Integrating Spiritual and Western Treatment Modalities in a Native American Substance User Center: Provider Perspectives

Abstract

Few studies examine how traditional Native American and Western healing practices are being integrated in Native American substance user treatment centers. Data are presented from a 2008 study of providers of integrated substance user treatment for Native Americans at an urban Western US center. Nineteen semi-structured interviews were conducted to examine 10 providers’ views of the integration of traditional and Western healing and the impact on recovery for clients. We used a grounded theory approach to data analysis with manual and NVivo codes and themes developed. Limitations and implications for practice are discussed.

INTRODUCTION

In relation to the total US population, Native Americans have high prevalence rates of past-year substance use and thus a great need for substance abuse¹ treatment.² For example, 20% of Native Americans aged 12 years and older reported past-year illicit drug use, versus 12% in the US population, and 7.8% were in need of drug user treatment (versus 2.7% in the United States; Substance Abuse and Mental Health Services Administration [SAMHSA], 2008). In addition, a study of Native Americans in 2003 found that Native Americans have high rates (20%–60%) of substance use and abuse disorders (Mitchell, Beals, Novins, Spicer, & AI-SUPERPFP Team, 2003). In 2000, 2.4% of the total admittances to publicly funded substance user treatment centers were Native, although they make up less than 1% of the US population (Drug and Alcohol Services Information System, 2003). There is no doubt then that Native Americans are in need of substance user treatment. Research has shown that the most successful substance user treatment for Native Americans utilizes traditional health practices (LaFromboise, Trimble, & Mohatt, 1990; Spicer, 2001).

Providing effective substance user treatment that incorporates both Western and traditional Native healing is challenging since the dominant and Native cultural values toward wellness are incongruent. While Western efforts toward treatment emphasize the role of the individual, a Native perspective emphasizes connections with others (Voss, Douville, Little, & Twiss, 1999). Western models of healing generally isolate individuals from social, physical, and spiritual environments and then reintroduce them after treatment has been completed and wellness has presumably been achieved (Coates, Gray, & Hetherington, 2006). Traditional Native American healing is interconnected and seeks to balance emotional, physical, mental, and spiritual aspects of people, their environment, and the spirit world (Hazel & Mohatt, 2001). And despite attempts to integrate Native perspectives into practice, the results are “adaptations, not organic exchanges” Coates et al., 2006, p. 381). Born out of a philosophy that challenges both the effectiveness and appropriateness of Western modalities of treatment, many communities and Native-serving treatment centers have culturally tailored their recovery programs with the Native client in mind. These integrative recovery programs include sweat ceremonies, talking circles, prayers, smudging, and sessions with recognized spiritual healers and are combined with Western mainstream practices, such as group therapy and Alcoholics Anonymous meetings (Jilek, 1994). However, integrative programs that incorporate cultural modes of treatment must understand the complex nature of urban Native communities where several tribal origins are known to exist. Coupled with this knowledge is the need to recognize the level of acculturation of the Native person or persons involved in the treatment program. Acculturation has been defined as a process of assimilation into the majority culture (Aponte & Barnes, 1995). Herman-Stahl, Spencer, and Duncan (2003) reported that of 2,449 Natives interviewed regarding substance use, low orientation to Native culture was associated with higher levels of multiple substance misuse, including heavy and extended drinking, illicit drug use, poly-drug use, and alcohol abuse and dependence. Studies of Native American traditional healing practices are rare (Blaine, 2000; McCabe, 2007) and few studies exist that report on integrative models of care for Natives (Gurley et al., 2001; Novins, Beals, Moore, Spicer, & Manson, 2004; Portman & Garrett, 2006). Using data gathered from providers of substance user treatment for Native American clientele at an urban agency in the Western United States, this study attempts to reduce this deficit in the literature. Objectives were to (1) have providers describe their views of how spirituality is conceptualized in light of the integration of Western paradigms of healing with Native American traditional healing in the context of an urban treatment program and (2) examine providers’ impressions of how traditional healing activities impact Native Americans in treatment and what effect these activities have on recovery.

METHODS

Clinical Setting

This study was conducted at a social service agency that provides resources and advocacy to Native American clientele on the West Coast of the United States. Programs at the center include diabetes workshops, family and individual counseling, after-school enrichment activities, case management, and an alternative high school. The center is Native oriented, meaning that the cultural, spiritual, and tribal values of its clientele are consistently reflected in the philosophies of the organization itself, its staff, and its policies. This study took place at the center’s outpatient substance user recovery program that addresses the emotional, cultural, spiritual, physical, and mental health needs of patients. The recovery program concurrently treats 20–30 Native Americans who are referred from residential and outpatient treatment facilities. Wellness activities include weekly talking circles, sweat ceremonies, smudging, prayers, consultations with a contracted Native American spiritual healer, Alcoholics and Narcotics Anonymous meetings, and vocational counseling.

Sample Characteristics

The recovery center is staffed with substance user treatment counselors, clinical psychologists, social workers, case managers, employment specialists, traditional practitioners, and administrators—14 of the 19 staff members are Native. The Native staff represents several tribes, clans, and linguistic backgrounds, which is a reflection of the tribal diversity that exists within the community. The study sample consisted of a convenience sample. Staff members who participated in the study were providers of substance user treatment at the aforementioned recovery center who had therapeutic, spiritual, administrative, and other job roles within the agency. The staff included 10 adults, with 8 self-identifying as Native American and 2 as Asian American (7 females, 3 males). Years of post-high school education ranged from 0 to 10. Job tenure at the agency ranged from 11 months to 15 years. The first author explained the study to the staff at a regularly scheduled staff meeting and invited individuals interested in participating to contact her to schedule an interview.

RESEARCH PROCEDURES

Semi-structured Interviews

Once the first author obtained a letter of support from the director of the center, Institutional Review Board approval was obtained. Participation was voluntary and unrelated to employee status; the director did not know who participated. This study utilized semi-structured interviews of providers in an outpatient Native American substance user treatment program. All staff, with the exception of one, underwent two interviews: an initial interview and a follow-up a few weeks later for a total of 19 interviews. All interviews were conducted by the first author who is a member of the Native community. The initial interview lasted an hour and the follow-up interview was 45 minutes. Interviews were conducted in the respective offices of staff and were audio taped for later transcription. Staff received one $20 gift card following their participation, regardless of the number of interviews completed. A semi-structured interview protocol consisted of open-ended questions that explored themes and subjects to guide the interviewee. A representative selection of interview prompts is as follows: “How do you think spirituality is defined in the context of this treatment program?” “To what degree are activities like sweats and talking circles required for recovery?” Staff were asked to speak about their job responsibilities, in particular treatment planning for clientele; describe the implications of a predominantly Native staff; discuss how this program differs from others of a similar nature, including the role of spiritual/traditional activities; and if they were healers, elaborate on previous alternative medicine experiences. The content of the second interviews was concerned with the staff’s definition of spirituality and the implications of different conceptualizations of spirituality among the agency’s clients, for example, “How is spirituality defined in the context of this recovery program?”; “What role does spirituality play in the recovery process?”; “If spirituality is inherent, to what degree are ritual healing practices required for recovery?” Staff was asked to speak about their opinions regarding the role of spirituality in substance user treatment, whether they saw it as a necessity for sobriety and wellness or not. Finally, staff was asked to comment on the former responses made by coworkers while maintaining confidentiality.

Data Analysis

The audiotapes of the initial interview were transcribed shortly after the interview. Using a manual, “open coding” method, the first author extracted themes to inform follow-up interviews. Grounded theory was used to develop and create theory out of the data. Grounded theory is an inductive theory development, in which themes are constantly being refined and modified as the data are further developed (Glaser & Strauss, 1977). For example, during initial interviews, there was a dichotomous view-point as to whether or not spirituality was required for one to achieve sobriety. In the second interviews, staff members were probed about their own opinions, as well as the overarching role of spirituality in substance user treatment. The second interviews were transcribed and then manually coded by the first author, with the major themes being integrated into the schematic layout formulated by the initial interviews. Then a qualitative analysis program, NVivo, was utilized to further analyze and cross check these codes and themes. Finally, three readers reviewed the resulting final themes and concurred on their content. The organization of themes was based on a constant comparison between the codes and the data; so, as more concepts were uncovered from the data, broader, larger themes were identified (Padgett, 2008).

RESULTS

Following the thematic analysis of interviews, themes relevant to the treatment experience were generated. The list of themes is a representative sample of the themes recovered from the data because they received unanimous support from all staff. However, the list is not exhaustive. Although additional themes were generated from the data, those included in this manuscript are the most relevant to the objectives of the present study. Narrative passages from interviews are used to demonstrate reasonable support, not necessarily absoluteness, for a given theme. The overarching themes are: (1) acceptance of bi-spirituality/mainstream religion, (2) level of acculturation, (3) role of spirituality and traditional activities in healing, and (4) staff goals for treatment.

Themes

Acceptance of Bi-spirituality/Mainstream Religion

Staff members indicated that their personal approaches to healing in the context of substance user treatment are tolerant and respectful. Staff maintained that although the treatment center’s spiritual activities are often guided by the tribal or even linguistic background of the practitioner conducting the ceremony, the agency takes a relatively open stance to all spiritual beliefs, including organized religion. Clients are encouraged to pursue a best-fit spiritual path on their own terms, with the expectation that they will be supported by staff regardless of which course they choose. In fact, Native-specific spiritual events often successfully coexist with an overt devotion to mainstream religion throughout and after the course of substance user treatment. Native Americans come from a long tradition of being subjected to organized religion that ranges from the presence of religious missions on reservations to the boarding school experience. Therefore, being culturally aware of this history aides the counselor in recognizing that some aspects of organized religion are still very pervasive within Native communities. Whether clients place equal emphases on their religious belief systems, or heavily favor one orientation over the other, bi-spiritual clients are supported and guided without judgment throughout their treatment experience.

• Well, the thing is that the Native American way is to respect all people, all colors, all nations, and in that way you would respect somebody else’s belief system. Just like we have some, a lot of Native, there’s the Native American Revival Church. There’s clients that are brought up with the belief of Christianity, Catholicism, Baptist. So, they’re already, in some ways, that’s one of their beliefs. So we just honor it, respect it, we never take away, we never judge. (Staff Member 3: substance user treatment counselor, Native, female, 3 years at the agency)

• We have the mix and I think the biggest thing is we are respectful because we do have people who are very traditional and raised in Indian ways, and more in tune with the elements part, in honoring Mother Earth. And then you have those who are strict Christians, by the book, who downplay, who think that traditional healing practices are sacrilegious. But we’re respectful and I think the common connection is that we’re all Indian and whatever our higher power is that we choose. (Staff Member 4: clinical administrator, Native/African American/European American, female, 4 years at the agency)

• We don’t stress things, because spirituality being a personal path. It doesn’t matter how you believe in the creator, as long as you believe in him. A lot of our clients are Christian and will go to the Native American Church, which is Christian-based and a lot of them do sweats and a lot of them do pipe ceremonies. If that works for them that’s fine, go do that. (Staff Member 5: talking circle leader/workforce case manager, Native, male, 6 years at the agency).

Level of Acculturation

Staff stressed that a significant factor in the treatment experience is the level of acculturation that clients endorse or the degree to which they adopt the traditions, language, and customs of the dominant culture. Some staff conceptualized client’s newly discovered connection to their Native heritage (and hence involvement with cultural activities) as a protective factor for relapse. Other staff indicated that the same processes used to strike a balance between the dominant culture and Native society lends itself to the development of substance-related coping skills even after treatment has ended. Nevertheless, staff described engagement in traditional activities during treatment as a cultural reawakening and a means for reintroduction back into Native society.

• If they’re not in touch, if they’re really acculturated and they’re experiencing this for the first time, there isn’t any forcing of one, of a person to believe, or to move too fast. I mean, there is an encouragement for them to get in touch with Native roots, I think, because we see culture as prevention, right? So getting that identity back, so to speak, is important. It’s seen as a protective factor. (Staff Member 2: therapist, Asian American, female, nearly 2 years at the agency)

• Most of our population is an urban population so a lot of times we’re lucky if they know what tribe they’re from. So, I think it plays a big part, especially for a lot of the people who come through here who are urban it sort of gets them introduced to some of their, some Indian commonalities. So I think it’s important. (Staff Member 10: youth counselor, Native, male, nearly 1 year at the agency)

• In this community, because it is urban and because it is so diverse and because the acculturation is so, the span is so wide, everyone comes with their own spirituality. I remember there was a woman I worked with, and she was Navajo, who was Mormon and Mormons are strict, it’s a very strict religion, yet she would go home to her reservation and participate in ceremony and I asked her “How do you reconcile that, how do you?” and she said “You know, I am Indian, but I’m also Mormon and they do work together.” They find a way to, even though the gods or the spirits may not be the same wording, they find an inner way. (Staff Member 9: therapist, Asian American, female, 1 year at the agency)

• I think it’s a cultural competence issue and a lot of our clients, who are raised with similar backgrounds, or they were raised by their grandparents and weren’t born on the reservation, so traditions aren’t, it’s like second hand knowledge. So we do a lot of teaching it, spirituality. Like taking them to the sweat lodge. “What does that mean?” “How do you pray?” “What is the use of smudge?” And then there’s other times when we have a lot of Native Americans who are coming off of the reservation so we have to deal with our culture shock. (Staff Member 1: substance user treatment counselor, Native/Caucasian, female, 4 years at the agency)

Role of Spirituality and Traditional Activities in Healing

Staff maintained that depending on a number of factors, participation in spiritual and traditional events lends itself to a dynamic treatment experience for clients. Some staff indicated that the structure inherent in spiritual and traditional events proves to be helpful in the recovery process long after formal treatment services have ended. Others elaborated on the fact that spiritual events teach clients practical coping skills for overcoming addiction in a way that is culturally relevant and appropriate. Becoming familiar with Native rituals and ceremonies may help clients to feel whole again, aiding them in recovering a sense of self that has likely been severed during the addiction process. At the same time, staff indicated that events like talking circles allow clients to process their experiences with addiction, allowing them to be more honest with themselves and with others.

• My goal is to introduce them to as many coping skills as they can have regarding substance use, spirituality, support network, resources, goal making, which is all kind of together and to practice that, and yeah, so that when they leave here, it’s like second hand. So like building a foundation when you leave here, knowing what a sweat is, who to contact to go on. (Staff Member 1: substance user treatment counselor, Native/Caucasian, female, 4 years at the agency)

• The piece that spirituality plays is that, like you said, we hope to give the clients enough tools. It’s called a bag of tricks, so that if money runs out, and that is their limitation, that they have something to fall back on. So, if it’s not spirituality, it’s the twelve steps, it’s AA, it’s meetings, it’s a sponsor, it’s sober treatment facilities, or treatment facilities they know they could call in a pinch, it’s their counselor. So I think spirituality is just one piece of the toolbox that we hope to give our clients. And I think in this program, the substance user program, healing, a lot of healing has to do with feeling whole, and feeling umm, a sense of belonging, umm, and feeling empowered. (Staff Member 9: therapist, Asian American, female, 1 year at the agency)

• For the youth, the youth that I have worked with, there really is a sense that they’re willing to learn whatever we teach them because they know so little, so we can bring in a powwow drum, even if it isn’t part of their tradition you know, they’ll gravitate towards it because they see that, as, you know, being a part of Indian. (Staff Member 10: youth counselor, Native, male, nearly 1 year at the agency)

• I think when a person is in crisis, when they’re not whole, the traditional components that we do offer, it’s not all of them, clearly, but it helps to heal and it helps to make you whole because addiction is not traditional. It’s not something that’s traditional at all and that’s been something that’s been introduced, so it’s kind of made us not whole. People are broken you know, not whole when they come in and when they’re in crisis, especially with addiction. (Staff Member 4: clinical administrator, Native/African American/European American, female, 4 years at the agency)

Staff Goals for Treatment

Staff was asked to speak about their goals for respective clients by the end of treatment. Staff responses fell into two groups: spiritual development as a primary goal and spiritual development as a secondary goal in the treatment process. For those who considered immersion in spiritual activities as their primary goal for clients, sobriety and spiritual engagement were one and the same. Without a sound investment in traditional and spiritual activities, sobriety is not likely to be achieved during or after treatment. For staff who described spirituality as a secondary goal to treatment, primary goals were identified as stabilization and recovery from substance use. For these staff, spiritual development would certainly be embraced if the client considered it to be a substantial factor in their recovery, but otherwise they considered participation in spiritually minded events as secondary to sobriety, safety, and outstanding medical concerns.

Spiritual Development as a Primary Goal

• I think it’s [spirituality] necessary, I think it’s just, you need that. Just, you can’t recover without having that strong connection, and whatever that is, I don’t believe it’s just for Native people, but, people who do well, and who stay in recovery, you’re still gonna have the same family, you’re still gonna have, you know, all those other stressors. Those don’t go away, but there’s something that you learn or that you connect with and I think that’s the spirituality. Whatever that connection is that you make, and that’s very personal and that’s very internal, whatever that connection is that you make, that gives you the strength to keep going and not using and making a different choice, and a different, and you know, taking a different pathway, I believe, it’s essential for recovery. (Staff Member 4: clinical administrator, Native/African American/European American, female, 4 years at the agency)

• I don’t believe you can recover really in 30 days. If you’ve been abusing for 30 years, and you’ve been in recovery for 30 days, yes your body may be clean but you haven’t changed how you think up here. I want them to try to hold on to some type of spirituality. Whether it just be smudging and praying by themselves or going to some church. Whether it be the Native American church, you know, Christian church, Catholic Church, whatever it is. But to keep some kind of connection in their heart with their spirituality because this can be so powerful helping them stay sober. You know, I mean, if it wasn’t for spirituality, I probably wouldn’t be sober. I’ve had this connection ever since I was a kid and even when I went away from it, that was what pulled me back and I know it works, I’ve seen how it works, and I’ve seen the ones who do stay on this and keep that spirituality in their lives are the ones that stay sober and then don’t end up relapsing and coming back to recovery. [Do you think it’s possible for someone to stay sober without maintaining spirituality?] I haven’t seen it yet. (Staff Member 5: talking circle leader/workforce case manager, Native, male, 6 years at the agency)

Spiritual Development as a Secondary Goal

• I think the goal of this program is to help people become sober. That’s first and foremost, I think. That’s my understanding. Sober and mentally healthy because those go hand in hand. So if spirituality is what they need to sustain health, then that’s what we will provide. If they use other things, psychotherapy, if it’s psychotropic medication, whatever it is that they need to become healthy, we will try and access that for them. The piece that spirituality plays is that, like you said, we hope to give the clients enough tools. It’s called a bag of tricks, so that if money runs out and that is their limitation, that they have something to fall back on. So, if it’s not spirituality, it’s the 12 steps, it’s AA, it’s meetings, it’s a sponsor, it’s sober treatment facilities, or treatment facilities they know they could call in a pinch. It’s their counselor, so I think spirituality is just one piece of the toolbox that we hope to give our clients. (Staff Member 9: therapist, Asian American, female, 1 year at the agency)

• You know, we’re really just more focused on their immediate safety. You know, and maybe finding a sweat lodge closest to them is not the first thing on our list. So, it really depends on the person, each client’s individual needs. It’s difficult to get a person continually coming after they’re not required to do so anymore. (Staff Member 2: therapist, Asian American, female, nearly 2 years at the agency)

DISCUSSION

The perceptions of staff members at this health center reveal the role that traditional healing plays in the recovery of urban Native Americans from their substance use. The intention of this study was not to draw a parallel between traditional and Western modalities of health but to examine ways in which they can be merged for a culturally appropriate treatment experience. While Native-specific addiction texts, for example, The Red Road To Wellbriety: In the Native American Way (White Bison Inc., 2002), are consistently used by staff, the results demonstrate that how the individual characteristics of the Native clients are also an important part of the program. Staff acknowledges that recovery clients may maintain ties with mainstream religion, be acculturated into mainstream society, bear the historical stress and trauma of boarding schools and missionary work, and may have minimal information about their tribal origins and traditions. Staff characterized the center’s approach to working with bi-spiritual clients as accommodating and tolerant. They were committed to the idea that urban Native Americans could reconcile all of the manifestations of their spiritual selves, regardless of specific orientation, without judgment or a sense of indoctrination as to what constitutes right and wrong. Even clients who objected to traditional healing, labeling it as “blasphemous” in some cases, were encouraged to attend all activities, even beyond those that were mandatory. Staff also indicated that navigating the path of bi-spirituality lends itself to the general acculturation process. The clients’ reconciliation of mainstream religious beliefs with traditional Native beliefs allows clients to function successfully in two very different worlds. Experts have concluded that when substance abuse intervention programs modify mainstream prevention programs with cultural elements relevant to urban Natives, the experimental groups show greater improvement in substance use measures at posttest and at a 6-month follow-up (Moran & Bussey, 2007). Furthermore, self-identification with both Native and Western cultures has been associated with increased levels of psychological well-being, including higher self-esteem, more internal locus of control, and fewer behavioral problems when compared with those who connected only with one identity or with neither (Moran & Bussey, 2007). In the light of the socio-demographic diversity of the clientele, traditional ritual healing activities are often referred to as “pan-Indian,” meaning that they are based on the tribal heritage, language, and subsequent training of the employee(s) who are leading them. Although some staff members did cite objections concerning authenticity and accuracy regarding the procedures of these activities, they did not necessarily appear to be influenced by these concerns. The integration of traditional spiritual and Western practices in this treatment center cannot necessarily be quantified. Furthermore, the program is not conceptualized as a Western program with minor Native influences, nor is traditional healing considered an optional subcategory of treatment. Rather, the traditional and Western influences are simply reflections of the two worlds within which Native clients must function in an urban environment. The integrative strategy at this treatment facility is functioning successfully in several respects. The interviews with staff members, including administrators, clinicians, and healers, indicate a unanimous dedication to the use of traditional Native and Western practices. Staff routinely indicated that they not only recognize spiritual healing as some piece of the treatment process, but also urge all of their clients, regardless of acculturation status, tribal affiliation, or past experience with traditional healing, to engage in it. Staff described several types of roles that traditional healing plays in the treatment process, including the development of coping skills, the provision of a daily structure, or a means to reconnect with their Native ethnicity. Although the outside perspective may urge program administrators to be in favor of a more Native traditional approach to substance user treatment compared with Western modalities, there are several contextual factors that prevent such from happening. First, the recovery center is funded from several sources, including Indian Health Services and other federal entities like the National Institutes of Health (NIH) and SAMHSA. It is unlikely, given the paucity of empirical research on alternative substance user treatment, that such centers would be readily funded without the inclusion of some empirically validated treatment techniques. Second, a cultural renaissance would not take into account the reality of urban living for today’s Native population. With staff commenting that some clients are not even aware of their tribal origins, a program that focused exclusively on traditional Native rituals and ceremonies would likely lead to the exclusion and isolation of some clientele. Furthermore, frameworks for establishing treatment programs that completely immerse clients in exclusively traditional practices have yet to be developed, leaving administrators and program directors with limited options outside of this choice. As it currently stands, staff members are firmly invested and committed to the specific integrative methods that the treatment center abides by. If the incidence of returning sober alumni to the center is any indication of the effectiveness and appropriateness of the policies used at this treatment center, then one can readily conclude that the current programming has been successful from a treatment standpoint.

Study’s Limitations

After reviewing the results of this qualitative study, the following limitations should be noted. The results of a study at one Native American substance user treatment center cannot be generalized beyond the sample, setting, and population. The sample in this study was small and purposive. The results were obtained from self-reports so the extent to which they correspond to actual behaviors is not known, and the staff perspectives on client views and behaviors are second hand views. Still, despite the movement for Native American treatment facilities to integrate traditional and Western healing into their programs, little has been detailed regarding the actual processes, structure, and outcomes of this integration.

GLOSSARY

Acculturation

The degree to which members of a group adopt the traditions, language, and customs of the majority culture

Integration

The incorporation of Western medicine and ritual healing activities as a means to culturally appropriate treatment

Mainstream religion

An organized, recognized approach to human spirituality that includes proscribed beliefs, practices, symbols, and narratives

Native American

Refers to indigenous peoples in North America, used interchangeably with American Indian

Ritual healing

Native American-based ceremonies and processes that promote mental and physical well-being including smudging, sweat lodges, and talking circles

Smudging

Purification ceremony that involves the burning of sage and/or other herbs in order to create a cleansing smoke

Spirituality

The beliefs and philosophies concerned with matters of the spirit, may include ideas about religion and faith

Sweat lodge

Ceremonial sauna that involves prayers, drumming, and offerings to the spirit world

Talking circle

A talking circle is a traditional form of Native American group communication where topics are discussed in a non-confrontational manner. Members are sensitive to cultural and symbolic traditions like the burning of sage (smudging) before the talking circles or the passing of an eagle feather or a shell to symbolize a person’s turn to talk. In talking circles, news is shared, help is offered, problems are solved, and stories are shared with the younger members of the group as a form of teaching

Urban Native

Refers to Native people who reside in metropolitan areas, as opposed to reservations

Western medicine

Conventional, mainstream approaches to wellness. In the context of recovery from substance use, this would include Alcoholics Anonymous and Narcotics Anonymous meetings, detoxification, and process groups