnection between effective alcohol treatment and prevention. There was no discussion about how passive acceptance of natural recovery may contribute to constant levels of exposure of alcohol risk factors among children and youth, perpetrating the multigenerational cycles of problem drinking and violence.

Limitations

Limitations of this study included small sample size, few demographic data, data combined across tribes, and researcher bias. The viewpoints of only a few adults were obtained from each tribe. Because purposeful sampling was conducted, the focus group findings may not have represented the thoughts and experiences of the entire tribal communities from which the individuals came from (Sim, 1998). Purposeful sampling was used because of the focus on community perspectives that were rich in depth and detail (Patton, 1999). The lack of demographic data collected from the participants also limited the generalizability of the current findings. The main aim of selection was to obtain a cross representation of participants with diverse interactions and experiences working with each tribe. This was achieved for all the focus groups, as documented in Table 1. A third limitation was that the data from five tribes from three different U.S. regions (Northern Plains, Northwest, and Southwest) were combined and analyzed together. This approach may have underestimated tribal-specific patterns and themes; however, the approach was implemented after preliminary analyses revealed few tribal differences. Another limitation was that the facilitators were American Indian, but not from the same tribes as those participating in the study. It is possible that their interpersonal skills and attributes may have influenced individuals’ responses and interactions with other focus group participants (Sim, 1998). Several participants, however, openly disclosed personal experiences with alcohol problems and violence victimization. Also, because the qualitative analyses were conducted by non-Native researchers, the interpretations may have been subjected to biases (Vogt, King, and King, 2004). To address this limitation, standard methods for improving the validity of the qualitative analysis were implemented, including triangulation with two analysts and review of findings by the primary focus group facilitator who is an American Indian (Patton, 1999).

Implications for Practice

The current findings suggest that dilemmas may exist in Indian country due to positive and negative factors associated with alcohol use. Different sides of the dilemmas, however, appear to be similarly influenced by cultural values and desire for strong Native identity and unity. Therefore, tribes may benefit from a value-driven approach to mobilize their local communities to prevent alcohol use. Value-based models in industrial management have been used by companies to successfully attract, retain, and maximize the strengths of employees (O’Reilly and Pfeffer, 2000). A possible application for mobilizing Native communities may include the following: (1) agreement of priority areas for reducing alcohol use, (2) identification of core cultural values, (3) alignment and consistency between values and alcohol prevention and intervention strategies and policies, and (4) strong tribal leadership that models core values and promotes environments that emphasize collective responsibility and facilitate changes in alcohol norms and expectancies (O’Reilly and Pfeffer, 2000).

Participants’ responses shed light on how tribes may align cultural values with alcohol intervention strategies. For example, recognition of Native pride may be achieved by addressing tribal-specific historical and multigenerational contexts of alcohol use and impacts of colonial stereotypes and dominance over contemporary Native drinking. Values in individual autonomy and self-reliance may be incorporated in abstinence-focused treatment models, the primary intervention ideology used by Indian alcohol programs (Abbott, 1998; May and Moran, 1995). Although some American Indians may be hesitant to become directly involved in the alcohol cessation behaviors and sobriety of loved ones, emphasis on values of family and tribal cohesion may encourage greater involvement in community-wide efforts. Such actions may reduce the isolation of individuals with drinking problems and support better decision making about alcohol use and other health behaviors. Native American values may also serve as the foundation for multilevel community-based prevention strategies that address interactions between individual, social, cultural, and environmental influences. Socioecological approaches, tailored for individual tribes, may effectively reduce the normalization of Indian drinking (Giesbrecht, 2007). It is noteworthy, however, that value-driven and socioecological approaches may conflict with current health policies that require the adoption of evidence-based interventions in Indian country, many of which have a more narrow focus.

Conclusion

The present findings need to be generalized with additional qualitative and quantitative studies. Alcohol researchers recommend combining qualitative and quantitative methods to validate qualitative findings and provide richer interpretations of quantitative findings (Nygaard, Waiters, Grube, and Keefe, 2003). Mixed methods research is particularly valuable for understanding of the role of culture in Indian drinking (Huebner, 2007). Future qualitative inquiry should expand on the nature of dilemmas and contradictions regarding alcohol use among Native communities. More research is needed on socioecological factors that contribute to community ambivalence and barriers to effective responses to problem drinking among individual tribes. Continued study in this area may inform the development of health policies and community-based prevention programs that more accurately address the continuum of function and dysfunction along which contemporary Native drinking exists.

Glossary

Colonialism

The effects of European domination that resulted in the destruction of Native life and culture and resettlement on remote lands

Culturally appropriate intervention

Also referred to as culturally relevant and culturally sensitive intervention. Treatment strategies that are made relevant to the unique demographic and cultural distinctions (i.e., norms, values, geography, language, traditions, and practices) of individual tribes

Divide and conquer tactic

A military strategy used by European colonists to conquer American Indian tribes by separating and turning them against each other

Drunken Indian stereotype

A judgment that all American Indians are alcoholics and are uncivilized, unruly, and violent

Biographies

Nicole P. Yuan, Ph.D., is an assistant professor in the Mel and Enid Zuckerman College of Public Health at the University of Arizona. She is a recipient of a Mentored Patient-Oriented Research Career Development Award funded by the National Institute on Alcohol Abuse and Alcoholism. She is also principal investigator of a sexual violence prevention and education program supported by the Arizona Department of Health Services with pass through funds from the Centers for Disease Control and Prevention. Her research interests include alcohol abuse, interpersonal violence, American Indian health, and community-based participatory research methods.

Emery R. Eaves, M.A., is a research specialist in the Department of Family and Community Medicine at the University of Arizona. She specializes in collection and analysis of qualitative and ethnographic data from a medical anthropological perspective. Her interests include complementary and alternative health care and treatment approaches to the treatment of chronic social and individual health issues.

Mary P. Koss, Ph.D., is a Regents’ Professor in the Mel and Enid Zuckerman Arizona College of Public Health at the University of Arizona. She served on the National Academy of Sciences Panel on Violence Against Women, is the sexual violence coordinator of the CDC-funded national online resource on research on violence against women, www.VAWnet.org, and currently a member of the Coordinating Committee of the Sexual Violence Research Initiative based in Johannesburg, South Africa. She is coediting for the American Psychological Association a two book series that will appear in 2010, Violence against women and children: Consensus, critical analysis, and emerging directions including maltreatment, sexual and physical violence. She was the principal investigator of the Ten Tribes Study.

Mona Polacca, M.S.W., has over 20 years of practical experience working on health and social issues affecting Native American tribes throughout the nation. She has been a featured conference speaker both nationally and internationally, themes focusing on indigenous peoples human rights, aging, mental health, addiction, and violence. In December 2008, she had the honor of being the representative of the Indigenous Peoples on a panel of world religious leaders who drafted and signed a statement “Faith in Human Rights,” in commemoration of the 60th Year of the United Nations Universal Declaration of Human Rights. She served as the field team leader on the Ten Tribes Study.

Keith V. Bletzer, Ph.D., M.P.H., is an adjunct faculty in the School of Human Evolution and Social Change at Arizona State University. He has conducted extended fieldwork in Central America, and worked on field projects in four regions of the United States. He was a recent recipient of a National Research Service Award through Arizona State University and has received intermittent funding for field research. His substantive interests include medical anthropology, social adversity in resource-poor communities, and narrative analysis.

David Goldman, M.D., has been chief of the Laboratory of Neurogenetics at the National Institute on Alcohol Abuse and Alcoholism since 1991. Throughout his career, he has focused on the identification of genetic factors responsible for inherited differences in behavior, and he has authored over 300 papers. His laboratory is currently exploring the genetics of alcoholism and related psychiatric diseases, and is well known for his work identifying effects of functional genetic variants on intermediate phenotypes for complex behavioral diseases.