Legislating addictions treatment services for American Indians: Provider perspectives and cultural adaptations

Background: In an effort to improve substance abuse treatment, the Oregon Legislature passed Senate Bill 267, mandating the use of evidence-based practices (EBPs). This policy impacts programs receiving state funding, and presents unique challenges for clinicians working in tribal communities and urban American Indian/Alaskan Native (AI/AN) treatment programs. Purpose: This study documents the provider's response to the mandate and challenges they face when implementing EBPs in AI/AN treatment programs. Methods: Focus groups and semi-structured interviews conducted at the time of implementation (2005), and again three years into policy implementation (2008), provide qualitative data regarding clinical experiences. Participants included counselors (n=10 in 2005; n=18 in 2008), treatment program directors (n=7 in 2005; n=7 in 2008), and stakeholders (n=5 in 2005; n=3 in 2008) from tribal communities and urban treatment programs. Analysis included coding with Atlas.ti software, followed by theme identification and interpretation. Results: Several recurrent themes emerged. Participants reported a paucity of EBPs that are culturally congruent and effective with AI/AN clients, requiring clinicians to spend additional time/resources adapting core components of practices established for mainstream clients. Providers' comments also suggest that the workforce is limited by poor access to training and absence of an infrastructure that supports quality improvement initiatives. Finally, the challenge of treating complex clinical issues including inter-generational trauma, loss of culture/identity, and the distrust of state officials and researchers was continually repeated. Discussion: Results of this study confirm that clinicians are facing multiple challenges that influence the implementation of the state's evidence-based mandate in tribal communities.