We identified three sets of challenges for bringing effective substance abuse treatment to AI/AN communities: challenges associated with providing clinical support, challenges associated with the infrastructure of the treatment settings, and challenges associated with the service/treatment system. These are summarized in Table
2. Of particular importance was the way these different sets of challenges interact synergistically with one another, creating a highly complex context for the delivery of these services. We first present these three sets of challenges separately for clarity and organization and then discuss their interrelatedness.
Table 2
Themes, subthemes, and examples: challenges to providing quality substance abuse treatment to AI/AN communities
Challenges associated with providing clinical support | Barriers to treatment seeking and engagement: sociodemographic | Homelessness |
Lack of transportation |
Legal issues |
High relapse |
Unemployment |
Barriers to treatment engagement and process | Complex trauma histories |
Diversity of patients |
Integrating culture into services |
Lack of motivation |
Stigma of treatment |
Challenges associated with the infrastructure of treatment settings | Frontline worker challenges: fatigue and burnout | Emotional and personal investment |
High caseloads |
Paperwork and administrative responsibilities |
Professional boundaries |
Shortage of staff |
Lack of program and treatment resources | Inadequate length of treatment |
Lack of office supplies and space |
Challenges associated with the service/treatment system | Barriers associated with providing | Limited housing options |
Adequate aftercare | Limited transportation resources |
Limited treatment options |
Appropriateness of treatments | Pressure to use Evidence-Based Treatments (EBTs) |
Excessive and unconstructive paperwork | Interference with clinical care |
Not pragmatic or useful |
Challenges associated with providing clinical support
Barriers to treatment seeking and engagement: socio-demographic
Participants cited AI/AN communities’ socioeconomic challenges as a primary obstacle to pursuing treatment. “There are so many survival needs that come first—housing, a job, food,” one provider explained, adding, “Things like outpatient treatment are probably last on the list” (Region E, Focus Group 1). Reiterating this idea, another provider observed, “People just do not have cars, gas, money, the ability to come here when they’re managing tough situations at home, kids, getting here” (Region E, Focus Group 1). As a result, providers indicated, only a small percentage of people in need of treatment actually receive it; and among the few who do receive it, treatment is often undermined. Capturing clients’ predicaments, one provider explained, “If I don’t have a roof over my head, then I don’t really care about finding my inner being, you know what I mean?” (Region F, Key Informant 3). Criminal records prevent clients from receiving employment, housing, and drivers’ licenses. These housing, transportation, and employment deficits, in turn, hinder a solid community-level foundation for treatment and sobriety. “Sometimes I forget they’re [h]ere for treatment. I’m just trying to get them a job or . . . to finish their GED . . . because [once they] get out of treatment, if they don’t have any of those things, they’re going to relapse most likely” (Region C, Key Informant 5). Because relapse rates and prevalence of misuse remain high, and substance abuse, considered a community-wide problem, persists: “You get one off the street and there’s two more to take his or her place” (Region C, Key Informant 5).
Barriers to treatment engagement and process
Individual trauma histories coupled with AI/AN communities’ shared history of oppression result in complex mental health and substance abuse problems that impact the treatment process:
“I grew up in an alcoholic home, I was raised in a foster home, I was in a boarding school, I may have had sexual abuse, I may have been physically abused or emotionally abused . . . .” That’s what’s walking in your door. It’s not simple. It’s not “I’m drinking a six-pack a day and I really get drunk on the weekends. Help me sober up.” [W]hat’s coming to light for our communities is the trauma that has happened for so many generations. . . . [S]o how do we fix that? (Region D, Key Informant 1)
Numerous providers cited clients’ “trauma upon trauma upon trauma” (Region B, Focus Group 1) and how these complex trauma histories can result in a significant mistrust of providers as well as additional mental health treatment needs.
Court-ordered treatment, mandated for a substantial percentage of clients, was described by study participants as undermining motivation, while stigma towards mental health and substance abuse treatment further precludes pursuing and continuing in treatment. Providers noted the additional challenge of bringing culture into services, due to the tremendous cultural and geographical diversity of AI/AN communities, and the fallacy of perceiving “all Indians as being Indians, rather than [understanding] we have 500 tribes in the United States” (Region F, Focus Group 1). Integrating culture, critical for the many AI/AN clients who prefer traditional rather than western approaches to treatment, is also hindered by limited cultural resources. Providers cited few local traditional healers and limited access to sweat lodges and powwows, most often due to transportation and funding deficits.
Challenges associated with the infrastructure of the treatment settings
Frontline worker challenges: fatigue and burn out
Serving clients with substantial, interrelated socioeconomic, substance abuse, and mental health needs demands considerable emotional investment from staff. As one provider elaborated, “you have to have a certain amount of flexibility and willingness to wade through the mud and muck of peoples’ lives every day because these people come in here when everything is falling apart” (Region B, Key Informant 4). Providers explained that personal commitment to clients’ treatment requires additional responsibility to maintain professional boundaries. It can also cause caregiver fatigue, resulting in high rates of turnover. A shortage of qualified staff, transportation barriers, and insufficient salaries yield chronic staff openings. As a result, “3 people have to do the work of 5” (Region C, Focus Group 1), thereby compounding caregiver fatigue.
Overwhelming paperwork and administrative demands, consuming up to 50% of time, further interfere with treatment, leaving providers feeling like “we’re constantly running against the clock,” “fighting to keep [our] nostrils above the proverbial water line” (Region C, Key Informant 4). The combination of high caseloads, patients with substantial needs, and significant administrative duties results in staff burnout related to feelings of ineffectiveness. Regarding her inability to meet clients’ needs, one provider commented, “I feel the desperation of people’s voices on the other end of the phone when they say they have to get intro treatment now and I have to tell them three to five months. . . . I hear their hearts drop on the floor” (Region C, Key Informant 4). Several program directors cited the need to provide staff with “mental health days” to recuperate and additional praise and support to sustain their efforts.
Lack of program and treatment resources
Limitations in programs’ physical infrastructure and other treatment resources add to workplace demands. Inadequate or poorly configured physical space (office space, waiting rooms, dining rooms, and group rooms) interferes with client confidentiality and programming. Computers, electronics, and kitchen supplies are often lacking, and training and treatment planning opportunities for clinical staff are limited. Capturing a common sentiment, one program director explained, “I’m always looking for funding. . . . It’s a huge challenge trying to provide everything you need….” (Region F, Key Informant 3), such as revamping treatment curricula or integrating novel treatment approaches. Specific limitations on the length of treatment (e.g., number of days in residential treatment, number of sessions in outpatient treatment) interfere with meeting clients’ significant vocational, housing, and treatment needs. “It’s a challenge to set treatment goals and to try to achieve them in 28 days, one provider noted, “because just about the time you get to know them and see a little progress, they’re ready to go” (Region F, Focus Group 1).
Challenges associated with the service/treatment system
Barriers associated with providing adequate aftercare
Numerous providers cited difficulties with aftercare, specifically limited housing and treatment options. Because housing is considered critical for sober living, inadequate housing resources impact lengths of stay:
[Clients] know if they go back to their homeland there’s all the drinking and drug use going on [so they] relocate, [but] sometimes we have people staying three weeks to a month later waiting for housing because of the [lack of] availability and the funding. (Region A, Focus Group 1)
Limited treatment options exacerbate transitions between residential and intensive outpatient or community reintegration, as well as between detoxification and treatment. They also result in lengthy waitlists and unmet treatment needs, particularly for pharmacologic treatment. “We’re lacking beds and treatment slots,” one provider explained, adding, “More and more people are saying ‘I need help,’ but that help isn’t there . . . because our waitlists are tremendous” (Region C, Key Informant 4). Transportation problems, including vast distances between the few treatment facilities and clients’ limited transportation resources, represent an additional barrier. Providers noted that some clients travel several hours each way, sometimes by foot or bicycle, to receive care.
Appropriateness of treatments
Funding sources frequently require using evidence-based treatments (EBTs), but numerous programs expressed concern about their applicability to AI/AN programs and their lack of flexibility, considered critical for working with AI/AN communities’ diverse needs. They also noted how EBTs have not been studied in AI/AN communities. “It’s all good and well to have evidence-based treatment,” one provider explained, “but for who? Who does it work for? . . . You’ve got to realize that it’s different in each community” (Region G, Focus Group 1). The pressure to use one EBT exclusively also contradicts providers’ tendency to, instead, “take a little from everything—from Matrix [an evidence-based program for substance abuse [
30]], from Red Road [an AI/AN adaptation of 12-step treatment approaches [
38,
39]], from whatever you can find” (Region D, Focus Group 1) in order to individualize treatment. Funding requirements to use EBTs combined with concerns about their applicability lead providers to feel “pushed into a corner” (Region F, Focus Group 3) and additionally burdened by treatment requirements that do not fit clients’ needs. “It may not be evidence-based,” one provider explained, “but what we’re doing works. . . . I don’t know how to make it evidence-based [but] if an expert came in who could figure out how to do [that], that would be great” (Region E, Key Informant 1).
Excessive and unconstructive paperwork
Administrative demands from government and funding agencies also hinder the personal connection deemed critical for collaborating with clients and facilitating treatment:
We’re burdened with the paperwork, a treatment plan, and everything being done in a timely manner, especially since we’re billing the State Mental Health Service . . . . [S]o they came and look at our files and all of that and they want these things done so we’re under pressure to do that. So we’re trying to balance that out with what the person really needs and how to connect with them. (Region F, Focus Group 2)
In addition to detracting from personalized and individualized care, funding agencies’ outcome measures also fail to portray the progress made. “What’s on paper does not show what happens in the lobbies and hallways” (Region C, Key Informant 4) one provider explained. Another provider noted, “sometimes the outcomes are . . . like a baby being born drug free . . . and that’s not something that you can necessarily measure by a survey” (Region F, Key Informant 3). Capturing the clash between clinical responsibilities and administrative burdens, another provider emphasized, “You don’t provide a service just because it helps your numbers. [You] provide a service because you have the heart to help an individual get better” (Region C, Key Informant 4).
Participants’ descriptions underscored significant clinical, program infrastructural, and service system challenges that interfere with their efforts to provide quality individualized and personalized treatment. Limited availability of housing, employment opportunities, and transportation (challenges associated with the service system/treatment system) interfere with treatment and hinder the necessary community-level foundation for sobriety, while complex trauma histories and diverse cultural needs (challenges associated with providing clinical support) create additional demands on programs that are underfunded and overextended. These demands also impact the work force, which struggles with high case loads and excessive administrative responsibilities and thus lacks the time, resources, and emotional reserve to provide quality care (challenges associated with the infrastructure of treatment settings). The pressure to implement EBTs and to monitor outcomes, which creates additional demands on clinicians and programs and which participants perceived as being of questionable clinical significance (challenges associated with the service/treatment system), further undermine care, which is itself often time-limited and difficult to access. As a result, patients are left with unmet needs, and providers feel ineffective.
The following quotations further illustrate how clinical, program infrastructure, and service system challenges interact with one another:
The caseloads are too big. Everything is rush[ed] [and] the quality is not there…. And yet, [funding and regulatory agencies] expect that [providers] know the evidence-based practices, they facilitate and administrate them, and that they do the quality one-on-one care, and the case management and the referral on top of regular case staffings, discharge summaries, phone calls to the community, and helping people pick up the pieces of their lives. [Providers] can’t do that with 25 people. . . . [Agencies] need to let us slow down and do more quality work with people’s lives…. I think that’s why we have the recidivism that we do. We’re not . . . giving [clients] what they need because our case managers are overworked. . . . Our people are traumatized, . . . hugely traumatized. . . . What they need is a lot of TLC coming in. (Region C, Key Informant 5).
This quotation illustrates how high caseloads and excessive clinical responsibilities (challenges associated with the infrastructure of treatment settings) combined with the pressure to use EBTs (challenges associated with the service/treatment system) undermine the provision of quality substance abuse treatment critical for patients with complex trauma histories and high recidivism rates (challenges associated with providing clinical support).
[M]ost of our clients have [substance-abused related] felonies [and they] can’t . . . qualify for public housing. [Clients] get clean, [try] to get [custody of] their kids [and try] to work full time, but there is not suitable housing for them that they can afford. . . . [A] lot of their family members or past friends may have been users [and that’s] counterproductive for them to go and live with a past user. . . . [B]ut they still have to have a roof over their head. . . . [It] can be real frustrating, very frustrating. And it’s frustrating on our part too because we’re looked at as “well, we’re coming to you for help,” but the resources just aren’t there. . . . [W]e don’t have a resource to help with that. (IHS Region F, Key Informant 3)
As illustrated in this quotation, the absence of housing resources (challenges associated with the service/treatment system) prevents clients with complex socioeconomic challenges from leaving communities with endemic substance abuse problems (challenges associated with providing clinical support), consequently thwarting their attempts at sobriety. As a result, providers are left feeling frustrated and ineffective (challenges associated with the infrastructure of treatment settings), while clients' considerable needs remain unaddressed.