Utilizing Drumming for American Indians/Alaska Natives with Substance Use Disorders: A Focus Group Study

Abstract

Background

Drumming has been utilized among American Indian/Alaska Native (AI/AN) tribes for centuries to promote healing and self-expression. Drum-Assisted Recovery Therapy for Native Americans (DARTNA), currently under development, is a substance abuse treatment utilizing drumming as a core component.

Objectives

Focus groups were conducted to assist in the development of the DARTNA protocol. Feedback obtained from these focus groups will inform a subsequent pretest of DARTNA and an empirical study analyzing its effectiveness.

Methods

Three focus groups were conducted among AIs/ANs with substance use disorders (n = 6), substance abuse treatment providers (n = 8), and a community advisory board (n = 4) to solicit feedback prior to a pretest of the DARTNA protocol.

Results

Overall, participants indicated that DARTNA could be beneficial for AIs/ANs with substance use disorders. Four overarching conceptual themes emerged across the focus groups: (1) benefits of drumming, (2) importance of a culture-based focus, (3) addressing gender roles in drumming activities, and (4) providing a foundation of common AI/AN traditions.

Conclusions

The DARTNA protocol is a potentially beneficial and culturally appropriate substance abuse treatment strategy for AIs/ANs. In order to optimize the potential benefits of a substance abuse treatment protocol utilizing drumming for AIs/ANs, adequate attention to tribal diversity and gender roles is needed. Scientific

Significance

Due to the shortage of substance abuse treatments utilizing traditional healing activities for AIs/ANs, including drumming, results from this study provide an opportunity to develop an intervention that may meet the unique treatment needs of AIs/ANs.

INTRODUCTION

Substance abuse among American Indians/Alaska Natives (AIs/ANs) has been persistently high throughout US history (1,2) and continues to be a significant public health issue (3). Based on data retrieved from 2004 to 2008 from the National Survey on Drug Use and Health (NSDUH), rates of past-month binge alcohol use and illicit drug use for adults were higher among AIs/ANs than the US national averages (30.6% vs. 24.5% and 11.2% vs. 7.9%, respectively). These persistently high rates of substance abuse among AIs/ANs may suggest that currently available substance abuse treatments, that is, evidenced-based treatments (EBTs), do not fully address the unique, culturally relevant treatment needs of AIs/ANs. Utilization of indigenous healing methods (i.e., drumming, dancing, bead making, sage preparation, basket making) has long been proposed by AI/AN community leaders as showing promise in terms of decreasing the burden of substance abuse in AI/AN communities (4,5). Furthermore, in two recent large community-based projects addressing mental health and substance abuse needs among AIs/ANs, AI/AN community members consistently expressed the need for the provision of traditional-based treatments for AIs/ANs with substance abuse problems (6,7).

Although there is significant interest within AI/AN communities to provide traditional-based treatments for AIs/ANs with substance abuse problems, opportunities to receive these services within the clinical setting are often limited. One reason is due to the reimbursement challenges clinics experience for these services. In order to facilitate changes that could allow for the reimbursement of traditional-based services, more studies are needed focusing on the development and analysis of traditional-based treatments. Studies demonstrating the effectiveness of traditional-based treatments may assist toward facilitating policy changes that could ultimately allow for the provision and reimbursement of traditional-based treatments.

Drumming is an AI/AN traditional-based activity that has been utilized for many centuries to promote healing and self-expression (8). Drumming’s similarities with cognitive behavior therapy (CBT) have been recognized due to its targeting of deficits and needs and assisting patients to increase their awareness of feelings, emotions, thoughts, and coping styles as well as to practice changing their behaviors (9). Drumming may also have biological effects that may mitigate various behaviors. For example, rhythmic auditory stimuli (including drumming, singing, and chanting) may generate auditory drive leading to increased alpha and theta wave production, which may contribute to a desired meditative state (10–13).

The purpose of this study is to obtain input with regard to a drum therapy treatment program for AIs/ANs with substance use disorders, “Drum-Assisted Recovery Therapy for Native Americans (DARTNA),” in order to assist toward the final development of this treatment program. Focus groups were conducted among (1) AIs/ANs with histories of substance use disorders, (2) providers who serve AIs/ANs, and (3) the DARTNA community advisory board (CAB).

METHODS

Drum-Assisted Recovery Therapy for Native Americans (DARTNA)

DARTNA is a culturally based drum behavioral therapy that is currently being developed for AIs/ANs with substance use disorders. Since drumming traditions may vary among indigenous tribes worldwide (over 3000 tribes worldwide), providing a treatment model that can accommodate diverse tribal traditions is essential. While DARTNA incorporates drumming as its focus of treatment, it also draws upon elements from other treatment programs that are congruent with indigenous-based healing concepts. These treatments include the 12-step principles, talking circles (AI processing group), and reference to the Medicine Wheel and 12 Steps program developed by Don Coyhis and White Bison, Inc (14). The Northern Plains Medicine Wheel is widely utilized as a conceptual framework and integrative approach to health and wellness for AIs/ANs (15). Many AIs/ANs have also found that the 12-step emphasis on a spiritual foundation for sobriety inspired them to learn more about their local cultural practices (16–18).

The preliminary DARTNA treatment protocol consists of a 3 hour treatment session, scheduled 2 times weekly over 12 weeks (Table 1). DARTNA is provided by a cultural/drumming teacher and a substance abuse counselor. DARTNA respectfully utilizes the approach used within the Medicine Wheel and 12 Steps program by incorporating the 12 steps within the Medicine Wheel (14). However, the DARTNA treatment protocol incorporates drumming activities within the corresponding quadrants of the Medicine Wheel (Figure 1). These drumming activities are intended to reflect the tribal traditions of the community where the treatment is being provided. During the first session, participants participate in making either their own personal drum or a group drum that they will use during their treatment. This activity offers participants a culturally relevant educational endeavor that may enhance their cultural identity and engage them in treatment.

TABLE 1.

Drum-Assisted Recovery Therapy for Native Americans (DARTNA) treatment session format.

DARTNA treatment session format

Monday/Friday*

First hour: Drumming education, overview of AA/NA 12 steps and Medicine Wheel concepts, reference to the Medicine Wheel and the 12 Steps Program from White Bison, Inc.

Second hour: Drumming

Third hour: Talking circle/Processing group

^*Note: The protocol was changed to twice/weekly, after incorporation of suggestions obtained from focus groups.

FIGURE 1.

Preliminary Drum-Assisted Recovery Therapy for Native Americans (DARTNA) Medicine Wheel (respectfully acknowledge White Bison, Inc. for conceptual approach).

Study Site

Los Angeles, California, is the study location selected for this study. Two-thirds of AIs/ANs reside in urban areas (19). Conducting this study in Los Angeles offers an opportunity to develop DARTNA in an urban geographic area that also comprises a diverse tribal population, thus assisting in the generalizability of DARTNA to other indigenous communities.

Design

Three focus groups were conducted among (1) substance abuse treatment providers serving AIs/ANs (2), AIs/ANs with current or past substance use disorders, and (3) the DARTNA CAB. The purpose of the focus groups was to solicit feedback and suggestions on the preliminary DARTNA treatment protocol, and to help guide the researchers in terms of the cultural appropriateness of the DARTNA treatment approach. The focus groups were conducted during October and November of 2010.

Substance abuse treatment providers and AIs/ANs with current or past substance use disorders were recruited via flyers in three clinics serving AI/AN patients and in one large AI/AN community center in Los Angeles. Providers included certified alcohol and drug counselors, social workers, counselors, psychologists, or physicians with experience providing substance abuse services to AIs/ANs. Inclusion criteria for the AIs/ANs with current or past substance use disorders consisted of meeting Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (20) criteria for current or past alcohol or drug abuse or dependence, self-identifying as having at least one-quarter AI/AN heritage, being at least 18 years old, and reporting no psychiatric conditions that would preclude focus group participation. Eight AIs/ANs responded, all of whom met the eligibility criteria.

Four cultural leaders of AI/AN descent within the Los Angeles area were invited to serve on the CAB. These individuals were well-respected AI/AN drummers, elders, and/or community leaders who have substantial knowledge and/or expertise regarding AI/AN drumming traditions, and were recognized by the AI/AN community for their undertanding of substance abuse issues among AIs/ANs.

Participants

Table 2 shows the demographic characteristics of the focus group participants. Females constituted the majority of substance abuse treatment providers (62.5%), whereas among AIs/ANs with substance use disorders, females were less represented (33.3%). There were an equal number of females and males on the CAB. Among the three focus groups, the average age ranged from 45.2 to 51.8 years. All participants in the three focus groups reported AI/AN as their ethnicity.

TABLE 2.

Substance abuse provider, community advisory board (CAB) member, and substance abuse patient characteristics.

Characteristics	Substance abuse treatment providers (n ¼ 8) no. (%)	Community advisory board members (n ¼ 4) no. (%)	AI/AN clients with past or current substance use disorders (n ¼ 6) no. (%)
Gender
Male no. (%)	3/8 (37.5)	2/4 (50%)	4/6 (66.7%)
Female no. (%)	5/8 (62.5%)	2/4 (50%)	2/6 (33.3%)
Average age in years (range)	45.2 (27–63)	51.8 (45–64)	45.2 (28–55)
American Indian/Alaska Native ethnicity no. (%)	8/8 (100%)	4/4 (100%)	6/6 (100%)
Bachelor’s degree or above no. (%)	6/8 (75%)	2/4 (50%)	0/6 (0%)
Average number of years in substance abuse field (range)	11.3 (2–30)	9.0 (0–15)	Not applicable

Data Collection

All three focus groups were held at the same treatment program in the Los Angeles area. Following an overview of the DARTNA protocol, participants were asked to discuss their general impressions of the protocol, recommendations for changes to the protocol, and suggestions for ensuring that the protocol is culturally relevant and accommodates the traditions of a variety of AI/AN tribes. As new issues and suggestions were raised by participants, they were incorporated into subsequent focus group discussions. Each focus group lasted approximately 2 hours, and participants were provided with a $40 gift card for their participation. The focus groups were audio-recorded and later transcribed. The study protocol was reviewed and approved by the University of California, Los Angeles (UCLA), Institutional Review Board.

Data Analysis

The transcripts were reviewed by three of the coauthors of this article for completeness and accuracy. Notes taken during the focus groups and the transcripts were reviewed for categories, patterns, and themes within and across the groups. A code list was developed and was guided by the focus group topics (e.g., recommendations, tribal diversity). Inductive codes were also added (e.g., gender roles, drum as sacred). Transcripts were coded and analyzed using ATLAS.ti (qualitative data analysis software).

RESULTS

Overall, focus group participants responded favorably when presented with the preliminary DARTNA treatment protocol and indicated that the protocol may be a potentially powerful treatment strategy for AIs/ANs with substance use disorders. Four overarching conceptual themes emerged across the focus groups: (1) benefits of drumming, (2) importance of a culture-based focus, (3) addressing gender roles in drumming activities, and (4) providing a foundation of common AI/ AN traditions.

Benefits of Drumming

Focus group participants spoke of multiple benefits from incorporating drumming into a treatment protocol for AIs/ ANs with substance use disorders.

Drumming as sacred medicine: Focus group participants described drumming as “sacred medicine” that has healing aspects. Participants conveyed that drumming can be appropriate and beneficial within the treatment setting. For example, a treatment provider stated, “Native people feel that drumming’s sacred. The drum is the heart beat, the source, the middle, center, Mother Earth.”

Development of a positive cultural identity: Participants also expressed that the DARTNA protocol would provide participants with an opportunity to facilitate the development of their own cultural identities, and thus enhance their self-concept and increase their self-esteem. One treatment provider noted the positive impact that drumming might have on individuals participating in DARTNA:

So we know there is a relationship with someone’s cultural identity and their substance use or other behavior problems. So there is already that relationship. So … being more connected to the culture is really going to help them whether they’ve drummed before or whether they’ve ever had any knowledge about their tribal culture.

Benefits for urban AIs/ANs: According to focus group participants, drumming was viewed as being potentially beneficial for urban AI/ANs who may not have participated in culturally based activities. Utilization of DARTNA within urban areas was seen as an opportunity to enhance the self-esteem of participants, which may then assist in their recovery from drugs and alcohol.

Importance of a Culture-Based Focus

Discussion among the three focus groups consistently highlighted the need for utilizing drumming based on AI/ AN culture and traditions. One male CAB member said:

I think it’s important, to me, if you’re going to integrate our culture and the drum into this, that it needs to be done in a proper way – in the way it was intended to be. Because that healing power is there in the drum and the songs if we use it in the right way.

Participants suggested that DARTNA teach the purposes of drumming in AI/AN cultures and the corresponding stories, songs, and dances. In addition, because singing typically accompanies drumming in AI/AN tribal groups, participants strongly suggested incorporating singing into the DARTNA drumming activities.

Focus group participants also expressed support for referencing the Medicine Wheel and 12 Steps program by White Bison, Inc., within the DARTNA treatment protocol. This program was credited for incorporating AI/AN traditions that may enhance the culturally based components utilized in DARTNA.

Gender Roles

The vast majority of participants (male and female) across the three focus groups reported having observed or having the understanding that women usually do not participate in drumming activities. One male patient stated, “In our tribe, the women don’t touch the drum. It’s bad luck for our drum.” Both female substance abuse patients commented that women usually do not participate in drumming activities. One female patient commented, “When the guys are drumming, I learned from my culture that we cannot be around when they are drumming.” Participants indicated that this was not a discriminatory or disrespectful practice, but rather based on AI/AN traditions and customs. Although the majority of participants commented that women do not typically participate in drumming activities, some substance abuse patients and provider participants (male and female) commented that women should be offered an opportunity to drum. One female treatment provider commented:

I kinda feel like I go against the norm that women should stand behind the men … I would like to see women allowed to be at the drum. But, you know, I agree with my elders that told me that you can’t mix these two powers.

After some discussion, the CAB advised that a pow-wow style drum be used for the subsequent DARTNA pretest with the male participants drumming and the female participants accompanying the drummers in singing. Also, the CAB felt that the pow-wow style drumming would be appropriate in this treatment setting since this is the typical format used in Los Angeles. However, the CAB suggested that personal hand drums for both men and women be considered as a viable option in future applications of DARTNA.

Providing a Foundation of Common AI/AN Traditions

Focus group participants stated that it is important to address tribal diversity in the development of DARTNA. However, the CAB highly recommended that DARTNA provide a foundation that recognizes and incorporates general common tribal traditions. In addition, the CAB and provider focus group participants emphasized that the role of the cultural leader is important in addressing issues related to tribal diversity, gender issues, and determining the appropriateness of the drumming activities employed.

DISCUSSION

This study provides a range of perspectives on the use of drumming for AIs/ANs with substance use disorders and as a component of the preliminary DARTNA treatment protocol. Generally, there was consensus among the focus groups that DARTNA represents a potentially beneficial and culturally appropriate treatment protocol for AIs/ANs with substance use disorders. Participants emphasized the need for ensuring that a culture-based focus is utilized due to the significance of drumming among AI/AN tribes. In addition, adequate attention to gender roles and tribal diversity was also emphasized.

Work conducted in these focus groups highlights the process of conceptualizing and developing traditional-based treatments for AIs/ANs with substance use disorders. The next steps of the DARTNA research project involve conducting a pretest of DARTNA among 10 AIs/ANs with a history of substance abuse by incorporating feedback obtained from the focus groups described in this article. Then, follow-up focus groups will be conducted among the participants, substance abuse providers, and the CAB to finalize the DARTNA protocol. After these developmental activities, a future clinical trial will be conducted to analyze the potential effectiveness of DARTNA. We believe the focus groups and developmental activities utilized in this study provides a framework for the future design, development, and analysis of potentially effective substance abuse treatments utilizing traditional-based healing methods for AIs/ANs. The steps taken and planned in these research activities will hopefully be a valuable avenue toward the future provision of evidenced-based substance abuse treatments that employ AI/AN traditional-based healing activities.

A relevant cultural consideration expressed in this study was the need for the DARTNA protocol to focus on AI/AN tradition. If patients participating in DARTNA are not provided with culturally based education as it relates to drumming among AI/AN cultures, focus group participants raised the concern that participants could be led toward a general US population-based approach. Thus, utilizing a culturally based approach would provide participants the opportunity to grow within their cultural identity and to successfully engage in a culturally relevant recovery program. This will be important in subsequent measurement of self-esteem in our subsequent testing of this intervention.

Participation in DARTNA was thought to offer an opportunity for participants to learn about the role of AI/AN men and women in drumming-related activities. Although women typically do not drum in most AI/AN tribes, recognition that AI/AN women may have prescribed roles in drumming activities within their tribal traditions was expressed. Providing participants with education regarding the broader uses and purposes of drumming, songs, dances, and traditions are suggested in order to address how AI/AN males and females could participate in these traditional activities. The role of women in drumming activities has raised some controversy in recent years (21). Issues associated with the changing role of women in contemporary society have been recognized as having relevance to the participation of women in traditional activities in which only men have historically been allowed. However, many cultural leaders express the need for adhering to and maintaining traditions rather than further diluting Native traditions, a trend that has been observed throughout US history. Based on our preliminary study findings, we would not conclude that AI/ AN women would be discriminated against should elders advise that women not drum within a tribal nation where historically women have not routinely participated in drumming. However, the authors recommend further discussions on this topic at both the national and community-based events addressing traditional healing. The authors suggest that cultural experts and clinicians in their respective tribal communities follow local tribal traditions as it relates to gender roles and drumming activities within DARTNA.

Recognition of tribal diversity as it relates to drumming traditions was emphasized throughout the focus groups. Participants stated that protocol drumming activities should take into account specific differences in styles of drumming, types of drums used, and specific teachings of drumming among different tribes. It should be recognized that no one approach to the drumming portion of the DARTNA treatment protocol would exist for all rural and urban tribal communities, and therefore, drumming activities employed within DARTNA should reflect the drumming traditions practiced where the protocol is being delivered.

This study was subject to several limitations. Focus groups were conducted with a small sample (n ¼ 18) of participants in one large urban population setting. Thus, generalizing these results to all AI/AN settings is not possible. In addition, the Northern Plains Medicine Wheel Model may not be culturally relevant for some tribes. In spite of these limitations, this study has identified various culturally relevant aspects related to drumming among AI/ANs, revealing various viewpoints as it relates to drumming and issues of gender, cultural identification, and tribal diversity.

In conclusion, this qualitative study provides relevant feedback from the Los Angeles area AI/AN community with regard to the DARTNA treatment approach and in providing drum therapy treatment for AIs/ANs with substance use disorders. Final development and subsequent testing of DARTNA may assist toward providing AIs/ANs with an evidenced-based substance abuse treatment for AIs/ANs utilizing a traditional-based treatment (drumming) as its core treatment component.