TIP 61: The Ultimate Beginner’s Guide to Providing Culturally Competent Behavioral Health Services for American Indians and Alaska Natives

Treatment Improvement Protocol (TIP) 61: Behavioral Health Services for American Indians and Alaska Natives, For Behavioral Health Service Providers, Administrators, and Supervisors

The TIP Series

The Treatment Improvement Protocol (TIP) series reflects the Substance Abuse and Mental Health Services’ (SAMHSA) mission to provide science-based and health service research, demonstrated experience, and implementation requirements. Each TIP manual contains the input of non-federal professionals who practice in the field, including clinical researchers, service providers, program administrators, and client advocates. The purpose of each TIP is to convey the latest research and clinical methods for treatment of substance use disorder or mental health disorder to practitioners in the field so that new and promising approaches can be implemented quickly and easily.

The Development of TIP 61

Published in 2018, TIP 61 is designed to work as a guidance document for those working with clients who identify with American Indian and Alaska Native cultures. All approaches for preventing and treating addiction and mental illness, and the counselor competencies for providing behavioral health services to American Indians and Alaska Natives are culturally adapted. Approaches have been tailored through a consensus-based process in collaboration with American Indian and Alaska Native professionals. This guidance was developed in consideration of the many disparities clients of diverse tribes and communities have experienced collectively in access to care, funding, resources for health services, quality and quantity of services, treatment outcomes, and health education and prevention services. The strategies, tools, and practices provided in TIP 61 help behavioral health providers to overcome or address these disparities. The bibliography of this – and all TIPS – provides references for all research used so that practitioners who wish to access original articles and studies have the option to delve even deeper into the process of building cultural responsive treatment services for working with American Indian and Alaska Native clients and communities. Available documents include the TIP 61: Full Document, for behavioral health service providers; TIP 61 – Executive Summary, for behavioral health service providers, program administrators, and clinical supervisors; and TIP 61 – Literature Review, for behavioral health service providers, program administrators, clinical supervisors, and researchers. Through TIP 61, particularly Part 1—Guide for Providers Serving American Indians and Alaska Natives—described here, all audiences will gain increased understanding of:

• American Indian and Alaska Native demographics, history, and behavioral health;
• Cultural awareness, cultural identity, and culture-specific knowledge for working with clients from the named cultures and communities;
• How health beliefs, help-seeking behavior, and healing practices are impacted by client cultures and communities;
• Interventions for prevention and treatment that are grounded in evidence-based and culturally adapted practices;
• Ways of becoming culturally responsive at the program level by using American Indian and Alaska Native beliefs and heritage in all aspects of programming and staffing (SAMHSA, 2018).

Figure 1

Key Messages of TIP 61

Figure 1 provides “Medicine Wheel” type visual example of how the full TIP 61 document “Key Messages” relate to each of its intended audiences and to the journey toward cultural competence (SAMHSA, 2018). Nine main themes or messages emerged from consensus panel conversations and are listed and paraphrased here, along with one or two relevant examples each of topics or tools covered. They are meant serve as “core concepts” for practitioners as they journey toward providing culturally responsive treatment.

1. “Importance of historical trauma” This section covers not only the history of traditional cultures and historical trauma, but also its impact on American Indians and Alaska Natives at the time it happened and how it currently still impacts them. The “Cycle of Historical Trauma” provides insight into the connection between trauma and increased risk of substance abuse and dependence, as well as risk of suicidality, mental disorders, and issues such as homelessness and unemployment. The Myths and Facts About American Indians and Alaska Natives section dispels many misconceptions, replacing them with accurate information.
2. “Acceptance of a holistic view of behavioral health” This principle does not have a section but is important as a basis for beginning all treatment for substance use and mental disorders because within this cultural perspective they are viewed as symptom rather than diseases, diagnoses, moral maladies or flaws.
3. “Role of culture and cultural identity” This section expands on the basic premise that substance use and mental disorders are a direct consequence of loss of culture and cultural identity. One excellent tool is the Cycle of Assimilation and Reconnection that helps provider and client examine current self-perceptions of cultural identity and helps begin the process of reconnecting with native cultural identity. Another strong part of this section is the insight into the importance of worldview, cultural values, sense of community, beliefs, and overall family structure are for implementing culturally responsive treatment.
4. “Recognition of sovereignty” In this section, the importance of understanding the sovereignty of tribal governments is stressed to underscore the importance of including the tribal systems in all aspects of treatment, including referrals, planning, cooperative agreements, and program development to help ensure success.
5. “Significance of community” Here the importance of including community leaders, councils, clients, potential clients, and client families is stressed for the purpose of receiving important input into the treatment process, matching treatment to clients, and to increase utilization of services by the community. One part of this section includes a Traditional American Indian and Alaska Native Values and Beliefs tool listing native cultural beliefs and values and questions about personal beliefs and values to help evaluate how culture affects beliefs and discover not only differences, but more importantly, similarities.
6. “Value of cultural awareness” This concept is vital to providers understanding how their own culture affects their worldview and that of their clients. Tools from the previous section are also particularly useful for self-examination of beliefs, experiences, and biases so providers can acknowledge how they impact interactions with clients.
7. “Commitment to culturally responsive services” This key concept reiterates the obligation for providers to protect the welfare of clients by dedicating themselves and their organizations to cultural competence and culturally responsive practice.
8. “Significance of the environment” This key message involves adapting business practices such as hiring native community vendors, workforce, and professional development activities that focus on culturally specific client and community needs to show respect for and actively engage clients identified with American Indian and Alaska Native cultures.
9. “Respect for many paths” This concept allows for the most cultural personalization of treatment because it recognizes that though a practice may be evidence based, if it is not based on native participation it may not be reasonable to impose the treatment method on native communities. Respect for many paths is the understanding that instead of “one right way, there are many paths to healing” (SAMHSA, 2018).

The journey begins in the east and ends in the north, moving through a full circle: “Everything the power of the world does is done in a circle. The sky is round, and I have heard that the earth is round like a ball and so are all the stars. The wind, in its greatest power, whirls. Birds make their nests in circles, for theirs is the same religion as ours. The sun comes forth and goes down again in a circle. The moon does the same and both are round. Even the seasons form a great circle in their changing and always come back again to where they were.” —Black Elk, Oglala Sioux (as interpreted by J. G. Neihardt) Source: Black Elk & Neihardt, 1932, p. 121.

Some of the highlights of Chapter 1, Parts 1 and 2 are:

• A general focus on developing the knowledge, skills, and application of cultural competence in treatment counseling. While not every concern is addressed, the more common of American Indian and Alaska Native clients’ needs are covered, making this an excellent place to begin the path leading toward cultural competence.
• EXHIBIT 1.1-1. Timeline of Significant Events in Native American History
• EXHIBIT 1.1-4. Traditional American Indian and Alaska Native Values and Beliefs
• EXHIBIT 1.1-5. Examples of Culturally Adapted Treatment Approaches
• EXHIBIT 1.2-1. Vignette Summary Table
• EXHIBIT 1.2-2. The Stages of Change Model
• Microaggressions section describing the “brief, everyday slights, insults, snubs, derogatory statements, or indignities” that American Indian and Alaska Native clients are exposed to, whether they are intentional or unintentional.
• An excellent “RESPECT” mnemonic describing culturally responsive attitudes and behaviors
• A description of Traditional Healing, how it works, and examples of some traditional healing methods used by American Indian and Alaska Native
• A section on Choosing Directions: Intake, Assessment, and Treatment Planning, including culturally appropriate assessment tools
• A section on Considering Culturally Adapted Treatment Approaches that assists providers in choosing culturally adapted evidence-based approaches and what considerations providers should be concerned about.

Part 1 Chapter 2:

Chapter 2 centers around four stories of providers and their clients, and incorporates the key messages from Chapter 1. The manual notes that “The consensus panel has made significant efforts to present realistic counseling scenes using culturally responsive approaches that include integrating traditional healing with mainstream approaches such as motivational interviewing (MI), family therapy, CBT, and psychoeducation, as well as other modalities.”  Four stories and vignettes incorporating key concepts covered in part 1 Ch 1. are included. “Master Provider Notes” are interspersed comments about the strategies used, possible alternative techniques, and insights into the client-provider relationship that reflect experience and wisdom of the consensus panel and other contributors.

The vignettes are very useful for integrating traditional practices with mainstream approaches. For instance, “Vignette 4—Philip: Making Connections Between Losses and Alcohol Use, Using One-Stop Outreach and Case Management Services for Homelessness and Treatment Service Needs, and Building Relationships Using Traditional Practices in Recovery, along with “Is it a Cultural Belief or is it a Diagnosis?” provide realistic illustrations and examples. The Master Provider Notes provide expert insights about commonly encountered issues such as suicide and homelessness, and “Learning from the Elders” helps providers to move away from the Eurocentric framework that most non-American Indians and Alaska Native operate within. This guidance always walks the fine line between mainstream and traditional approaches while focusing clearly on the culture, needs, and what is appropriate for the individual client. The vignettes are mini success stories that illustrate how well treatment can work when providers take the time and make the effort to be culturally responsive and to implement both traditional and mainstream strategies as each client requires.

Part 1, Chapters 1 and 2 are directed primarily at the audience of providers who are seeking to become culturally competent and provide culturally responsive treatment. TIP 61 is a guidance document that truly provides a “path” for those who are willing to walk it. The method by which this document was produced, involving a variety of clinical researchers, service providers, program administrators, and client advocates from a wide variety of American Indian and Alaska Native cultures takes advantage of all of the richness that cultural diversity has to offer. While Part 2 Chapters 1 and 2 on Becoming a Culturally Responsive Organization and Developing a Culturally Competent and Responsive Workforce have not been covered extensively in this post, the social, health and business benefits to organizations that take a culturally responsive approach to care are abundantly obvious. Part 2 appears to be full of the nuts and bolts of managing at the organizational level, but in a strengths-based, integrated and culturally responsive way. Included are the processes for:

• Learning the basics of how to collaborate with tribal leadership,
• Understanding and respecting differences,
• Learning tribal history and the impact history and historical trauma have on communities,
• Establishing trust for open, honest, and culturally appropriate communication,
• Providing trauma-informed care,
• Making use of inherent tribal strengths, and how to meet the challenges of administration with viable, culturally appropriate solutions,
• Use of data and how to gather and analyze it for reports and to obtain funding.

Add to all of this a very useful section that clarifies the terminology used in the document and a comprehensive Part 3: Literature Review, and this document is one that belongs not on the bookshelves, but in the toolbox of every behavioral health provider, behavioral health service provider, program administrator, clinical supervisor, and researcher pursuing cultural competence and the provision of culturally responsive treatment services for substance use and mental disorders. Please see our Resources and Uploads section for many of the resources referenced in TIP 61.

References

Substance Abuse and Mental Health Services Administration. Behavioral Health Services for American Indians and Alaska Natives. Treatment Improvement Protocol (TIP) Series 61. HHS Publication No. (SMA) 18-5070EXSUMM. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2018.

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