NATIVE TRANSFORMATIONS IN THE PACIFIC NORTHWEST: A STRENGTH-BASED MODEL OF PROTECTION AGAINST SUBSTANCE USE DISORDER

Abstract

This paper presents findings from the Native Transformations Project, an exploratory community-based participatory research study that aims to identify sources of strength and protection against substance use disorder in three tribal communities in the coastal Pacific Northwest. Preliminary results from the study describe the specific settings, acts, and behaviors that build strengths and provide protection at the family, community, individual, and spiritual levels within coastal Pacific Northwest local tribal cultures. Findings from this study give voice to stated community preferences for grassroots Native intervention programs based in local cultural knowledge, worldviews, values, and theories of change, that operate at the local level on their own terms.

“What generation of our people is going to not have alcohol or alcoholism in their family or home? I want it to be in mine.”

The quotation above comes from a participant interviewed for the Native Transformations Project (NTP), which explores strengths, protections, and resilience against substance use disorder (SUD) in three tribal communities in the coastal Pacific Northwest, hereafter called Coast Salish. While the devastating impacts of drugs and alcohol for American Indian and Alaska Native (hereafter collectively referred to as Native) people and communities are well known (Substance Abuse and Mental Health Services Administration [SAMHSA], Center for Behavioral Health Statistics and Quality, 2011; SAMHSA, Office of Applied Studies, 2012), we know significantly less about the lives of those Native people doing well and living strong in their communities (Mohatt, Rasmus, et al., 2004). There is broad understanding of the critical need for more effective, culturally grounded prevention and intervention strategies to increase resilience and recovery from SUD in Native communities (Allen, Mohatt, Beehler, & Rowe, 2014; Gone & Calf Looking, 2011; Hawkins, Cummings & Marlatt, 2004). How to devise, develop, and deliver effective treatment and prevention services to meet tribal community-specific cultural needs is considerably less well understood.

Coast Salish tribal people continue to suffer disproportionately from SUD relative to other ethnic minority and non-minority groups (Akins, Mosher, Rotolo, & Griffin, 2003). In particular, opioid (e.g., heroin, prescription painkillers) dependence and overdose among Coast Salish people has increased dramatically since 2000, emerging as a current top tribal health priority in Washington State (Radin, Banta-Green, Thomas, Kutz, & Donovan, 2012; Radin et al., 2015). While these studies generally reveal higher levels of SUD among Native people in Washington State, they also show that differences may be lessened when individual-, community-, and cultural-level risk and protective factors are taken into account (Akins et al., 2003).

This study takes place within three rural, reservation Coast Salish communities located in Washington State. The study was initiated in response to tribal community requests for research to increase understanding about Coast Salish strengths and well-being to identify factors that facilitate recovery from, and protect against the development of, SUD. The study was engaged with the goal that tribes could use its findings to develop, enhance, and evaluate tribal community prevention, intervention, and recovery services by building Coast Salish strengths and protections against SUD.

SUD Intervention Grounded in Native Culture, Worldview, and Theory of Change

A recent review of Native SUD prevention efforts found a fundamental disconnect across a majority of the programs described, between “the theories used to guide development of prevention programs in AI/AN [American Indian/Alaska Native] communities and culturally appropriate theoretical constructs of AI/AN worldviews” (Walsh & Baldwin, 2015, p. 41). The most prominent theories guiding contemporary and available substance abuse interventions come from Western psychology (e.g., Transtheoretical Model, Prochaska & DiClemente, 1983; Social Cognitive Theory, Bandura, 2001) and biomedical models (e.g., Dole, 1988). Most studies testing the effectiveness of these SUD interventions are conducted predominately among the majority Euro-American population, with generally little or no representation from minority populations, and Native populations in particular (Gone & Alcantara, 2007).

The prominent SUD interventions (Botvin, Griffin, & Nichols, 2006; Kazdin, 2008) most widely used in Native communities often focus solely on the individual and emphasize factors such as personal agency (i.e., the individual’s autonomous decision making; Bandura, 2001), individual motivation to change (Prochaska & DiClemente, 1983), and cognitive appraisal of the pros and cons of changing (Prochaska et al., 1994). While these may be important factors to consider for people from various cultures, these models neglect to consider the influences of family, community, cultural and spiritual factors, all of which are central to the experiences of tribal community members. When factors key to the experience of Native people are not addressed in theories or interventions, it is not surprising that prevention and treatment programs often fail to demonstrate their desired outcomes in these populations (Casey, Rawson, Li, & Hser, 2011; Dickerson et al., 2011; Evans, Spear, Huang, & Hser, 2006).

Increasingly, Native community members are advocating for cultural approaches to addressing SUD on their own terms. Whitbeck, Walls, and Welch (2012) note broad-based efforts composed of grassroots Native intervention programs, operating in parallel to these more limited research efforts with Native populations described in the existing literature. These Native programs, instead of adapting existing programs, are based in local cultural knowledge, worldviews, values, and theories of change, and operate at the local level. These local initiatives are often only informally evaluated; as a result, they are rarely, if ever, reported in the SUD research literature. These grassroots efforts sometimes are portrayed as arising out of a clash between Western and Native clinical paradigms (Calabrese, 2008); however, their absence from the SUD research literature also reflects broader tensions between the cultural worldview of Native communities and the theories, worldviews, and cultural assumptions of Western social and biomedical health science research (Gone, 2012).

There are several important drivers to the development of local cultural interventions in tribal communities. Foremost is a broad motivation to address SUD within many Native populations, coupled with an apparent divergence in the match of the predominant intervention programs to Native clients. Beals et al. (2006) reported that 13.3% of participants in the American Indian and Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP) sought help for substance use problems during the year prior to assessment. Of those with past-year SUD, 38.9% had sought help. Of this group, 52% sought Western professional services; 41%, Alcoholics Anonymous 12-step support groups; and 40%, traditional healers. Strikingly, in comparison to National Comorbidity Survey (NCS) data, the Native populations in the study cited above were slightly more likely to actively seek out help than were those in the U.S. general population. However, the existing research (Dickerson et al., 2011; Evans et al., 2006) suggests that despite this interest in participation in programs to address SUD, when Native people do seek treatment, the types of treatments currently offered by Western model programs result in lower treatment retention and utilization rates, in contrast to non-Native matched controls. Also of note in the AI-SUPERPFP findings was the substantial proportion of Native people with SUD who consulted traditional healers to address their SUD problems. This finding is again reflective of the consistent interest among Native people in cultural approaches to address SUD. This combination of research findings fuels the growing argument for SUD interventions based in or more oriented toward Native theories of change and grounded in local Indigenous culture (Gone & Calf Looking, 2011).

People Awakening: Beginnings of a Translational Pathway

Important steps toward the goal of developing Native theory-driven SUD interventions have been taken, with significant gains over the last decade (Allen et al., 2006; Donovan et al., 2015; Mullany et al., 2009; Rasmus, Charles, & Mohatt, 2014). Of greatest relevance to the current study are efforts of the People Awakening Project (Allen, Mohatt, Beehler, & Rowe, 2014; Mohatt, Rasmus et al., 2004; Mohatt et al., 2008), a community-based participatory research (CBPR) study that has spanned nearly 20 years. The collaborative work began when a group of Alaska Native (AN) leaders requested that university researchers assist them in a project to explore AN pathways to sobriety and wellness. Dr. Gerald Mohatt at the University of Alaska Fairbanks helped answer this call to action, and the People Awakening Project was proposed with the aims of portraying another, unheard side of the Alaska Native story (Mohatt, Hazel et al., 2004), profiling sobriety, well-being, and strengths, in contrast to the often negative public attention on AN communities (Weaver, 1988). The People Awakening Project focused on often overlooked stories of strength, hope, and positive identity and identified indicators of AN protection and well-being that are enduring parts of the culture and its Aboriginal way of life. The People Awakening Project began by collecting 101 life history interviews from AN people who had never developed an alcohol use disorder (AUD), or had successfully recovered from AUD and maintained their wellness for 5 or more years. Their life histories revealed key protective factors that might help assist these research participants with recovery from AUD (Mohatt, Rasmus, et al., 2004), and suggested protective factors that might help prevent the development of AUD. These protective factors identified in the People Awakening Project became the building blocks for an AN theory-driven intervention to reduce youth suicide and AUD that was focused in the Central Yup’ik communities of Alaska (Allen, Mohatt, Beehler & Rowe, 2014; Rasmus et al., 2014).

A key tenet that permeates the ongoing efforts of the People Awakening Project is its strength-based approach (Allen, Mohatt, Beehler, & Rowe, 2014). This strength-based approach focuses on building protection, rather than reducing risk. As a result, the approach requires researchers to ask intriguing questions, such as: What is protective against SUD? What factors mediate pre-existing risk factors? Which are most amenable to intervention? Strength-based approaches direct inquiry to identify specific factors within a community, family, individual, and culture that build well-being by providing protection.

The People Awakening Project began as a discovery-based CBPR qualitative study. The initial study evolved into a program of CBPR intervention research with direct treatment and prevention applications. NTP seeks to replicate the successes of People Awakening in building a translational research pathway from basic, descriptive research to intervention development. The current study, as the first study in a planned program of research, is discovery based, and, through qualitative inquiry, aims to identify Coast Salish tribal-specific sources of strength and protection, and strategies for achieving and maintaining wellness. The study is conceived as a first step in initiating a program of CBPR intervention research to develop a strength-based, Indigenous theory-driven intervention to prevent SUD among the NTP partnering tribes.

METHODS

Tribal Context and CBPR Process

The NTP brought together local representatives from three Coast Salish tribal communities with researchers from the Northwest Indian College and the University of Alaska Fairbanks as part of a CBPR (Minkler & Wallerstein, 2008) initiative to reduce disparities in SUD.

Two of the primary researchers on the team have developed long-term relationships with Coast Salish communities, having worked in various capacities in health, social service, and education for the tribes for almost 20 and 40 years, respectively. Tribal representatives from the three study communities approached the researchers in 2011 to undertake a project to identify Coast Salish strengths that were protective against SUD, and that could ultimately be used to improve existing SUD treatment services, as well as to develop community-based prevention services.

The three participating tribal communities were engaged both separately, through a local process, and together, through the development of the Native Transformations Community Action Board (CAB).

Each tribal community has its own system of governance, and a local oversight group was established at each site to guide the project through the appropriate local channels. The research was approved and implemented at each site according to its own tribal-specific decision-making process. Each tribe selected representatives to be members of the cross-site CAB that would meet monthly for the duration of the project. The resulting CAB consisted of 11 tribal representatives from the three communities, along with Tribal College/University project staff. The CAB has met monthly (29 times) since the project began and continues to meet as needed. The CAB has been active in guiding and contributing substantially within all stages of the research, including development of the research questions and data collection tools, recruitment and interviewing, analysis of the data, and interpretation and sharing of the results.

Participants

Our original goal was to recruit and interview 60 adults (ages 21 years and older) from the three tribal communities, proportional to the size of each community and stratified per CAB recommendations by age group (21-35 years, 36-55 years, 55 years and older), gender, and sobriety category (lifetime wellness and secure wellness, defined below). The CAB chose the two categories of wellness as being more holistic and better representing the reality as lived in the three Coast Salish communities than sobriety. Lifetime wellness was defined as individuals who may have experienced other hardships and challenges, but had not had a problem with drugs and/or alcohol, and were considered good role models of resilience. Secure wellness was defined as those individuals who did at one time in their lives have a problem with drugs and/or alcohol, but had changed their lives and had not had a problem with drugs and/or alcohol for 3 or more years and were at the current time considered good role models of recovery.

We interviewed 62 adults from the three communities, exceeding our recruitment goals, and could have interviewed many more interested participants but were constrained by timeline and budget. As can be seen in Table 1, there were 26 individuals in the Lifetime Wellness group and 36 individuals in the Secure Wellness group, with age group and gender represented fairly equally across each of the wellness categories and tribal communities.

Table 1. Native Transformation Project Research Participant Age Group, Gender, Community and Wellness Group.

	Tribe A (n = 27)		Tribe B (n = 21)		Tribe C (n = 14)
Sobriety Status	Female	Male	Female	Male	Female	Male
Lifelong Wellness: 21-35	2	1	1	0	1	1
Lifelong Wellness: 36-55	1	3	1	2	1	1
Lifelong Wellness: 55+	2	2	2	1	4	0
Secure Wellness: 21-35	4	1	1	2	0	0
Secure Wellness: 36-55	1	2	2	3	1	2
Secure Wellness: 55+	4	4	1	5	2	1
Total	14	13	8	13	9	5

Procedures

By recommendation of the CAB, two of the primary researchers conducted all of the interviews for the project. CAB members assisted with local recruitment, nominating individuals from their communities known to be role models of strength and wellness. CAB members assisted the interviewers in making contact with nominated individuals from their communities, and sometimes went with the interviewer to the interviews. In a few cases, they stayed for the duration of the interview, at the request of the interviewee. Volunteers also were sought through local advertisement of the research at community meetings and health forums held at each tribal site. Finally, a snowball recruitment approach was utilized, with each participant being asked to nominate another individual or individuals from their community who they considered to be positive examples of living well and being strong.

Each interview took place over the course of 1-2 days, and on average, lasted between 2 and 5 hours. Interviews were recorded using digital voice recorders, and all interviews were transcribed by a professional service. These interviews were conducted as part of a larger study of substance use and SUD histories using survey methodologies.

The transcribed life history interviews were uploaded into ATLAS.ti qualitative data management software, and analyzed by the entire project team. We used a constructivist grounded-theory approach (Charmaz, 2000) that incorporated a co-construction of the analytical process. The two interviewers coded the data using grounded-theory process steps that moved from memoing to open coding, and then to selective coding and theoretical coding (Glaser, 2005). The CAB reviewed memos and open coding lists, and then developed additional codes that were added at the selective and theoretical coding stage. A final code list was developed and approved by the CAB to answer the primary research questions of the study, which were to identify Coast Salish sources of strength and protection, and strategies for achieving and maintaining wellness.

The two interviewers coded the transcripts line by line. Each coder independently coded two randomly selected interviews to assess inter-rater agreement before the selective and theoretical coding stage began, and again at midpoint. First order agreement coefficients (AC1; Gwet, 2012) were computed to determine level of agreement. An ACI of .87 and .85 was obtained, respectively, indicating strong reliability.

RESULTS

Open coding of the life history interviews revealed sources of strength and strategies for wellness that were organized by the selective codes: family sources of strength, community sources of strength, individual sources of strength, and spiritual sources of strength. Family sources of strength include factors within Coast Salish lineage and family systems contributing to resilience and recovery, such as extended family, role and place in family, parenting and grandparenting strategies, and family traditions. Community sources of strength include references to community traditions and resources, opportunities to learn and participate in educational and wellness activities in the community, and environmental factors, such as having access to tidelands, hunting grounds, and sacred places. Individual sources of strength include references to personal strengths, and to strategies for being well and strong and for improving self-efficacy. Spiritual sources of strength include engagement in spiritual gatherings and activities in the community, personal spiritual engagement and beliefs, and prayer.

Family sources of strength were coded with highest frequency of any selective code on our code list, with 637 independent references. Code frequencies for community sources of strength, individual sources of strength, and spiritual sources of strength were 345, 501, and 241, respectively. Narratives from these four code families were analyzed separately by our team to identify patterns of recurring or shared protective factors within each of these four domains. Results provide deep description of these protective factors and wellness strategies, summarized in Table 2, which emerged from our analysis of Coast Salish sources of strength.

Table 2. Coast Salish Protective Factors.

Family Sources of Strength	Individual Sources of Strength
Teachings	Awareness
Family Roles, Rules, and Rituals	Working on Living
Protective Parenting	Helping Others
Ancestors	Honoring Your Gift/Speaking from the Heart
“Uncles”	Power of Mind
Powerful Women	Indian Names/Being a Namesake
Grandparents
Community Sources of Strength	Spiritual Sources of Strength
Opportunities for Learning and Healing	Welcoming in the Spirit
Social Connections	Belief in Prayer
Strong Elders	Gatherings
Traditional Laws	Warnings
Harvesting and Sharing Resources	Rites of Passage
Healthy Connections to the Past	Being on the Land/Water

Family Sources of Strength

Teachings

Protective families generally pass on teachings. Teachings provide moral guidance and instruction on how to live well. In the words of an NTP participant, teachings can “shoot like arrows into a person,” setting or righting a person on a path toward wellness.

The teachings that my dad and my grandmother and my mom shared were a big part of making me who I am. Mom and dad taught me was when you talk or when you speak, speak from your heart and my dad always said use as little words as possible. So those were good teachings and even from childhood he always said use your ears first, you’ve got two ears, one mouth, listen and think before you speak. At funerals, me and my brother and younger brother when things were done and chairs needed to be put away, we were expected to do that. My aunt and her husband eventually, we call it stood me up, as a young man, and said, well they didn’t say it but I knew that’s what it was, you’re going to be a cultural speaker. You’re going to stand up and speak for people at our ceremonies, particularly at funerals. So they didn’t ask me, they stood me up and it’s just the way it happens and so those teachings about thinking before you talk were putting me on this path. I don’t see those teachings anymore. I think all that leads into how you treat other people, how you treat yourself.

Family Roles, Rules, and Rituals

Families with clear roles for each member and rules to follow tend to be protective. Family rituals are activities that families do together on a regular basis, such as eating together, going to powwows, going out fishing, and helping at ceremonies and funerals. Family rituals provide stability and build cohesion.

My aunt had a huge part in my life. She was strict on rules, making sure of where I was at, what I was doing, when I was going to come back with limitations on when I could go places or who I can hang out with. A few times she did kind of loosen up, that’s when I slipped a few times. It started in middle school thinking I was part of the cool group of kids and whatnot, claiming the one color and thinking I was a gang banger and smoked weed. Me and one of my friends got caught smoking weed on school campus and we got emergency expulsion for a week, and my aunt, she didn’t like it at all. That’s when everything got tightened back down and I just kind of became a homebody, cleaned up the house, chores, helped her. As I was growing up with her, she was one of the cooks for all the funerals and ceremonies, different types of ceremonies, whether it be funerals, powwows, marriages, namings, gatherings. I helped her out in the kitchen and out on the floor, setting up tables, placing things. I’m pretty sure that was a huge part too by keeping busy and helping out with the community.

Protective Parenting

Having strong parental role models is also a critically important source of strength and protection within families. Grandparents and extended family members have critical protective roles in Coast Salish families, but the presence of a healthy and strong parent in the lives of our participants was also a key recurring theme in stories of strength.

In retrospect though, looking back at the situation, I think the experience with my grandmother especially after everything I’d been through in my childhood just really finally clicked me into a mindset that really prepared me for today. It was a real melding of both worlds-kind of thinking. I grew up in the inner city and had parents that although they weren’t together, and although they had their shortcomings, really instilled a lot in me as a young man. Then on top of that, being able to live with my grandmother, and just kind of learn from an Elder who grew up in that old-school time when Elders lived within the old teachings. It just really helped my way of thinking of things traditionally speaking.

Ancestors

Kinship knowledge (knowing who one’s relatives are, and being an active part of one’s lineage) is protective.

When you talk about the Indian culture, there’s one thing that is predominant in all of it, is family is central. Family is central to everything. It begins and ends with your family. We’re taught that our families go beyond first cousins and that we can claim a relationship in a lot of different ways and can go seven or eight or nine generations back. And you want to be related to families that have a lot of respect because you know if you claimed as a relationship, certain families, you get inherent respect that is shared by everyone because they do things in certain ways or they’re very dedicated to the traditions and teachings. And when you’re dedicated to teachings, you’re doing things in a proper way and good things happen to you.

Uncles

Protective families have strong male role models who, like the watchmen on a reef net canoe, look after the younger members of their families. “Uncles,” an English term closest to the Coast Salish meaning, play a key role in Coast Salish communities, providing guidance and discipline when needed. The role of uncle can be assumed by any of the older male relatives in an extended family system.

In our community a long time ago, the teachings to the kids came through stories, and the uncles. You see that a lot still. Boys who are misbehaving, their dads send them off to live with an uncle. And what I’ve observed from that is the uncle can be a little bit more strict and harder on a young man than a dad can be in teaching them how to follow the rules.

Powerful Women

Protective families often have central female figures that provide the “glue” and the teachings that hold a family together and keep a family strong.

I think what brought me through all this was my grandfather’s culture. He was raised by his mom, single parent, very strong, hard working woman. Our belief in our culture is something that’s been handed down to my grandfather comes from the mother, his mother. It was always handed down to the female of the family because it’s the female that’s supposed to be the glue of the family. And that was drummed into my head, that if I get a family to be the glue.

Grandparents

Grandparents, like uncles, can be any Elder member in an extended family system. Grandparents have a critical role in the development of wellness. Protective families generally have at least one strong grandparent figure who takes an active role in the upbringing of the grandchildren.

My son, he’s in sixth grade and he already says he’s going to college and knows what he wants to do with his life. It was pretty comical because his soccer coach was talking about college and he popped up and he said yes, I’m going to college or my grandma will kill me if I don’t go. And I looked at him because I was standing there and I said to him, and what will Mommy do? And he’s like, I don’t know. And he said I’m not worried about that, I’m worried what Grandma will do. It was like oh wow. It was pretty funny. He said Grandma’s going to make sure I make myself a good life. So I mean we talk about college and stuff, but he’s inseparable from Grandma and it doesn’t matter what we talk about, but with Grandma it’s like the law. If Grandma says something, that’s what it is. Sometimes I’ll ask him why do you feel that way and he said because Grandma’s your mom too and she’s the boss. So can’t argue with that I guess. She taught me well so I don’t mind.

Community Sources of Strength

Opportunities for Learning and Healing

Protective communities generally include opportunities for learning new skills, gaining new knowledge, and healing. Opportunities include access to both Euro-American and Coast Salish learning and healing.

Probably one of the best things that happened here on the reservation is when they provided on the job training and we got some real special instructors that really supported us. Some of us were encouraged to go to college. That was a big change finding out I really could learn and finding out a direction to go in, finding out something I loved to do. I was nineteen and was already married and flunked out of college and then went to the aqua-culture training program and found out I really could learn and then tried college again and ended up graduating.

Social Connections

Protective communities often build interdependence and provide emotional support. Social networks describe social connections in a community. Strong social networks create intergenerational interconnections. Social networks with strong, loving relationships, and those that include Elders, build resilience.

There was a sense of community then and there was a woman’s circle that my mother had in that period of time, and the women were quite strong. They had something meaningful. The relationships were built. So those same aunties are my aunties today and those women are still important to me. I saw a woman the other day in the casino of all places and she looked at me like, ’I should know you but who are you.’ She didn’t say anything, it was on her face. I told her my name and then my parent’s names and she goes, ’Oh I should love you.’ Now for me I thought it’s not me she’s talking to about that love; it was the love of everything. I can see her going back in time and connecting because there were all those kinds of pieces. I think for most of the people that I grew up with at that time will tell you some of the same things, that there was some structure, there was some community, there was these aunties and uncles that were watching and looking, and as we’ve grown, I’ve noticed that my children don’t have that sense of community. They don’t have that sense of the strengths of aunts and uncles in the same way.

Strong Elders

Strong Elders direct a path for learning and wellness for the people, family, and community. Strong Elders have the respect of the community and recognize their role and power to help the community heal.

Okay so sometimes on Facebook it can get kind of dramatic. One time when I actually put my feelings out, and I didn’t even make it really strong out there, I just made like a small comment and an Elder responded to my post. She said let’s have lunch and lets talk about this, and she had no idea what it was and I couldn’t say no because she’s an Elder, and so I went and had lunch with her and I think that is huge. I felt really, really supported because a lot of times… I actually worked for the Elders and a lot of them are going through their own struggles and don’t know how to interact with the younger generation. I mean I loved them and I cared for them, but it was so hard sometimes to always respect them just because of how they treated you as a young person. But then when that Elder reached out to me, it put a huge different twist on it. I’m like okay there are Elders out there that care and I feel like that’s really important in Native communities across the board is that they have that support from the Elders.

Traditional Laws

Protective communities guide themselves, enacting local rules and standards from within and teaching inherent rights.

It’s important that we continue to carry out these traditional laws. And they said if we talk long enough we can find out how we’re all related and we may have to go back to seven, eight, nine generations but we can all tie ourselves together. So we try to work that way. We try to think that way that when there’s something that happens in this community, it’s part of our family. So we act appropriately.

Harvesting and Sharing of Resources

Protective communities engage in traditional subsistence practices, including fishing, hunting, and gathering, with the sharing of resources among their members.

In a bigger sense, there’s work that keeps us together as a community and a meal is always there. Resources are always to share, there’s always food at the table spread, people are giving a meal and sometimes other resources are shared and traded and it’s all driven by resources. It’s all driven by what you’re harvesting. I call it the harvesting and gathering. You harvest the resources and you gather as a people. So during the time of harvesting, there’s the values and respect that’s shared between the family and then there’s bigger sets of traditions that are shared during the larger gatherings and I really believe it all resolves around resources, fish and animals and everything that kept our culture alive since we can remember.

Healthy Connections to the Past

Being part of a community’s success story is often protective. Recognizing the historical strengths of one’s community and the strengths of one’s ancestry also builds resilience.

In growing up with my grandparents, we always had to be proud of our coat as Native people. Don’t ever, ever take your coat off. The coat meaning our Indian heritage, our pride in our being a Native. Don’t ever take your coat off. You take your coat off and you’re open for everybody to hurt you. I kept my coat on though. I had to protect myself. Again protecting myself because nobody else will. My grandchildren, my granddaughters don’t believe that there was a time when people treated Indians so badly. I told them don’t ever, ever let anybody call you a dirty little Indian. You stand up, you show them your coat. You show them your knowledge of being who you are because I’ve already put names on my children, their cultural names. And mine was put on me when I was younger. You’re then taught to learn where that comes from, who had that name before you, how were they. And I say to my children that’s part of that coat. With that coat you’re carrying with you all that past.

Individual Sources of Strength

Awareness

Opening up to learning and healing can build strength and resilience. Gaining awareness is a key part of the process of awakening and transformation.

I realized that I had this whole pathway to follow. There was a great deal of reflection on what my mother did for our Nation, what my father did and what my grandparents did and my great parents did for us as a people and it was kind of like this spiritual thing. It was so strong in me that I was coming home from the smokehouse and I came to a stop light there outside the reservation and I started crying uncontrollably. It was like one in the morning, just all by myself and it was just so overwhelming and it was about my failures, it was about what was right, it was about my kids and like I was just blowing it. So I had to figure out what I am going to do then.

Working on Living

Individual contributions to family survival and success are often protective.

We had our duties to do, chores to do and it was nothing for me to get up at 6:30 in the morning and do something. Like I said my mom and dad taught us how to do that kind of stuff, I mean get up and go to work, get up and go to work whether it’s picking berries or whatever. And the hours of work at home was nothing compared to the ten hour days we spent in the berry patches and cucumbers and stuff. So it was easy duty for me and we just enjoyed it. It was really a rewarding thing. I still thank my dad and my mom for doing that survival mode with me.

Helping Others

Doing and caring for others, especially Elders, helps build resilience.

When I was really young my mom would take me to Grandma’s quite a bit. So my Grandma was another support for me, but she died when I was ten or eleven. I can remember cooking and cleaning a lot. She showed me how to crochet, how to manually do quite a bit with the home. Then when I got older into my teenage years, she had me babysit for some of my aunts and uncles and she’d also send me to the Elders houses’ that lived by us and she’d have me go sit and talk to them or help clean their houses. So if their dishes needed to be done, I’d go and do their dishes. If their bathroom needed to be cleaned, things like that. So I learned how to cook and clean at a young age but then when she’d send me to go help cook and clean for the Elders I never looked at it like a chore, it was just something that we did because it was something that they needed help with. But I remember just being so interested because they always had cool stories to tell, funny stories and tribal stories and I really took a big interest in learning about my family tree.

Honoring One’s Gift and Speaking from the Heart

Gaining knowledge of one’s own personal strengths and special abilities contributes to protection. Honoring oneself, as one is, and learning to speak from the heart, build resilience.

So within the community, everybody’s got a gift and we’re taught that you need to honor that gift. If you don’t use it, the Creator’s going to take that gift away. Whether it’s your voice, or speaking from the heart, or whether you’re a cook or a hunter, those are gifts that God gave you to help your people.

Power of Mind

Individual spiritual power was seen as protecting bodies and minds. Individuals with power of mind believe in themselves and demonstrate strong self-efficacy.

Even at childhood I said when I have my kids, my kids will never, ever go through this. So I remember very, very young saying never again. When I’m old enough and on my own and I’m able to change my life, none of that will be in my life. So it’s kind of weird and you know I never really talked about that but I mean, that was some pretty big feelings to have as a child. Most kids are worried about watching TV and running to get their bike or whatever, but I was thinking about… I was always thinking about even as young as elementary school, I was always thinking about my life as an adult and how different it would be then when I was a child and how those bad things scared me.

Indian Name and Being a Namesake

Having an Indian name and knowing about the relative for whom one was named build strengths.

Native pride isn’t a tattoo, it’s how you live. It’s the humbleness you have about where you come from, the family that you come from, the Elders that came before and that’s my grandmas, my grandpas, my uncles. It’s that pride that you have and where you come from. That was one of the things that dad said is to be proud to have your family name. Be proud of the people that you come from. You come from strong people. Strong beliefs. Don’t do things to drag that name through the mud.

Spiritual Sources of Strength

Welcoming the Spirit

An important protective factor is recognizing the spirit that lives within, and knowing how to engage in a healthy spiritual relationship.

As an alcoholic I think we’ve lost our spirituality. We lost our spiritual connection through our alcoholism and our drug addiction. I don’t think our spirit wants to be in our body as long as it’s being abused by alcohol and drugs, so it leaves. So when I sobered up, it was like the spirit came back in and it wants to live in this house again, but I don’t know who he is. So through this, I’m learning my spirituality, my culture. I have a higher power. I have God. And it feels so good to have that feeling of wholeness. It’s comfortable. It’s a warm feeling. I don’t know how to explain it, but it was somebody that wasn’t there while I was using. It takes a while to understand it. It takes a while to understand the spirituality. That’s what’s really lonely I think when we’re using, is there’s not a spirit living inside of you and we’re more spirit driven people than we are human driven people. This human life is just what we have. The spiritual is going to live forever. So it feels good to welcome that spirit back in.

Belief in Prayer

Similarly, believing in and accepting the power of prayer, and knowing how to pray, were seen as protective and strengthening.

Creator first. If you don’t do that then you won’t have a fighting chance. That’s the way I look at it. Because if you got nothing to believe in at the start and then it’s going to be a tough battle because you’re going to get knocked down and the Creator’s going to be the one picking you back up. It’s why the beliefs. Like I said I got my Native culture and my powwow culture and Shaker, everything that I’ve learned tells me it wasn’t that bottle that made me feel better. It wasn’t the counselor that made me feel better. It was the prayer that I had when I was at my worst. If people can remember that then they can get through it as long as they believe. You’re always Indian and all Indians have always known how to pray. It’s just that they need to practice it more to be better people, be stronger people, to be proud.

Gatherings

Protection is often created by engaging in ceremonial and spiritual activities, together with other members of the family and community.

So a lot of the Tribes have ceremonies. We’ve been taught that if you thank salmon for giving up its life to you, you thank the deer, the elk, for giving its life so you could survive you’ll always be successful because that resource it allows itself to be caught so that we can be successful but only when we pay our respect. So a lot of us when we go fishing, we thank salmon, we thank the water, we thank the resource itself for being good to us.

Warnings

Giving verbal and nonverbal signs of acknowledgment and respect for the spirits and the spiritual life was frequently described as protective.

Well she taught me respect yourself, of course. You’re Native. You walk tall. You’re the first people that ever walked in this country and don’t let anybody put you down because of that. And so I always remember that. And then she would teach me things like—well first of all always respect your Elders no matter who it is. Always respect your Elders and I’ve always done that. I could just see my mom turning in her grave if I ever didn’t do that and things like; you don’t eat food in a cemetery, you don’t drink in a cemetery, you don’t step on graves, things like that. You don’t whistle after dark. I remember all the little things. You don’t cry outside after dark. You don’t hoot and holler after dark unless it’s in a ceremony and you don’t sleep with your curtains open or your blinds open.

Rites of Passage

Events marking an important stage in a person’s life often protect by building a sense of purpose and place as part of a community. Rites of passage can include receiving an Indian name, receiving a song, receiving first Communion, and hunting one’s first animal.

He’d walk me through sticker bushes. He says those are people’s words. If they sting, it just goes away. That’s another thing. The stinging nettles, they sting just for a little while and they’ll go away. Those are people’s words. Don’t let them hurt you. I think we as grandparents need to be teachers again and not be so darned busy. I hear people talk about their culture but they don’t live it. Words are cheap. You got to feel it. You got to walk it and I do now. Like even helping somebody with their funeral, there’s a protocol. Like I just came from one yesterday. I had my granddaughter walking with me, I’m teaching her. I told her you’re going to be my legs. I just told her what she had to do and she did it. You’re grandma’s legs. She went and did it and I feel my grandfather, like he’s channeling me to teach her now using his tools. I don’t see very much of that. I don’t. I don’t see that in our community very much at all. You got to do it. The way they did me, I’m doing it to my granddaughter. She’s going to go for the walk in the sticker bushes too.

Being on the Land and Water

Being out in the forest, in the mountains, and out on the sea are generally protective because those activities strengthen one’s spirit.

My Papa was a fisherman, he was a commercial fisherman. There would be a lot of times where he’d just take mamma and I out in the boat with him, out in the open ocean and I was a little kid, okay. You’re wondering, how the heck did she stay on the boat? Because those are high waves half the time. Well, they tied me to the boat. So if I fell over and they don’t see me on the boat, they just pull me back in. Now Papa, when I was a teenager, he says there’s a reason I did that to you if you really think about it. The waves are the things in life. I’ve tied you to my boat. You fall off, I’m always going to be there. That’s family. So I told my kids I don’t have a boat but I’ll share my story. I got a Suzuki… But I’ve never, ever forgotten it. I’m still tied to the boat. I’ll always be tied to the boat. But being tied to that boat is I’m tied to my culture. I’m tied to my heritage. That’s where our strengths have to come from. That’s where our teachings and everything comes from, from our family boats.

DISCUSSION

The NTP described a rich array of Coast Salish cultural strengths. These strengths can be used as the building blocks to a cultural theory of protection from SUD in this tribal setting. These results convey a detailed, deep description of the specific settings, acts, and behaviors that generally provide protection on the family, community, individual, and spiritual levels within Coast Salish local tribal cultures.

The People Awakening Project offers a blueprint for how this type of protective factors model (Allen, Mohatt, Fok et al., 2014) can be used to guide culturally grounded intervention development (Rasmus et al., 2014). The People Awakening work also provides an example of how protective factors can be used as tribal-specific behavioral health indicators that can be measured (Mohatt et al., 2014).

The descriptions of protection emerging from the NTP findings also suggest why importing mainstream treatment and prevention models into this cultural context may not be the most effective approach. Similar to the People Awakening findings (Mohatt, Rasmus et al., 2004), NTP identified a number of distinctive, tribal-specific protective factors unaddressed by existing mainstream intervention. For example, the culturally distinctive protective factor of “powerful women” aligns with Coast Salish Indigenous social orientation through the mother’s lineage (Suttles, 1987). Also distinctive is “honoring one’s gift and speaking from the heart,” which aligns with Coast Salish values of public speechmaking and oral exposition (McHalsie, 2007).

In addition, a number of the NTP findings overlap to a significant degree with similar, but not entirely identical, concepts mapped by the People Awakening protective model and by researches working within other tribal settings. Examples of this overlap include the Coast Salish protective factor “power of mind,” which displays a number of parallels to “ellangneq (awareness)” in the Yup’ik context (Allen et al., 2006). Similarly, “helping others” in the Coast Salish context bears a number of similarities to “communal mastery” in Yup’ik settings (Fok, Allen, Henry, & Mohatt, 2012), which, in turn, was a variable originally studied with Northern Plains American Indian women (Hobfoll et al., 2002). These and other findings of cultural distinctiveness and of overlap with other tribal settings suggest convergence with the translational CBPR intervention research pathway adopted by People Awakening (Allen, Mohatt, Beehler, & Rowe, 2014). They suggest the potential for broader and more generalizable applications of the NTP findings for community-based and culturally grounded efforts to create more effective substance abuse interventions for Native people.

Despite this promise, a number of limitations exist regarding the generalizability of the NTP findings. First, interpretations of the data may be generalizable only to the participants from the three Coast Salish tribal communities that took part in the NTP study. Additionally, participants in the study were all over the age of 21, and findings may not be generalizable to youth in the communities. Finally, the study looked broadly at resilience from SUD, but the majority of participants described wellness from AUD or polysubstance use disorder that involved alcohol. Currently, the three tribes participating in the study all report rising incidence in opioid misuse and overdose. Findings from the NTP study may not be generalizable across all types of SUD. More research is needed to ascertain the relevance of our findings to other Coast Salish individuals and communities, and the degree to which the results generalize across other tribal cultures, age groups and SUD experiences.

The next steps in a program of CBPR intervention research involves a crossing of paths with the roadmap provided by the People Awakening Project (Allen, Mohatt, Beehler, & Rowe, 2014). Similar to the People Awakening translational pathway, our next step with Native Transformations is the development of a Coast Salish Wellness and Protective Factors Model that could be tested using measures developed from the People Awakening work along with new measures specific to the Coast Salish American Indian community context (Allen, Fok, Henry, Skewes, & People Awakening Team, 2012; Allen, Mohatt, Fok, et al., 2014; Fok et al., 2012; Fok, Allen, Henry, & People Awakening Team, 2014; Mohatt, Fok, Burket, Henry, & Allen, 2011). Such efforts have the potential to address a number of key Coast Salish elements in these communities left unaddressed in mainstream interventions.

The NTP findings describe key elements of what is lacking in conventional interventions as applied to tribal communities. The findings may provide explanations for 1) why outcomes for Native people treated with conventional interventions are not as positive as outcomes for the populations that comprise the evidence base of these interventions (Dickerson et al., 2011; Evans et al., 2006), 2) why minor adaptations of existing interventions may not be as effective with Native populations, and 3) why such adaptations, to be promising, must be extensive and based on a Native worldview (Venner, Feldstein, & Tafoya, 2007). These findings give voice to stated community preferences for grassroots Native intervention programs based in local cultural knowledge, worldviews, values, and theories of change, that operate at the local level on their own terms. However, at their heart, the NTP findings are a message of hope, and the strengths they portray provide an answer to the participant’s question that opened our paper, “What generation of our people is going to not have alcohol or alcoholism in their family or home?” NTP provides the tools for “it to be in mine.”