Native Americans, Alcoholism, and the Failure of Treatment
January 12th, 2009 |
A GoodTherapy.org Featured Column written by Mary Ellen Barnes, Ph.D. & Ed Wilson, Ph.D., MAC
Click here to contact Mary Ellen and/or see her Profile
Click here to contact Ed and/or see his Profile
A colleague recently asked me for my assessment of the applicability of the “disease model” of alcoholism with regard to Native Americans. She asked not only because my adopted children are Inyupik, and from alcohol devastated families in northwestern Alaska, but also because I have worked in non-traditional ways of combating alcohol abuse for over twenty years.
My answers have evolved out of the past forty years of my experience, work, observations, research, discussion, and reflection.
To begin with, the repeatedly discredited “disease model” negatively impacts everyone suffering from alcohol abuse – not just Native Americans; and second, “Native American” is also a counter-productive term, one implying that there is only one homogeneous group indigenous to North America. Nothing could be farther from the truth.
To exemplify, Alaska alone, is home to three distinctly different “Native” groups: Aleuts; the Yupiks and Inyupiks (”Eskimos”); and over twenty different “Indian” tribes. Within and between these entities the degree of alcohol use and abuse varies widely and so do solutions to their alcohol related problems.”
However, it is true that across the continent, including Alaska and Canada, Native Americans do exhibit a higher percentage of alcohol abuse and dependence than many other groups, though again, not in every case. Still, given the high incidence it’s tempting to want alcoholism to be a disease, rather than looking for more complicated and less forgiving causes. However, regardless of the group being considered, alcohol abuse and dependence rates really are a reflection of an accumulation of contributing social, psychological, biological, and cultural factors.
Consider for a moment one such factor: that alcohol use is frequently a matter of learned behaviors based on community and cultural expectations. Most of us adopt alcohol use, and abuse, as patterns from our family, our community, and society at large. Who introduced alcohol to Native Americans? Prospectors, whalers, soldiers, and others whose immoderate alcohol “use” is now reflected in many of today’s Native American’s usage, and these stereotypical patterns continue to be handed down from one generation to the next.
Of course these learned behaviors could be changed if they weren’t serving a purpose, which, unfortunately, they do. For example, in many cases being drunk is a readily accepted excuse to diverge from cultural norms – an excuse to act out aggressively rather than adhering to a passive conformity, for example. Community members hesitate to criticize someone for getting drunk and acting out this week when they may themselves want to get drunk and do the same next week. (Again, however, please remember that this isn’t a pattern unfamiliar to many other communities.)
Drinking is also a way of achieving some temporary respite from crowded living arrangements that don’t allow for any privacy. Thirty years ago my neighbor on the upper Yukon was one of eight people occupying a cabin roughly fifteen by twenty feet – a cabin without electricity, running water, or any distractions. Who could blame him for disappearing into an alcohol induced stupor from time to time?
Alcohol also helps blot out the depression and frustration that comes from a seemingly hopeless future. In many communities the most capable people have left, pursuing educational, vocational, and social opportunities. Generations have seen a steady decline in leadership, stability, and ability. In some cases, nearly all of the women have left, preferring the easier life available to them with non-Native husbands, college education, or city jobs. Who can blame them for leaving, or for the hopeless young men left behind from drowning their loneliness?
In addition to personal and community factors there are also political factors. Leadership within some Native American entities, like other ethnic or religious entities, is sometimes jealously held by families or individuals who see promoting alcohol abuse as a way of maintaining their positions and preventing rivals from threatening their power. “As long as they’re drunks, and their children are drunks, my children’s future is secure,” is how one Fairbanks Athabascan matriarch put it to me over twenty years ago, echoing her western Alaska Yupik counterpart two decades before that. They were right.
The unending problem, of course, is that alcohol also makes all of the problems it “solves” worse; providing temporary fixes which preclude long term solutions. Depression that encourages alcohol abuse, while making the depression worse, is only one of a number of short and long term “Catch 22” features of alcohol misuse.
Returning to my colleague’s original question, viewing alcohol abuse as a “disease” makes maintaining the status quo easier for everyone. It obscures the real problems and sidetracks everyone from seeking and implementing real solutions.
On the other hand, if it’s a choice, , then changing the habits of use and abuse becomes matters of individual, family, community, and political choice. Predictably, however, there aren’t a lot of people anxious to sign up for responsibility when being a victim is so much more appealing, at least for today. After all, having a disease over which I am powerless is the perfect excuse to keep on drinking. Changing, on the other hand, requires a sustained effort along with the acceptance of responsibility for one’s own situation and decisions.
The picture I have painted in this brief essay is, of course, a simplification – a picture that includes only some of the major factors that contribute to the ongoing destruction of what? Nor have I discussed the individuals, communities, and tribal groups who have successfully navigated through alcohol’s traps and temptations and achieved a sober and satisfactory life. Many more could, and would, with social and political supports that addressed the underlying needs and factors from a realistic perspective.
Is that apt to happen? Not as long as “treatment” reinforces the hopelessness and powerlessness that that failed industry provides and depends upon. Not as long as leaders externalize the causes they profit from financially and politically rather than addressing the real needs, problems, and attitudes which support continued alcohol dependence. Not as long as “alcoholism” is seen as a cause rather than a symptom. Not as long as being a victim is preferable to assuming responsibility for ourselves and for our communities.
Clearly, alcohol abuse is not a disease, and the solutions – including real assessment of individuals and communities; the provision of active opportunities vocationally, socially, and recreationally; and the refutation of a passive “disease” mentality – are no different for Native Americans than they are for the rest of us. But it requires the courage to acknowledge the mistakes of the past, to implement real change, and to withstand the objections and sabotaging of those who profit from business as usual.
For more information about Mary Ellen Barnes, Ph.D. & Ed Wilson, Ph.D., MAC visit http://www.non12step.com
©Copyright 2009 Mary Ellen Barnes, Ph.D. & Ed Wilson, Ph.D., MAC. All Rights Reserved. Permission to publish granted to GoodTherapy.org. The following article was solely written and edited by the author named above. The views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the following article can be directed to the author or posted as a comment to this blog entry.
20 comments so far
I totally agree with alcohol making the things it temporarily solves much worse. Ethnicity and traditions is only an excuse. Most times people dont want to leave their comfort zone and help themselves making that the primary reason for not wanting help with alcoholism.
I agree that when you drink, it’s a choice you take upon yourself, whether it starts as a stressful situation, or because you are missing something in your life. Alcohol seems to make you forget for a moment the things that you do not want to face or accept. I know many people believe it’s a disease and I often wonder myself if its a disease or a habit as in smoking.
I think many people face this, not just Native Americans…. There are things that trigger someone who wants to depend on alcohol, whatever that may be. The different situation mentioned in this article just goes to show why people turn to alcohol.
Perhaps Native Americans have turned to alcohol to help drown their misery over the conditions and the ways in which they are continually treated in this country.
Sarah, you have a good point there. Native americans were treated unfairly. It seems like nothing has changed and we wonder why a lot of us turn to alcohol, even if it is a temporary fix.
I agree that the disease model doesn’t really work all that well, although it seems to be a good place to start once a person decides they want to stop the abuse. However, I think the idea that it’s a choice certainly turns the model on its head. Along with that comes so many other possibilities, but no less challenge than trying to change a serious set of behaviors/habits.
I would be hard pressed to think of any individual or group that can’t claim to have been “treated unfairly” and as long as that excuse is acceptable to justify self-destructive behavior then very few people are going to change.
I found this article to be very informative as were the responses. On the matter of choice, however, beyond social and political influences, there are neurological/physiological influences although I am not comfortable with the disease model either. I think of, for instance, my patient who suffers from a psychotic disorder. It is quite common for individuals who experience auditory hallucinations to drink in order to quell the voices. These individuals also have a very difficult time letting others know that they hear voices due to stigma. So, yes, they do “choose” to drink but they do not “choose” to hear voices and they certainly don’t “choose” to be stigmatized. Ultimately, I do have to bring her to the realization that she does have some choice now that she has more of an understanding of her dilemma. But I would have to say that there are many circumstances wherein people are abusing alcohol in order to ameliorate symptoms of mental illness, symptoms that are impossible to bear. This makes the matter of “choice” one of degree. It is not black and white — quite colorful like the rest of the world.
The disease model as an explanation for alcohol abuse has always bothered me as well. I think that completely takes away the matter of choice from the problem, and ultimately that is not right. We all make choices in our lives, some good and some bad, and that is what the millions of people who have issues with alcohol are doing as well. Nothing is stopping them for getting it together and making better choices. I am not being judgemental but just stating the facts as I see tham.
Alison makes a number of excellent points, not least of which is the sometimes very “dual diagnosis” problem. Yet this too gets confusing as so many “mental illnesses” disappear along with the alcohol abuse and it takes a very aware and skilled physician to figure out the chicken and egg progression here.
Aside from these actual combined cases however, there is no research that supports a “disease model” and no lack of research which shows exactly the opposite. The model was initially put forth to justify insurance coverage but companies quickly caught on to that and have, mostly, refused to cover “treatment” with a less than 5% efficacy.
While the disease model does purport to lessen stigma it doesn’t seem very effective in this regard either. Frankly, it merely reinforces the “victum” mentality which usually justifies continued and expanded abuse. We, and our clients, have never had any problem understanding circumstances, habits, background, and other considerations as ample grounds for forgiving our history while preserving personal ability to make and maintain change without any continued and counter-productive focus on alcohol.
Finally (sorry to be long wonded this morning, apparently my coffee fix has kicked in) thank all of you for the thoughts and insights that keep us thinking and changing.
Thank you for this very interesting and informative article. I found it compelling. Your reasons for the development of the disease model are well stated. However, given the lack of evidence supporting this model (by the way, would love a quick summary!), why does it remain so popular among mental health professionals? The disease model was still being taught when I was in graduate school 8 years ago. Especially with the push for evidence-based practice, why are programs based on the disease model still being funded? Thanks!
In reviewing the research, look at the resources page on our website http://www.non12step.com and look both at the “Orange Papers” link )which has some problems but a lot of good citations) and the “Alcohol Problems and Solutions” site at the State Univassity of New York which is easily the best unbiased source on the web. We’ll also happily look at the diesase model in more depth in another entry.
Thank you!!
What a very controversial article. Although I am not familiar with the disease model, it seems like it is very well stated here along with many responses. I guess no one knows really how the Native Americans really felt and except they, themselves and I am sure to the native americans, they had their reasons.
I feel very sad for the Native Americans in this country whose needs and the care of have been completely ignored and overlooked by our country. They were the original inhabitants and we should do a better job to take care of any of our people, no matter the culture that they are from.
Do you think there is something about the Native American genetic line that leaves them predisposed to alcoholism? It seems to be so prevalent in that culture and I wonder if there has ever been any kind of common genetic marker discovered for those who suffer with this.
Genetic markers are the Holy Grail of alcohol research, but none have surfaced. The best work has come out of the MN Twin Study which indicated that possibly a 6% increase in vulnerability to alcoholism might exist – but that’s an insignificant number.
Granted, everyone wants to avoid responsibility for their alcohol abuse, and hence responsibility for overcoming it, but it’s really counterproductive thinking. There really are no lack of social, emotional, social, and psychological causes that could be addressed if the will existed and if those who profit from business as usual would find something productive to do.
Alcoholism is a disease, with well documented variability to susceptibility. But drinking is not a disease, it is a choice. And the effects from the disease of alcoholism can be avoided by making the choice not to drink. So in my book, both assumptions are correct. That is, there is a disease or at least a susceptibility process, but it can be controlled by choices that we make. We cannot get around the responsibility factor. It is not unlike adult onset diabetes. Diabetes is a disease, but in many cases it can be controlled simply by diet (choices). The disease of diabetes does not result in such problematic societal ills as alcoholism so it is treated differently in the social spectrum. But for alcoholism, because of the underlying currents that lead to drinking in the first place, our approach to treatment and right choices has to be sensitive, broad based, intuitive, strong and forgiving, all at the same time.
Excellent post. I agree that the disease model is a problematic way to look at alcoholism in Native Americans, just as it is problematic to label physically active children in financially challenged, overcrowded inner city schools as having ADHD or to diagnose borderline personality disorder in women from abusive family backgrounds. I think some people worry that if we discard the disease model completely, we will go back to stigmatizing people with problems and failing to recognize the ways in which they are actually unable to choose to be healthy, but what you’re saying is that we can adopt a compassionate point of view that rejects the disease model and at the same time fully acknowledges all the many challenges people face in the process of trying to change their behavior.
Thank you – there is always the tendency to want to afix a label as though that would somehow fix the problem, and, yes, it’s nice to have one that eases responsibility. But that’s always a two edged sword. If I’m not responsible for my behavior, then I am excused from changing it.
Of course there are always causes, and these are frequently understandable, which still allow an individual the responsibility, and the dignity, to create a better life for themselves. Unhappily the “disease” model merely reinforces continued and increased alcohol abuse.
I agree with the fact that the disease model reinforces continued and increased alcohol abuse. I believe that through the history of abuse with our native peope. There were times where the traders had these get togethers where everyone drank to excess, the native americans did what they were shown and thought it the right way to drink. Even our elders stated this was a way of learning. Today you hear from all of our cultures in America, learn from your elders. But yet we also learn good as well as bad. This habit of learning to drink is something that we have taken in and accepted as a community. Where the learning stops with change is at the community level. We can individually get sober, we can have a circle of spiritual friends that are also sober and support one another. But when we face the communities, its our communities that are not healthy. So Community as Prevention needs to be explored further and changes need to be made. As for someone saying that the idea of success being living in an urban setting, or being employed and making good money, I believe it’s an individual perception.